Dear Editor,
A 29-year-old female patient, received a dose of the yellow fever vaccine, developing
headache, oral ulcers, and bilateral ocular erythema, edema and pruritus 4 days later.
She sought medical attention and was instructed to use eye drops containing polymyxin
B,
neomycin and dexamethasone. The following day, she presented worsening of symptoms,
with
fever, decrease in general clinical condition, and brownish-erythematous macules on
her
hands. She was admitted to the Emergency Care Unit, remaining hospitalized for three
days, when dipirone, diclofenac and systemic dexamethasone were prescribed.
Due to the worsening of the clinical condition, the patient was transferred to our
hospital on the eighth day after vaccination, with generalized confluent
brownish-erythematous macules and plaques, blisters, and epidermal detachment on the
back and face (Figure 1).
Figure 1
Confluent erythematous plaques, with epidermal detachment and blistering
After being diagnosed with toxic epidermal necrolysis (TEN), she was promptly admitted
to
the Intensive Care Unit (ICU), and IV human immunoglobulin was introduced at a dose
of
3g/kg (180g administered over 5 days), prednisone 20mg/day for 5 days, and acetaminophen
500mg if needed. She was maintained under contact isolation precaution, with nasogastric
tube feeding, mucosal humidification, and occlusive bandages with Vaseline
® . In the following days, she presented detachment of nail plates
of her fingers and toes, and cutaneous necrosis on the face (Figure 2). She evolved
with progressive improvement of clinical,
ophthalmologic and dermatological conditions.
Figure 2
Evolution of facial lesions with epidermal necrosis and, as well as important
mucositis
She was discharged after one month, with cutaneous reepithelialization, generalized
residual hyperchromic macules (Figure 3) and
granulation tissue in the nail folds. The patient persisted with decreased visual
acuity, maintaining follow-up with ophthalmology.
Figure 3
Improvement of facial lesions after treatment and hospital discharge
Adverse drug reactions (ADR) are cutaneous manifestations that can occur after the
use of
any chemical by any route of administration. The best known are erythema multiforme
(EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN), considered
by some authors as a spectrum of the same disease.
1
ADR occur mostly after use of medications such as
anticonvulsants, neuroleptics, antibiotics, antifungals, diuretics, non-hormonal
anti-inflammatories, and analgesics. EM was reported after HPV and meningitis vaccines,
and its onset after vaccination generates contraindication to new doses, due to the
risk
of SJS and TEN.
2,3
Although rare, there are reports of TEN induced by
vaccines such as triple viral, triple bacterial, influenza, polio, and BCG.
4
TEN is characterized by the detachment of the epidermis (> 30% of the body surface)
due to necrosis.
4
The clinical
manifestations occur 4 to 28 days after the introduction of the chemical substance.
Prodromes may occur, such as fever, odynophagia, cough, ocular burning, and oral
mucositis. The cutaneous lesions are erythematous macules with poorly defined contour
and purpuric center, usually starting on the face and then spreading down the neck
and
torso to the arms, legs, and feet. TEN can affect the nails, causing onycholysis and
subsequent shedding.
1
The insult at the
dermal-epidermal junction generates flaccid blisters that break easily, resulting
in
extensively denuded and friable dermis, with positive Nikolsky's sign. Stomatitis,
balanitis, colitis, conjunctivitis and blepharitis may occur, as well as involvement
of
the respiratory and gastrointestinal tracts.
Treatment should occur in an ICU environment with isolation, heating, and removal
of the
causative drug. In addition, support with hydration, albumin replacement and a
hypercaloric diet should be provided. The main complications are sepsis (secondary
to
cutaneous infection) and severe ocular and genital lesions. Ocular lubricants are
necessary, and the patient must be monitored by an ophthalmologist because eye sequelae
are the main cause of disease morbidity.
5
The use of corticosteroids is controversial. Other options for
treatment include immunoglobulin and cyclosporin. However, the efficacy of these
measures is still controversial.
3
Yellow fever is an endemic disease in Brazil, and registered epidemic outbreaks signal
the reemergence of the virus, as occurred in late 2017 in Jundiaí (SP). A large
proportion of cities have low vaccination coverage and require mass vaccination of
the
local population.
The most effective method to prevent yellow fever is vaccination with the 17D sample.
Currently, pregnant women, immunosuppressed patients, and people with a history of
allergy to egg protein should not be vaccinated, due to the risk of developing type
I
allergic reaction (anaphylaxis).
We report a rare case of TEN triggered by yellow fever vaccination, given the importance
of this serious adverse effect. Until now, the manual of the Brazilian Ministry of
Health has made no mention of TEN as a possible adverse reaction to yellow fever
vaccine.