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CORRESPONDENCE |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 825-828 |
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| Exacerbation of lupus erythematosus panniculitis after administration of COVID-19 mRNA vaccine |
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Ceylan Avci1, Nilüfer Diana Şirin1, Turna İlknur1, Banu Lebe2, Sevgi Akarsu1
1 From the Department of Dermatology, Dokuz Eylul University, Faculty of Medicine, İzmir, Turkey
2 Department of Pathology, Dokuz Eylul University, Faculty of Medicine, İzmir, Turkey
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Ceylan Avci
Department of Dermatology, Dokuz Eylul University, Faculty of Medicine, İzmir
Turkey
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_591_22
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How to cite this article:
Avci C, Şirin ND, İlknur T, Lebe B, Akarsu S. Exacerbation of lupus erythematosus panniculitis after administration of COVID-19 mRNA vaccine. Indian J Dermatol 2022;67:825-8 |
How to cite this URL:
Avci C, Şirin ND, İlknur T, Lebe B, Akarsu S. Exacerbation of lupus erythematosus panniculitis after administration of COVID-19 mRNA vaccine. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:825-8. Available from: https://www.e-ijd.org/text.asp?2022/67/6/825/370326 |
Sir,
Little is known about the safety of COVID-19 vaccines in patients with autoimmune and inflammatory skin diseases such as cutaneous lupus erythematosus. Herein, we describe a patient with lupus erythematosus panniculitis who developed disease flare after the second dose of COVID-19 mRNA vaccine.
A 28-year-old female presented with erythematous plaque on the nasal dorsum and left side of her face. The first manifestation of the disease was nine years ago, as a small erythematous nodule on her nasal dorsum. The patient had a history of hypothyroidism and rhinoplasty, and her father had familial Mediterranean fever. A biopsy performed at that time was non-diagnostic and after eight months of prednisolone treatment her lesions regressed. In 2019, indurated plaques appeared on the face, ears, right supraclavicular and left deltoidal areas without any skin surface changes. She was diagnosed with morphoea, and she used hydroxychloroquine irregularly for one year. Under hydroxychloroquine therapy, the extent and severity of her lesions decreased and lipoatrophy on the affected sides appeared. In September 2021, 10 days after the second dose of BNT162b2 mRNA COVID-19 (Biontech/Pfizer) vaccine, erythematous induration spread towards of her left cheek and left side of her nose. There was no history of any other drug use, infection, or sun exposure that could have caused her disease flare. On physical examination, oedema in the left infraorbital region, erythematous-livid coloured induration on the left maxillary and left mandibular region were observed [Figure 1]a. The patient also had lipoatrophy on the right suprascapular and left deltoidal areas [Figure 1]b and [Figure 1]c. An examination of punch biopsy tissue of the lesion revealed lymphocytic lobular panniculitis [Figure 1]d. Laboratory test results showed normal levels of blood cell counts, urinalysis, CRP, erythrocyte sedimentation rate, and renal and liver function. Serological study found low grade antinuclear antibodies (ANA; >1/100 to <1/320, granular pattern) and borderline positivity for AntiRNP/Sm. Based on the clinical, histopathological and laboratory findings, the patient was evaluated as lupus erythematosus panniculitis (LEP), and systemic involvement was not detected. The patient was started on hydroxychloroquine 200 mg twice a day and prednisolone 0.5 mg/kg per day. After three weeks of treatment, oedema, erythema, and induration of the lesions significantly decreased, and gradual prednisolone dose tapering was administered [Figure 1]e. | Figure 1: (a) Patient photograph at admission, showing oedema in the left infraorbital region, erythematous-livid coloured induration on the left maxillary and left mandibular region. (b and c) Lipoatrophy on the right suprascapular and left deltoidal areas. (d) Punch biopsy tissue of the lesion showing subcutaneous lymphocytic lobular panniculitis, haematoxylin and eosin (H and E), 10× original magnification. (e) Patient photograph after three weeks of prednisolone and hydroxychloroquine treatment showing improvement of the oedema, erythema, and indurated lesions
Click here to view |
LEP is an uncommon variant of cutaneous lupus erythematosus, characterized by a tender, erythematous subcutaneous induration that usually occurs on the upper arms, face, trunk, buttocks, and thighs. Although the exact aetiology of LEP is not known, it is reported that the history of trauma on the lesion area may be a triggering factor.[1] Additionally, environmental factors such as medications and vaccines can exacerbate cutaneous lupus erythematosus.[2] In the literature, three cases of subacute cutaneous lupus erythematosus (SCLE) and one case of Rowell syndrome induction and three cases of pre-existing SCLE exacerbation after COVID-19 vaccination have been reported [Table 1].[2],[3],[4],[5],[6],[7],[8] In one of them, transition of SCLE into systemic lupus erythematosus was observed which responded to prednisolone treatment within seven days.[3] To the best of our knowledge, no case of exacerbation of LEP have been reported after the administration of COVID-19 vaccine. | Table 1: Patient characteristics of cutaneous lupus erythematosus triggered or exacerbated after COVID-19 vaccine administration
Click here to view |
BNT162b2 mRNA vaccine, which is administered in two doses, acts by both humoral and cellular immunity. After the second dose, there is a significant increase in neutralizing antibody levels, while the antigen-specific response of IFNγ by CD4+ and CD8+ T cells is also observed.[9]
We think that there is a relationship between vaccination and the flare of skin lesions of our patient who was misdiagnosed with morphoea profunda priorly. The absence of reaction in the vaccine injection area and the exacerbation of pre-existing lesions suggest that the vaccine caused the disease flare by stimulating the systemic immune response. Although there is a possibility of disease flare, the American Association of Rheumatology recommends vaccination for patients with autoimmune and inflammatory rheumatological diseases due to risk of severe COVID-19 infection.[10] Since facial lipoatrophy is a difficult complication of LEP, we want to emphasize that exacerbation may be observed in these patients after SARS-CoV-2 vaccine administration.
Acknowledgements
The patient in this manuscript has given written informed consent for the publication of her case details.
Author contributions
Ceylan Avcı wrote the first draft of the manuscript. Ceylan Avcı and Nilüfer Diana Şirin prepared the figure and table. Banu Lebe evaluated the punch biopsy tissue of the lesion and supplied the photograph. Ceylan Avcı, Turna İlknur and Sevgi Akarsu were directly involved in the treatment of the patient. All authors added critical intellectual content and read and approved the final version of the manuscript.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Castrillón MA, Murrell DF. Lupus profundus limited to a site of trauma: Case report and review of the literature. Int J Womens Dermatol 2017;3:117-20.  |
| 2. | Kreuter A, Licciardi-Fernandez MJ, Burmann SN, Burkert B, Oellig F, Michalowitz AL. Induction and exacerbation of subacute cutaneous lupus erythematosus following mRNA-based or adenoviral vector-based SARS-CoV-2 vaccination. Clin Exp Dermatol 2022;47:161-3. |
| 3. | Kreuter A, Burmann SN, Burkert B, Oellig F, Michalowitz AL. Transition of cutaneous into systemic lupus erythematosus following adenoviral vector-based SARS-CoV-2 vaccination. J Eur Acad Dermatol Venereol 2021;35:e733-5. |
| 4. | Gambichler T, Scholl L, Dickel H, Ocker L, Stranzenbach R. Prompt onset of Rowell's syndrome following the first BNT162b2 SARS-CoV-2 vaccination. J Eur Acad Dermatol Venereol 2021;35:e415-6. |
| 5. | Niebel D, Ralser-Isselstein V, Jaschke K, Braegelmann C, Bieber T, Wenzel J. Exacerbation of subacute cutaneous lupus erythematosus following vaccination with BNT162b2 mRNA vaccine. Dermatol Ther 2021;34:e15017. |
| 6. | Rechtien L, Erfurt-Berge C, Sticherling M. SCLE manifestation after mRNA COVID-19 vaccination. J Eur Acad Dermatol Venereol 2022;36:e261-3. |
| 7. | Zengarini C, Pileri A, Salamone FP, Piraccini BM, Vitale G, La Placa M. Subacute cutaneous lupus erythematosus induction after SARS-CoV-2 vaccine in a patient with primary biliary cholangitis. J Eur Acad Dermatol Venereol 2022;36:e179-80. |
| 8. | Joseph AK, Chong BF. Subacute cutaneous lupus erythematosus flare triggered by COVID-19 vaccine. Dermatol Ther 2021;34:e15114. |
| 9. | Sadarangani M, Marchant A, Kollmann TR. Immunological mechanisms of vaccine-induced protection against COVID-19 in humans. Nat Rev Immunol 2021;21:475-84. |
| 10. | Wack S, Patton T, Ferris LK. COVID-19 vaccine safety and efficacy in patients with immune-mediated inflammatory disease: Review of available evidence. J Am Acad Dermatol 2021;85:1274-84. |
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