key: cord-1018936-1zc7zoy5
authors: Zengarini, C.; Pileri, A.; Salamone, F.P.; Piraccini, B.M.; Vitale, G.; La Placa, M.
title: Subacute cutaneous lupus erythematosus induction after SARS‐CoV‐2 vaccine in a patient with primary biliary cholangitis
date: 2021-12-02
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.17827
sha: 920a983fb394c438abf649bab41f1bdcbbe99213
doc_id: 1018936
cord_uid: 1zc7zoy5

We describe a subacute cutaneous lupus erythematosus (SCLE) case developed after vaccination with mRNA COVID-19 vaccine1 . A 30-year-old Italian woman presented due to the sudden occurrence of papules and plaques on her face and upper back. The eruption started following a day spent outdoors, ten days after receiving the SARS-CoV-2 mRNA vaccine second dose (Pfizer, Cominarty). At the time of our consultation, we observed purplish, erythematous and scaly papules and plaques on the upper back [Image 1A], cheeks, temples and forehead [Image 2A]. The rest of the skin was unaffected.

Dear Editor, We describe a subacute cutaneous lupus erythematosus (SCLE) case developed after vaccination with mRNA COVID-19 vaccine. 1 A 30-year-old Italian woman presented due to the sudden occurrence of papules and plaques on her face and upper back. The eruption started following a day spent outdoors, ten days after receiving the SARS-CoV-2 mRNA vaccine second dose (Pfizer, Cominarty). At the time of our consultation, we observed purplish, erythematous, and scaly papules and plaques on the upper back (Fig. 1a) , cheeks, temples, and forehead ( Fig. 2a) . The rest of the skin was unaffected.

She reports that she has not changed her habits, has not introduced new drugs or suffered from new diseases in the last year. However, her past medical history was complex: she was born with biliary tract atresia, operated on with Kasai surgery. She developed portal hypertension and was treated with ursodeoxycholic acid for primary biliary cholangitis. Past Skin biopsy showed hyperkeratosis, superficial perivascular and perifollicular lymphocytic infiltration and vacuolization of the basement membrane.

Blood exams showed marked leukopenia and thrombocytopenia, complement consumption, increased anti-dsDNA, anti-Sm, and anti-nRNP and new positivity for anti-Ro/SSA, compared to the last panel of exams.

The histological characteristics, positivity to anti-Ro/SSA antibodies and clinical manifestations led to the diagnosis of SCLE. 2 Suspecting a vaccine cause, we evaluated the probability of an adverse drug reaction using the Naranjo scale. 3 We considered timing, the absence of new drugs introduced or changes in habits and the previous case reports retrieved in literature, some of which have similar cases. 4 According to the Naranjo scale, we considered the SCLE onset as probably triggered by the SARS-CoV-2 vaccination.

We started systemic steroid treatment with a suboptimal prednisone dose (0.4 mg/kg/day) due to the increased infectious risk and daily furoate mometasone topical cream. After three weeks, therapy led to an almost complete resolution of the skin lesions, still with residual hypopigmentation on the back (Figs 1b and 2b) .

We then referred the patient to the rheumatologist to evaluate the introduction of systemic hydroxychloroquine.

Among the possible explanations, we know that tumor necrosis factor-alpha (TNF-a) and interferon-gamma (IFN-c) are increased by infections and vaccinations, which lead to cytokine release and CD4-type 1 helper T cell (Th1) recruitments. High levels of Th1 cells and inflammatory state have been reported in affected skin of patients with SCLE manifestations, which can explain flare episodes in predisposed patients. 5 In this case, the patient had positive antibodies specific for LE (ds-DNA and anti-histones) but not anti-Ro/SSA. Until now, she had never manifested any clinical signs of LE except for an alteration of the hemogram, probably caused by splenomegaly secondary to portal hypertension.

With this case report, we aim to increase the awareness of the rare skin manifestations elicited by Sars-Cov-2 vaccines. We recommend dermatologists to carefully evaluate any skin reactions that may arise after a vaccination.

Transition of cutaneous into systemic lupus erythematosus following adenoviral vector-based SARS-CoV-2 vaccination

European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus

Adverse Drug Reaction Probability Scale (Naranjo) in Drug Induced Liver Injury. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury

National Institute of Diabetes and Digestive and Kidney Diseases

Induction and exacerbation of subacute cutaneous lupus erythematosus following mRNA-based or adenoviral vector-based SARS-CoV-2 vaccination

Comparative analysis of subacute cutaneous lupus erythematosus and chronic cutaneous lupus erythematosus: clinical and immunological study of 270 patients

The authors have no conflict of interest to declare.The patients in this manuscript have given written informed consent to the publication of their case detail.

Data available on request from the authors. To the Editor, The scientific understanding of the dermatological implications of COVID-19 is rapidly evolving. A variety of cutaneous manifestations associated to COVID-19 have been described in recent reports published in the literature. 1 Emerging evidence shows that children with COVID-19 can develop a condition called "multisystem inflammatory syndrome in children" (MIS-C), which is also known as "pediatric