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Introduction
Administration of BNT162b2 mRNA COVID-19 vaccine on a large scale was performed to combat the COVID-19 pandemic. Leading to the identification of various rare but significant vaccine-associated side effects one of which is myocarditis and pericarditis post vaccination.1 There have been reports of COVID-19 vaccine-associated vasculitis, both as a new onset IgA-positive leukocytoclastic vasculitis in an otherwise healthy adult man and also a leukocytoclastic vasculitis flare in an adult woman with autoimmune conditions.2 3
Case report
Our case is a 15-year-old Indian girl presenting with bilateral lower limb rash 2 hours after second dose of BNT162b2 mRNA COVID-19 vaccination, and 1 week after her first dose. The rash started at the right medial knee before spreading to bilateral lower limbs. The maculopapular rash was purpuric, palpable and non-blanching. She also had a fever and a tender right ankle swelling (figure 1). No angioedema, no wheeze or dyspnoea was noted. The patient has a history of atopy including asthma and allergic rhinitis which was well managed without medications.
Maculopapular purpuric palpable and non-blanching rash in keeping with a vasculitic rash. Part a shows both legs, part B is a close up of the left leg while part C is a close up of the right leg.
Given the ankle arthritis, fever and a vasculitic rash, clinical suspicion was for small vessel vasculitis, clinically Henoch-Schönlein Pupura (HSP), likely triggered by the second vaccine. A series of investigations were performed (table 1). Biochemically, the most significant results were the elevated C3 1.74 g/L (0.80–1.60 g/L), erythrocyte sedimentation rate 48 mm/hour (3–15 mm/hour), C reactive protein 10.7 mg/L (0–5 mg/L). Haematologically, there was also a mild leucocytosis 10.2×109/L high (4–9.6×109/L) and a mild neutrophilia 7.42×109/L (1.90–6.6×109/L) with no disturbance in the coagulation. Renally, there was no evidence of renal impairment, however, proteinuria and a high leukocyturia was noted. Subsequent biopsy of the rashes showed evidence of a leukocytoclastic vasculitis with negative direct immunofluorescence.
Summary of patient’s investigations
After being started empirically on 90 mg ertocoxib and topical betamethasone valerate 0.1% cream, patient improved symptomatically. On review in clinic in about 2 weeks after the initial flare of the rash, the rashes have since resolved. The clinical history with the physical examination, laboratory findings and clinical response to treatment is highly suggestive of a BNT162b2 mRNA vaccine-triggered HSP.
Discussion
This is a rare case of BNT162b2 vaccine-triggered HSP which has been noted in paediatric cases.4 Though the BNT162b2 vaccine is generally safe, there have been reports of autoimmune/inflammatory complications.1 The mechanisms underlying the pathogenesis of vaccination-associated vasculitis remain unclear, although innate immunity‐mediated response to viral agents or vaccine excipients via molecular mimicry, epitope spreading, bystander activation and polyclonal activation have been proposed.5 For the vasculitis to be suggested to be vaccine linked, it should be of a relatively short, self-limited course which may occur after a latent period of about 1–2 weeks, showing a wide geographic distribution and with no alternative explanation that can be identified and in some instances shows response to immunosuppressive therapy.6 These were features seen in our case.
This report hopes to highlight to clinicians some of the potential rare complications associated with BNT162b2 vaccination. Hopefully encouraging further studies to identify the relationship between vasculitides and vaccination. Future studies can be performed to further improve the already considerable vaccine safety profile, hopefully reducing vaccine hesitancy and increasing future vaccine uptake.
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This study does not involve human participants.
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Footnotes
Contributors SW contributed to (1) concept or design, (2) acquisition of data, (3) analysis or interpretation of data, (4) drafting of the manuscript and (5) critical revision for important intellectual content. SW had full access to the data, contributed to the study, approved the final version for publication and takes responsibility for its accuracy and integrity.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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