Nationality | Thailand4 | Guyan5 | Malta6 | Tunisia7 | France8 |
Gender | Male | Male | Female | Female | Female |
Age | 74 | 66 | 26 | 40 | 54 |
Time when lesions started to appear | 25 hours after the 1st dose | Within 24 hours of receiving the 2nd dose | 15 days after the 1st dose; subsequent lesion appeared 14 days after the 2nd dose |
3 days after the 1st dose.
Subsequent lesions appeared 7 days after the 1st dose |
24 hours after the 1st dose; subsequent lesion appeared 4 days after the 2nd dose. |
COVID-19 vaccine type | Adenoviral-vectored | mRNA | mRNA | Adenoviral-vectored | mRNA |
Associated symptoms | None reported | Fever, myalgia | None reported | None reported | None reported |
Past medical history | End stage renal disease, Atrial fibrillation, Ischemic stroke | Hypertension, hyperlipidemia, diabetes, chronic kidney disease, coronary artery disease, idiopathic hypothyroidism | None reported | None reported | Seasonal allergic rhinitis |
Medication history | None reported | Amlodipine, aspirin, brimonidine solution, clopidogrel, famotidine, furosemide, gabapentin, insulin aspart and glargine, levothyroxine, lisinopril, metoprolol, pravastatin, tamsulosin |
Hydroxyzine prior to receiving the 2nd dose of
vaccine.
Topical 1% hydrocortisone and terbinafine applied on the 2nd lesion was ineffective |
None reported | None reported |
Skin Exam | Multiple, well‐defined, round to oval, erythematous to violaceous plaques with central dusky appearances and bullous formation | Extensive areas of painful violaceous patches many of which developed into large flaccid bullae |
1st lesion: mildly pruritic, erythematous, annular
patch 7 cm below the injection site in the same arm, developing central
erosion surrounded by a halo over 2 days, then resolved spontaneously.
2nd lesion was a similar patch although with prominent vesiculation at the center which eventually ruptured and scabbed. |
A well-defined bullous erythematous plaque sur-rounding the injection site, plus two other lesions on the upper and lower limbs | A 3-4 cm-well-defined erythematous patch |
Location | Trunk and both extremities | Abdomen, buttocks, and lower extremities | Same arm in which injection had been done | Upper and lower limbs | Left wrist |
Labs | Unremarkable |
Hyperkalemia, hyperglycemia, mild transaminitis, serum CK of 347, and an
incidental finding of mild AKI on CKD.
Normal serum Ab to bullous pemphigoid |
Not discussed in the article | Not discussed in the article | Not discussed in the article |
Pathology | Subepidermal separation with superficial and deep perivascular inflammatory cell infiltration plus mixed inflammatory cells infiltrate composing of lymphohistiocytes and numerous eosinophils. Melanophages were seen in the upper dermis. | Full-thickness epidermal necrosis and a very sparse lymphocytic inflammatory infiltrate |
Overall, lichenoid interface dermatitis was found.
Patchy lymphohistiocytic infiltrate in the upper dermis around skin adnexal structures, lymphocytic infiltration of the basal layer of epidermis, basal cell vacuolar damage, Civatte body formation and pigment incontinence, dermal-epidermal junction clefting |
Epidermal necrosis, bullae formation, superficial and deep perivascular mixed infiltrate of lymphocytes, neutrophils and eosinophils, and dermal melanophages were detected | Acute vacuolar interface changes and keratinocyte necrosis with superficial perivascular infiltrate of lymphocytes. |
Final diagnosis | Generalized bullous fixed drug eruption | Extensive bullous fixed drug eruption | Fixed drug eruption | Generalized bullous fixed drug eruption | Fixed drug eruption |
Treatment | Topical 0.25% desoximetasone cream | Ibuprofen and high-dose oral prednisone, bullae drainage followed by mupirocin and Vaseline for wound care. | Not discussed in the article | Potent topical corticosteroids and hydroxyzine | Topical beclomethasone dipropionate |
Outcome | Lesions gradually resolved within 2 weeks with subsequent post-inflammatory hyperpigmentation. | Discharged from hospital after 7 days with prednisone taper and outpatient follow up recommendation | Not discussed in the article | Resolution of the lesion after a few days of treatment with subsequent development of post inflammatory hyperpigmentation | Clearance of the lesion in 21 days without residual hyperpigmentation |