Chronic spontaneous urticaria after COVID-19 primary vaccine series and boosters

• DOI: 10.1016/j.jdcr.2022.05.012
• Publication Date: 2022-05-26T06:22:19Z
• Authors: Alexis Strahan; Rowanne Ali; Esther E. Freeman
• Keywords: 2019-20 coronavirus outbreak

IntroductionA range of cutaneous reactions has been reported in response to SARS-CoV-2 vaccination. Of the findings, most common ones include mild, self-limiting injection site and a morphologic spectrum vaccine-related eruptions papules plaques.1Bellinato F. Maurelli M. Gisondi P. Girolomoni G. Cutaneous adverse associated with vaccines.J Clin Med. 2021; 10: 5344https://doi.org/10.3390/jcm10225344Crossref PubMed Scopus (24) Google Scholar,2McMahon D.E. Kovarik C.L. Damsky W. et al.Clinical pathologic correlation COVID-19 vaccine including V-REPP: registry-based study.J Am Acad Dermatol. 2022; 86: 113-121https://doi.org/10.1016/j.jaad.2021.09.002Abstract Full Text PDF (45) Scholar Chronic spontaneous urticaria (CSU), also known as chronic idiopathic urticaria, is an inflammatory reaction classified by appearance waxing waning pruritic, erythematous wheals for >6 weeks. Prior reports after vaccination have focused on either acute or exacerbation previously diagnosed CSU.3Magen E. Yakov A. Green I. Israel Vinker S. Merzon BNT162b2 mRNA (Pfizer-BioNTech) against SARS-CoV-2.Allergy Asthma Proc. 43: 30-36https://doi.org/10.2500/aap.2022.43.210111Crossref (8) Scholar, 4Thomas J. Thomas Chatim Shukla Mardiney vaccine.Cureus. 13e18102https://doi.org/10.7759/cureus.18102Crossref 5Bermingham W.H. Ardern-Jones M.R. Huissoon A.P. Krishna M.T. Forewarned forearmed: potential risk effective uptake global public health.Br J 185: 838-839https://doi.org/10.1111/bjd.20495Crossref (5) Here, we describe 3 cases new-onset CSU: 1 Pfizer BNT126b2 2 Moderna messenger RNA-1273 (mRNA-1273) booster vaccine.Case 1The patient 68-year-old woman who first experienced mild pruritic eruption few days initial dose vaccine. These evanescent resolved shortly before her second dose. Four dose, she similar but more widespread consisting upper portion body. lesions progressed over weeks large urticarial plaques lower extremities, chest, abdomen. The responded favorably 6-day taper prednisone at starting 60 mg from outside provider day 18 rebounded when therapy was discontinued. pruritus improved slightly loratadine, cetirizine, famotidine. At time presentation, 7 persisted, having difficulty sleeping (Fig 1) .The dermatopathology report punch biopsy indicated interstitial perivascular infiltrate dermis abundant eosinophils consistent urticaria. Laboratory data revealed elevated immunoglobulin E levels (288 IU/mL; reference value, 0-100 IU/mL) positive spike antibody test result. Complete blood cell count, liver function panel, basic metabolic panel were all within ranges.The timing onset vaccination, dose-response (starting exacerbated dose) are suggestive vaccination-induced CSU. continued H1 H2 blockers. Omalizumab added 150 subcutaneously 4 This dosage resulted partial response. subsequently increased 300 complete clearance. elected continue omalizumab injections monthly along daily 180 fexofenadine. On this medication regimen once fexofenadine, received 8 months did not experience any flare symptoms. She intends receive recommended doses future.Case 2The 24-year-old without rash following mRNA-1273 fully resolve between doses, intensified then persisted until Ten later, Twelve booster, developed eruption. Migratory, surrounding erythema significant dermatographism 2) appeared face, back, had no medical history, history atopy medications presentation.Fig 2Case demonstrating administration dose.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The patient's significantly separate trials diphenhydramine cetirizine; however, discontinued both due side effects. Within 48 hours discontinuation, rebound appeared. began fexofenadine twice 1000 IU vitamin D daily, which controlled prescribed 20 famotidine event breakthrough pruritus, occur while therapy.Laboratory screening antinuclear antibodies (titer, 1:320; <1:80); repeat result negative (titer <1:80). markers (including C-reactive protein) erythrocyte sedimentation rate, tryptase levels, thyroid-stimulating hormone ranges.Symptom course dose-response, severity each successive concerning CSU induced Symptoms managed regularly scheduled antihistamine therapy; recurs 24 28 discontinuing medications. will treatment additional further discontinuation trials.Case 3The 31-year-old man presented his He vaccinations early 2021, experiencing transient systemic symptoms, headache, chills, fever, reaction. Eleven severely head, extending neck arms next days. night. migratory, intermittent that spontaneously could be provoked showering pressure skin. 15 palms became erythematous, painful. evaluation result.The initially 2-week oral steroids however caused discomfort. Antihistamine adjusted cetirizine 10 evening. combination minimal effect profile provided adequate symptom relief. 12 eruption, remained therapy, dermatographic interference activities sleep.DiscussionCSU clinical diagnosis recurrent lasting weeks, average 5 years adults, unknown etiology. present 0.1% population impact quality life. exact etiology remains largely unclear involves repeated activation dermal mast subsequent release vasoactive chemical mediators.6Greaves urticaria.J Allergy Immunol. 2000; 105: 664-672https://doi.org/10.1067/mai.2000.105706Abstract (413) Despite variety proposed triggers, mainstay elimination triggers use generation antihistamines. goal control comfort. Therefore, may tailored tolerance.7Bauer Dickel H. Jakob T. al.Expert consensus practical aspects urticaria.Allergo Int. 30: 64-75https://doi.org/10.1007/s40629-021-00162-wCrossref (10) If symptoms persist, E-targeting monoclonal shown success controlling persistent symptoms.8Maurer Rosén K. Hsieh H.J. al.Omalizumab urticaria.N Engl 2013; 368: 924-935https://doi.org/10.1056/NEJMoa1215372Crossref (702) ScholarCSU various well-established vaccinations, live, subunit, toxoid mean 8.4 small cohort.9Magen Shalom Waitman D.A. Kahan N.R. vaccination.Int Adv Res. 2018; 6: 1434-1439https://doi.org/10.21474/IJAR01/6574Crossref primary series described date.3Magen Scholar,4Thomas In cases, demographic variables female sex, middle age, Caucasian race.3Magen Scholar,10Pitlick M.M. Joshi A.Y. Gonzalez-Estrada Chiarella S.E. Delayed vaccination.Allergy 40-43https://doi.org/10.2500/aap.2022.43.210101Crossref (9) It worth noting these findings skewed toward those access vaccination.CSU yet studied extensively here 3. prevent (case novel. All patients able their doses. With introduction mRNA-based incidence receiving established. Patients created support groups discussion boards topic, Facebook group 4500+ members titled "Chronic Spontaneous Urticaria After Support Group," suggesting need address concerns area provide appropriate counseling.Improper classification allergy can prove detrimental achieving personal protection herd immunity. important recognize entity anaphylaxis (defined respiratory compromise, reduced pressure, swelling tongue/throat, hives exposure) does preclude completion series.In summary, rare presentations one developing recurrence third therapy. For vaccine-associated CSU, counseling options importance important. presentation.The sleep.