Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Net Letter
89 (
1
); 160-160
doi:
10.25259/IJDVL_791_2021
pmid:
35962494

Erythema multiforme-like reaction following COVID-19 vaccination

Department of Dermatology, All India Institute of Medical Sciences, Patrapada, Bhubaneswar, Odisha, India
Department of Pathology, All India Institute of Medical Sciences, Patrapada, Bhubaneswar, Odisha, India

Corresponding Author: Dr. Biswanath Behera, Department of Dermatology, All India Institute of Medical Sciences, Patrapada, Bhubaneswar, Odisha, India. biswanathbehera61@gmail.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Kowe PA, Behera B, Sethy M, Viswan P. Erythema multiforme-like reaction following COVID-19 vaccination. Indian J Dermatol Venereol Leprol 2023;89:160.

Sir,

A 40-year-old male presented with eight days history of multiple severely itchy red eruptions all over the body. The lesions started over the extremities 24 hours after the first dose of COVID-19 vaccine (“Covaxin®” a whole–virion inactivated SARS–CoV–2 antigen, Strain: NIV–2020–770). They were not associated with constitutional or systemic features. He consulted a vaccination center and was prescribed cetirizine and calamine lotion without any improvement. He denied a history of recent infections or medications prior to the onset of the skin rash. He did not have a history of previous pneumoccocal or influenza vaccines. There was no history of any systemic involvement. Cutaneous examination revealed multiple erythematous macules, papules, vesicles, and targetoid lesions over the bilateral extremities, trunk and back [Figures 1a to c]. Palm and soles were not affected. Other mucocutaneous, general, and systemic examinations were within normal limits. Dermoscopy under polarised mode (Heine Delta 20T, 10×) from targetoid papules showed central brown peppering and peripheral pinkish-white structureless area (a targetoid pattern) [Figure 2]. His laboratory investigations, complete blood count, erythrocyte sedimentation rate, C-reactive protein, liver function test, and serum urea and creatinine were within normal limits. Histopathology (from a vesicle and a papule) revealed orthokeratosis, spongiosis, intra-epidermal vesicle and focal basal cell hydropic degeneration. The dermis showed moderate-to-severe oedema and perivascular lymphocytes along with a few eosinophils and neutrophils [Figures 3a and b]. Due to the predominant spongiotic reaction pattern and the absence of significant basal vacuolar degeneration and necrotic keratinocytes, the diagnosis of erythema multiforme-like reaction was made. Naranjo scale of adverse drug reaction probability was used to assess the causality; the score was 4, confirming that the vaccine possibly induced the erythema multiforme-like reaction.1 This adverse event was reported to the Pharmacovigilance Programme of India. According to the World Health Organization-Uppsala Monitoring Centre criteria, it was certainly an adverse event secondary to the vaccine (Pharmacovigilance Programme of India Report No. In-IPC-300547804).1 Based on the modified Hartwig and Siegel severity assessment scale, this event comes under the moderate category (level 3).2 The patient was started on prednisolone 30 mg/day, following which he noticed a significant improvement in skin lesions in one week. The patient was counselled to carry a drug card and advised to abstain from the second dose of the same COVID-19 vaccine.

Multiple erythematous macules, papules, vesicles and targetoid lesions on the back
Figure 1a:
Multiple erythematous macules, papules, vesicles and targetoid lesions on the back
A closer view shows multiple targetoid lesions (blue arrows) and vesicles (red arrows)
Figure 1b:
A closer view shows multiple targetoid lesions (blue arrows) and vesicles (red arrows)
Multiple erythematous papules, vesicles (red arrow), and targetoid papules (blue arrows)
Figure 1c:
Multiple erythematous papules, vesicles (red arrow), and targetoid papules (blue arrows)
Dermoscopy under polarised mode (Heine Delta 20T, ×10 magnification) from targetoid papules shows a targetoid pattern comprising central brown peppering (arrows) and peripheral pinkish-white structureless area
Figure 2:
Dermoscopy under polarised mode (Heine Delta 20T, ×10 magnification) from targetoid papules shows a targetoid pattern comprising central brown peppering (arrows) and peripheral pinkish-white structureless area
Histopathology shows spongiosis, intraepidermal vesicle, focal basal cell hydropic degeneration, erythrocyte extravasation (red arrow), and superficial dermal oedema (blue arrow) (H & E, ×100)
Figure 3a:
Histopathology shows spongiosis, intraepidermal vesicle, focal basal cell hydropic degeneration, erythrocyte extravasation (red arrow), and superficial dermal oedema (blue arrow) (H & E, ×100)
Erythrocyte extravasation and eosinophils (blue arrows). Red arrows point to the Langerhans cells (H & E, ×400)
Figure 3b:
Erythrocyte extravasation and eosinophils (blue arrows). Red arrows point to the Langerhans cells (H & E, ×400)

Immunisation with the currently available COVID-19 vaccine is the most important and effective measure in controlling this pandemic. However, there is an increase in the emergence of vaccine-related adverse reactions. Both active and inactive content of the vaccine can lead to these events. These include vaccine ingredients such as inactivated or killed viruses and their antigens, conjugating agents, preservatives, stabilisers, adjuvants, antimicrobial agents, excipients (inert substances increasing the bulk of the vaccine) and culture medium used during processing of vaccine.3

Erythema multiforme is a cutaneous hypersensitivity reaction pattern in response to infections and drugs.4 Reports of erythema multiforme following vaccination are infrequent.5 As per Lavery et al. post-infection and post-vaccine induced erythema multiforme have the same etiopathogenesis.4 He hypothesised that erythema multiforme associated with infection is due to a cell-mediated immune response.4 In the index case, the inactivated virion present in the vaccine and its antigen expressed on the surface of keratinocytes possibly resulted in the stimulation of helper-T cells and release of cytokines such as interferon-gamma leading to inflammation. It is known that excipient induced allergic reactions are usually localised to the injection site and are less severe, whereas viral antigen-induced reactions are generalised in distribution and more severe. The second scenario was observed in our case.5

In conclusion, we report a case of erythema multiforme-like reaction following the COVID-19 vaccine. In today’s era of emerging cutaneous adverse drug reactions following COVID-19 vaccination, every case should be reported to the pharmacovigilance department to increase awareness among treating physicians.

Acknowledgement

We acknowledge Mrs. Pinki Mohanty, Pharmacovigilance associate, Indian Pharmacopoeia Commission, NCC-PvPI, Ghaziabad, for helping us register the adverse reaction to COVID-19 vaccine.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

References

  1. , , . A study of agreement between the Naranjo algorithm and WHO-UMC criteria for causality assessment of adverse drug reactions. Indian J Pharmacol. 2014;46:117-20.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , . Preventability and severity assessment in reporting adverse drug reactions. Am J Hosp Pharm. 1992;49:2229-32.
    [PubMed] [Google Scholar]
  3. , , , , , , et al. Allergic reactions to current available COVID-19 vaccinations: Pathophysiology, causality, and therapeutic considerations. Vaccines (Basel). 2021;9:221.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , . A flare of pre-existing erythema multiforme following BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine. Clin Exp Dermatol. 2021;46:1325-7.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , . Immune-mediated adverse reactions to vaccines. Br J Clin Pharmacol. 2019;85:2694-706.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
2,701

PDF downloads
2,761
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections