Dear Editor:
A 77-year-old male who developed eruptive skin lesions was admitted to our clinic.
Two weeks after receiving the third injection of the vaccine (July 15), he complained
of arthralgia, myalgia, and general fatigue and also experienced intestinal symptoms
such as bloody diarrhea and abdominal pain. He reported a mildly itchy rash with his
first (February 12) and second-dose (March 16) immunizations, without fever, difficulty
breathing, edema, oliguria, or other systemic symptoms. He denied any prior history
of vaccinations, food, drug, or environmental allergies, or systemic autoimmune diseases,
nor any other recent changes to his medications.
Dermatologic examination revealed diffuse palpable, tender, non-blanching violaceous
coalescent patches on the thighs, calves, feet, and hands. There were also bullous
hemorrhagic lesions distributed bilaterally on the extensor sides of the lower legs
and feet (Fig. 1A, B). The rest of the physical examination was unremarkable.
Fig. 1
A Dermatological examination reveals multiple, discrete to confluent palpable purpuras
distributed symmetrically over both lower limbs. B Bullous hemorrhagic lesions distributed
bilaterally on the extensor sides of the lower legs and feet. C Histopathology of
a lesion suggests leukocytoclastic vasculitis with small vessels in the dermis showing
plump endothelial cells surrounded by a perivascular mixed inflammatory infiltrate
with karyorrhectic debris and extravasation of RBCs. (H & E, 200x). D Inflammatory
cells comprising neutrophils and lymphocytes infiltrating the vessel wall. Leukocytoclasia
is seen. (H & E, 400x)
Pathologic laboratory testing revealed elevated C-reactive protein levels of 60 mg/L
(normal: 6), D-dimer levels of 6028 (normal: 500), and sedimentation rates of 44 mm/h
(normal: 20). The white blood cell count, peripheral smear, liver, and renal function
tests were within normal ranges. Rheumatologic tests showed positive antinuclear antibodies
(ANA: 1/ 100) and PM-SCl++, while other autoimmune workup revealed no pathologic findings
including complement CH 50, C3, C4, rheumatic factor, antidsDNA, c/p-ANCA, antiphospholipid
antibodies, and ENA panel – e.g. Jo1, U1-RNP-, SCL70-, Sm-, and Ro/La-antibodies.
Cryoglobulin and screening for viral infections (hepatitis A, B, and C, CMV, EBV,
Coxsackie, parvovirus B19, and HIV) were also negative. A nasal swab proved negative
for the SARS‐CoV‐2 virus. CT scans of the thorax and abdominopelvic yielded normal
results. Dermatopathologic examination of the skin biopsy was compatible with small
vessel LCV in the dermis showing plump endothelial cells surrounded by a perivascular
mixed inflammatory infiltrate with karyorrhectic debris and extravasation of red blood
cells (Fig. 1C, D). Direct immunofluorescence did not reveal any deposits in the vessels.
His abdominal pain and stool tests on occult blood-positive favor occult bleeding
associated with LCV of gastrointestinal involvement.
From the correlation of the clinical presentation, laboratory findings, and recent
COVID-19 vaccine, we established the diagnosis of cutaneous and gastrointestinal LCV,
possibly triggered by the third dose of immunization, by excluding possible triggers
such as concomitant medication, other infectious, malignant, and autoimmune causes.
As our patient presented with pronounced skin and gastrointestinal involvement, we
treated him with oral prednisolone at a dose of 0.5 mg/kg/day, with a rapid response.
At a follow-up 14 days later, all clinical manifestations and laboratory findings
were resolved.
So far, cutaneous vasculitis presenting with typical skin lesions has been well reported
in mild as well as fulminant COVID-19 infections. Vasculitis in COVID-19 has been
attributed to SARS-CoV-2-associated endothelitis, which could be because of the virus
directly invading the endothelium or owing to an inflammatory response that results
in immune complex deposits in the vessels [1].
Recently, COVID-19 vaccinations associated with LCV and autoimmune adverse effects
have been described, but they are relatively rare. The Coronavac vaccine (Sinovac,
China) contains inactivated whole or split virion representatives of COVID-19 viruses,
as well as several adjuvants (aluminum) that are unlikely to cause immunopathology.
It’s still unclear if it’s a hypersensitivity reaction to the SARS-CoV-2 spike protein
or the other vaccination component [2]. The COVID‐19 vaccine may provoke hyper-activation
of the immune system secondary to cross‐reactivity and molecular mimicry between the
virus and self‐antigens, consequently triggering autoimmune disorders such as vasculitis
in genetically predisposed individuals [3].
To our knowledge, there were few previous case reports of vaccine-associated reactivation
or new-onset LCV or IgA vasculitis after COVID-19 with mRNA or inactivated SARS-CoV-2
vaccines at the first or second doses, but none at the third dose [4–9]. In addition,
in some case reports, mRNA COVID-19 vaccinations have been linked to new-onset or
recurrent ANCA-associated vasculitis with kidney impairment [10]. Compared to other
reported cases, he developed GIS involvement and responded faster to corticosteroids.
In our case, the large antigenic trigger because of the booster re-exposure of the
third dose may have contributed to the development of cutaneous LCV with GIS involvement
without known predispositions to the type 3 hypersensitivity.
The purpose of this case report is to increase awareness of the potential side effects
of the vaccine. However, more studies are needed to better characterize the adverse
effects of these vaccines on elderly individuals.