Leukocytoclastic vasculitis after exposure to COVID-19 vaccine

Figure 1 Purpuric lesions on the lower limbs on the first day of hospitalization. 60-year-old female patient with a history of chronic liver isease, portal hypertension, polycythemia vera, hypothyoidism, and type 2 diabetes mellitus, presented to the mergency Section of a University Hospital reporting the ppearance of painful purpuric lesions in the lower limbs hree days before. She denied fever, chills, arthralgia, r trauma. She denied the use of new medications. She eported receiving the second dose of the COVID-19 vaccine Oxford-AstraZeneca) approximately eleven days before. he denied a similar previous clinical picture. On physical xamination, she had purpuric lesions and palpable papules, hich did not disappear on digital pressure (Figs. 1 and 2). She reported daily use of propranolol, metformin and evothyroxine. She described stability of the polycythemia era since December 2015. She was submitted to two ower-limb skin punch biopsies for histopathological analyis and immunofluorescence (IF). Prednisone (1 mg/kg/day) as started once a day. The histopathological examination howed a mixed inflammatory infiltrate with predomiantly perivascular fragmented neutrophils associated with xtravasated red blood cells (Fig. 3a--c). IF showed deposits f IgA and IgM on the walls of postcapillary vessels (Fig. 3d). he histological picture was compatible with leukocytoclasic vasculitis. The patient denied symptoms or a previous linical picture of COVID-19. The possibility of cryogloblinemia was suggested, and serum cryoglobulins were easured, which were negative. She had elevated Ceactive protein levels and leukocytosis with a leftward hift. The remaining blood count results, liver function, oagulogram, and partial urine tests were within the noral limits or compatible with the comorbidities (Table 1). fter three days of hospitalization, she showed improveent of the lower limb lesions and painful symptoms. After seven-day treatment with 60 mg prednisone, a progresive reduction was started, and she was discharged from he hospital on 40 mg/day of prednisone. Immunization is a highly important resource in the fight gainst pandemics, especially the current one caused by OVID-19. However, possible side effects have not yet been ully described. As portrayed by Cohen et al. (2021) and

A 60-year-old female patient with a history of chronic liver disease, portal hypertension, polycythemia vera, hypothyroidism, and type 2 diabetes mellitus, presented to the Emergency Section of a University Hospital reporting the appearance of painful purpuric lesions in the lower limbs three days before. She denied fever, chills, arthralgia, or trauma. She denied the use of new medications. She reported receiving the second dose of the COVID-19 vaccine (Oxford-AstraZeneca) approximately eleven days before. She denied a similar previous clinical picture. On physical examination, she had purpuric lesions and palpable papules, which did not disappear on digital pressure ( Figs. 1 and 2).
She reported daily use of propranolol, metformin and levothyroxine. She described stability of the polycythemia vera since December 2015. She was submitted to two lower-limb skin punch biopsies for histopathological analysis and immunofluorescence (IF). Prednisone (1 mg/kg/day) was started once a day. The histopathological examination showed a mixed inflammatory infiltrate with predominantly perivascular fragmented neutrophils associated with extravasated red blood cells (Fig. 3a---c). IF showed deposits of IgA and IgM on the walls of postcapillary vessels (Fig. 3d). The histological picture was compatible with leukocytoclastic vasculitis. The patient denied symptoms or a previous clinical picture of . The possibility of cryoglobulinemia was suggested, and serum cryoglobulins were measured, which were negative. She had elevated Creactive protein levels and leukocytosis with a leftward shift. The remaining blood count results, liver function, coagulogram, and partial urine tests were within the normal limits or compatible with the comorbidities (Table 1). After three days of hospitalization, she showed improvement of the lower limb lesions and painful symptoms. After a seven-day treatment with 60 mg prednisone, a progressive reduction was started, and she was discharged from the hospital on 40 mg/day of prednisone.
Immunization is a highly important resource in the fight against pandemics, especially the current one caused by COVID-19. However, possible side effects have not yet been fully    It is unclear whether the COVID-19 vaccine can reactivate or trigger autoimmune diseases. 1---4 Leukocytoclastic vasculitis has been described in a range of infections and after administration of some vaccines, such as pneumococcal, influenza, rotavirus, hepatitis A and B, HPV. 3,4 We already know that SARS-CoV-2 can cause immune system hyperactivation through cross-reactivity and molecular mimicry, 5 and it is possible that after the administration of the second dose of the vaccine, immune complexes comprising vaccine antigens and native antibodies initiated the vasculitis. 4 The temporal association between the COVID-19 vaccine and the development of the skin condition is significant. This report suggests the possibility that the COVID-19 vaccine has the potential to induce leukocytoclastic vasculitis.

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Authors' contributions
Matheus Fritzen: Statistical analysis; approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.
Gabriella Di Giunta Funchal: Statistical analysis; approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.
Mariana Oliveira Luiz: Statistical analysis; approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.
Giovanna Steffenello Durigon: Statistical analysis; approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.

Dear Editor,
PASH syndrome is a rare autoinflammatory syndrome (AIS), which consists of pyoderma gangrenosum (PG), acne conglobata and hidradenitis suppurativa (HS). 1 No standard treatment has been determined, although case reports have focused on systemic antibiotics, immunosuppressants and biologics. 2,3 A 45-year-old male presented with a 20-year history of HS on axillae and the inguinal region (Hurley stage III) ( Fig. 1A and B). He had diabetes in treatment with metformin, and chronic hepatitis B infection. A sacrococcygeal pilonidal cyst was present (Fig. 1C), as well as ice pick scars (from