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\title{Cutaneous vasculitis after COVID-19 vaccination in a 41-year-old male}



\author[1]{mehran pournazari}%
\author[1]{shirin assar}%
\author[2]{Faraneh Farsad}%
\author[1]{Dena Mohamadzadeh}%
\affil[1]{Kermanshah University of Medical Sciences}%
\affil[2]{Shahid Beheshti University of Medical Sciences}%


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  \date{May 20, 2024}


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\textbf{Cutaneous vasculitis after COVID-19 vaccination in a 41-year-old
male}

Mehran Pournazari\textsuperscript{1}, Shirin Assar\textsuperscript{1},
Faraneh Farsad\textsuperscript{2}, Dena Mohamadzadeh\textsuperscript{1}

\textsuperscript{1}Clinical Research Development Center, Imam Reza
Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran

\textsuperscript{2} Research Centre of Loghman Hakim Hospital, Shahid
Beheshti University of Medical Sciences, Tehran, Iran

\textbf{Corresponding author:}

Dena Mohamadzadeh, MD

Resident of Internal Medicine,

Clinical Research Development Center,

Imam Reza Hospital, Kermanshah University of Medical Sciences,

Kermanshah, Iran

e-mail: denamohamadzadeh75@gmail.com

Phone: +989183290113

\textbf{Abstract}

Cutaneous vasculitis has been associated with both Coronavirus
disease-2019 (COVID-19), and SARS-CoV-2 vaccines. We reported a
41-year-old male who developed bullous lesions and erythematous plaques
leading to atrophic patches two weeks after injection of the second dose
of the COVID-19 vaccine. The skin biopsy showed leukocytoclastic
vasculitis. The disease was self-limited and no recurrence of symptoms
happened after six months of follow-up.

\textbf{Case presentation}

The patient was a 41-year-old male who presented to our rheumatology
clinic with atrophic lesions of the neck and left ear and
hyper-pigmented plaques on the left thigh. He claimed that he developed
bullous lesions on his neck, and left thigh about two weeks after
injection of the second dose of COVID-19 vaccination. When he was asked
about the type of the injected vaccines, he reported that the first dose
was Sinopharm BIBP COVID-19 vaccine (BIBP-CorV), and he voluntarily
injected the second dose one month after the first one which was
Oxford/AstraZeneca (ChAdOx1-S {[}recombinant{]} vaccine) COVID-19
vaccine. He did not inform the vaccination center about the time and
type of the first injection. His past medical history, drug history, and
familial and social history were unremarkable.

On the meeting day, his vital signs and general examination were within
normal limits except for cutaneous lesions. An atrophic and depigmented
patch was observed on the lateral of the neck. The tip of his left
auricle was atrophic (Figure 1). Purple and pigmented plaques were
detected on the anterior of the left thigh (Figure 2). There were no
signs or symptoms in favor of systemic inflammatory disease. Laboratory
routine tests including cell blood count, renal and liver function tests
and thyroid function tests were all within normal limits.

A biopsy was taken from the thigh lesion which showed vasculitis of the
small vessels with infiltration of inflammatory cells, mainly
neutrophils in the vessel wall, and findings were compatible with
leukocytoclastic vasculitis. Immunological tests were conducted to
investigate possible systemic diseases and revealed negative results for
antinuclear antibody (ANA), anti-double-stranded deoxyribonucleic acid
(anti-ds DNA) antibody, perinuclear and cytoplasmic anti-neutrophil
cytoplasmic antibody (P \& C-ANCA), Anti Ro, Anti La,
angiotensin-converting enzyme (ACE), C3, C4, CH50 and anti-cyclic
citrullinated peptide (anti-CCP). Due to the absence of a systemic
disease, the patient was treated with non-steroidal anti-inflammatory
drugs and she was followed up monthly in a rheumatology clinic. There
was no recurrence of the symptoms six months after the vaccine
injection.

\textbf{Discussion}

Cutaneous vasculitis (CV) is defined as an inflammatory disorder
affecting the small vessels of the dermis. Clinical manifestations are
urticarial, papules, plaques, palpable purpura, ulcers, nodules and
livedo. Cutaneous vasculitis is classified based on the type of
inflammatory infiltrations on the biopsy specimen, and the size of the
involved vessels, etc. The most important subtypes are neutrophilic
vasculitis, lymphocytic vasculitis, necrotizing vasculitis, thrombosing
vasculitis, eosinophilic vasculitis, and granulomatous vasculitis. CV
could be part of a systemic vasculitis or occur separately and be
self-limited. The most common etiologies are infections, autoimmune
systemic disorders, malignancies, drugs, and vaccines. CV represents a
self-limited course in most cases. Systemic corticosteroids and
immunosuppressive agents might be required in severe and systemic
diseases {[}1{]}. Different types of vasculitis have been reported as
adverse events following immunization. Culprit vaccines are influenza,
BCG, human papillomavirus, and hepatitis B vaccines {[}2{]}. CV has been
associated with both Coronavirus disease-2019 (COVID-19), and SARS-CoV-2
vaccines {[}3, 4{]}. The inflammatory response triggered by the vaccine,
and immune complex deposition within the vessels wall of the dermis have
been described as the cause of this adverse event. The responsible
antigen for such an immune reaction might be the vaccine component
encoding SARS-CoV-2 spike glycoprotein {[}5{]}. In conclusion, LCV could
be a possible adverse event of different SARS-CoV-2 vaccines. Clinicians
and manufacturers should be aware of this adverse event.

\textbf{Ethics approval and consent to participate}

Approval was not needed by the local Clinical Research Ethics Committee
for case reports.

\textbf{Consent for publication}

Written informed consent was obtained from the patient for publication
of this case report and any accompanying images. A copy of the written
consent is available for review of the Editor-in-Chief of this journal.

\textbf{Conflict of interests}

The authors declare that they have no competing interests.

\textbf{Data availability statement}

Data is available if requested

\textbf{Funding}

We received no funding.

\textbf{Authors' contributions}

MP conceived the idea to report the case. FF was responsible for data
collection. DM and SA drafted the manuscript. MP and FF commented on the
manuscript. All authors read and approved the final manuscript.

\textbf{Acknowledgments}

Not applicable.

\textbf{References}

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\end{enumerate}\selectlanguage{english}
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