McMahon DE, Kovarik CL, Damsky W, Rosenbach M, Lipoff JB , et al.
Journal of the American Academy of Dermatology •
Cutaneous reactions after COVID-19 vaccination have been commonly reported; however, histopathologic features and clinical correlations have not been well characterized. We evaluated for a history of skin biopsy all reports of reactions associated with COVID-19 vaccination identified in an international registry. When histopathology reports were available, we categorized them by reaction patterns. Of 803 vaccine reactions reported, 58 (7%) cases had biopsy reports available for review. The most common histopathologic reaction pattern was spongiotic dermatitis, which clinically ranged from robust papules with overlying crust, to pityriasis rosea-like eruptions, to pink papules with fine scale. We propose the acronym "V-REPP" (vaccine-related eruption of papules and plaques) for this spectrum. Other clinical patterns included bullous pemphigoid-like (n = 12), dermal hypersensitivity (n = 4), herpes zoster (n = 4), lichen planus-like (n = 4), pernio (n = 3), urticarial (n = 2), neutrophilic dermatosis (n = 2), leukocytoclastic vasculitis (n = 2), morbilliform (n = 2), delayed large local reactions (n = 2), erythromelalgia (n = 1), and other (n = 5). Cases in which histopathology was available represented a minority of registry entries. Analysis of registry data cannot measure incidence. Clinical and histopathologic correlation allowed for categorization of cutaneous reactions to the COVID-19 vaccine. We propose defining a subset of vaccine-related eruption of papules and plaques, as well as 12 other patterns, following COVID-19 vaccination.
McMahon DE, Amerson E, Rosenbach M, Lipoff JB, Moustafa D , et al.
Journal of the American Academy of Dermatology •
Cutaneous reactions after messenger RNA (mRNA)-based COVID-19 vaccines have been reported but are not well characterized. To evaluate the morphology and timing of cutaneous reactions after mRNA COVID-19 vaccines. A provider-facing registry-based study collected cases of cutaneous manifestations after COVID-19 vaccination. From December 2020 to February 2021, we recorded 414 cutaneous reactions to mRNA COVID-19 vaccines from Moderna (83%) and Pfizer (17%). Delayed large local reactions were most common, followed by local injection site reactions, urticarial eruptions, and morbilliform eruptions. Forty-three percent of patients with first-dose reactions experienced second-dose recurrence. Additional less common reactions included pernio/chilblains, cosmetic filler reactions, zoster, herpes simplex flares, and pityriasis rosea-like reactions. Registry analysis does not measure incidence. Morphologic misclassification is possible. We report a spectrum of cutaneous reactions after mRNA COVID-19 vaccines. We observed some dermatologic reactions to Moderna and Pfizer vaccines that mimicked SARS-CoV-2 infection itself, such as pernio/chilblains. Most patients with first-dose reactions did not have a second-dose reaction and serious adverse events did not develop in any of the patients in the registry after the first or second dose. Our data support that cutaneous reactions to COVID-19 vaccination are generally minor and self-limited, and should not discourage vaccination.
Erythromelalgia is a rare and very difficult to treat pain syndrome that usually presents as severe bilateral burning pain in the extremities. Here we present a case of a 34-year-old female with erythromelalgia who we treated successfully with a lumbar epidural infusion of ropivacaine and fentanyl. The patient had complete relief shortly after the epidural infusion, and she remained stable with only minor pain two weeks and nine months later. With this case, we have reviewed the interventional treatments of erythromelalgia. We suggest epidural infusion as the first line interventional management, followed by sympathetic block. Spinal cord stimulation can be considered if other interventional managements fail.
Journal of clinical oncology : official journal of the American Society of Clinical Oncology •
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 40-year-old woman with a past medical history of hypertension and occasional premature ventricular contractions was found on routine blood work in June 2011 to have mild thrombocytosis, with a platelet count of 405,000. In November 2011, repeat analysis revealed a platelet count of 433,000, and by February 2012 her platelet count was 509,000. She had no evidence of leukocytosis or anemia and no symptoms of early satiety, night sweats, pruritus, or erythromelalgia. She was referred to a hematologist for evaluation of persistent isolated thrombocytosis in March 2012. Her spleen was not palpable, and a quantitative polymerase chain reaction (PCR) test for JAK2/V617F was negative. A bone marrow biopsy and aspiration revealed a mildly hypercellular marrow (70% to 80% cellularity), with an elevated myeloid:erythroid ratio of 5:1, increased megakaryocytes including micromegakaryocytes in the absence of increased blasts. Cytogenetic analysis revealed the presence of the Philadelphia chromosome translocation in 17 out of 20 metaphases. The remaining three metaphases were normal karyotype. Quantitative PCR for BCR-ABL1 yielded a value of 29.6% on the International Scale.
Erythromelalgia is an extraordinary pain syndrome first described by S. Weir Mitchell in 1878. Episodes of severe burning pain in the distal limbs, accompanied by striking redness and warmth of the skin, are precipitated by heat or activity and can be terminated only by cooling the affected part. Primary erythromelalgia is a sporadic or autosomal-dominant hereditary disorder whose symptoms begin in childhood. Secondary erythromelalgia occurs in association with thrombocythemia, collagen-vascular diseases, diabetes mellitus, peripheral neuropathy, and use of certain drugs. Aspirin is effective for patients with thrombocythemia, but most other cases are very resistant to treatment. The pathogenesis of erythromelalgia has remained puzzling, especially the peculiar switch-like manner in which symptoms are turned on by heat and turned off by cold. Following Ochoa's description of the ABC (angry backfiring C nociceptors) syndrome, it seems plausible to regard erythromelalgia as a problem of sensitized skin polymodal C-fiber receptors. C-fiber threshold to activation by heat would be lowered to 32 degrees C to 36 degrees C; activated C fibers would cause vasodilation via axon reflexes with redness, heat, and swelling. Cooling would bring the nociceptors below threshold. Secondary erythromelalgia may result from humoral factors released from platelets or ischemic tissues or from C-fiber injury in some cases of neuropathy, whereas primary erythromelalgia could be due to a mutation of the capsaicin receptor.
