Sweet syndrome induced by SARS-CoV-2 Pfizer-BioNTech mRNA
vaccine
AS Darrigade, MD1, H Théophile, MD2,
P Sanchez-Pena, MD2, B Milpied, MD1,
M Colbert4, MD, S Pedeboscq5, MD, T
Pistone6, MD, ML Jullié, MD7, J
Seneschal, MD, PhD1,3
1 : Department of Adult and Pediatric Dermatology,
Bordeaux University Hospitals, France
2 : Department of pharmacovigilancy, Bordeaux
University Hospitals, France
3 : Research Unit INSERM U1035
4 : Department of geriatry, Clinic Bordeaux Nord,
Bordeaux, France
5 : Department of pharmacology, Bordeaux University
Hospitals, France
6: Department of infectious disease, Bordeaux
University Hospitals, France
7: Department of anatomopathology, Bordeaux University
Hospitals, France
Manuscript word count: 607
Key words : sweet syndrome, SARS-CoV-2, Pfizer-BioNTech mRNA vaccine,
delayed hypersensitivity, IDR
Corresponding author: A.S. Darrigade, Dermatology Department,
Saint-André Hospital, 1, rue Jean Burguet 33000 Bordeaux, France
Phone: +33556794705
Fax: +33556794975
anne-sophie.darrigade@chu-bordeaux.fr
Funding source: No financial disclosures
Financial Disclosure: No external funding for this manuscript
To the editor,
A 45-year-old woman, without any past medical history or allergy
presented in our clinic with a rapid onset of diffuse skin eruptions.
Five days earlier, she received the first injection of the SARS-CoV-2
Pfizer-BioNTech mRNA. Concomitantly she took 1000mg paracetamol to
prevent any post-vaccination syndrome. She well tolerated the preceding
vaccines (influenza every year) before this one.
The eruption started 24h after vaccine injection and was composed at
time of the clinical exam of erythematous infiltrated papulosis located
all over the body, without face involvement (Figure 1). No other
extracutaneous symptoms were noted. Blood exams showed increased blood
count levels with increased neutrophils count (8.77G/l), hepatic
cytolysis (AST 67UI/L and ALT 116UI/l) with high level of PCR (115mg/l).
SARS-CoV-2 PCR test and serology were negative. Viral tests for EBV,
CMV, parvovirus B19, and Herpes simplex/Herpes zoster showed only a
slight EBV reactivation. Histopathological examination of the skin
biopsy showed a hyperplastic epidermis with an edematous papillary
dermis. A superficial and deep dermal perivascular, periadnexal and
interstitial dense infiltrate composed of neutrophils, eosinophils and
lymphocytes was also a feature. Leukocytoclastic vasculitis was also
seen (Figure 2A-2B). Clinical and pathological exams were compatible
with the diagnosis of SS induced by SARS-CoV-2 Pfizer-BioNTech mRNA
vaccine. Systemic steroid therapy (prednisone 0.5mg/kg/d) for five days
was started and led to rapid improvement of the skin condition without
any recurrence after treatment discontinuation. She did not receive the
second vaccine injection.
Patch-tests performed (14 days after steroid treatment stop, one month
after SS) on both on healed and normal skin with pur SARS-CoV-2
Pfizer-BioNTech mRNA vaccine prepared less than 4 hours before were
negative (Figure 1C 2-3). Then, intradermoreaction (IDR) with vaccine
diluted at 1/10 on normal skin was positive in delayed reading (Figure
1C 1). Cutaneous biopsy was realized on the positive IDR reaction,
showing an abundant inflammatory infiltrate predominantly with
lymphocytes (Figure 2C).
Cutaneous reactions after vaccine injection are rare, and
heterogenous1. They could be related to the vaccine or
the adjuvant. In addition, vaccine could trigger flares of chronic
inflammatory conditions as it was previously
reported1. At that time, minor local side effects are
reported with SARS-CoV-2 vaccines such as pain, swelling or redness;
hypersensitivity reactions were anaphylactic reaction but no severe
delayed hypersensitivity are reported2-3. Three cases
of acute febrile neutrophilic dermatosis are reported in the
international bank of WHO, one in United Kingdom, one in United States
of America and our case. Under SARS-CoV-2 Pfizer-BioNTech mRNA vaccine
four cases of vasculitis had been reported after injection. In France
one case of relapse of neutrophilic disorder was reported one day after
SARS-CoV-2 Pfizer-BioNTech mRNA vaccine. The adjuvant associated with
the SARS-CoV-2 Pfizer-BioNTech mRNA vaccine is polyethylene glycol (PEG)
20003. However our patient never received infusion
containing PEG or polysorbate before. Patch-tests with PEG or
polysorbate alone were not performed because of the negativity of the
patch-test with the SARS-CoV-2 Pfizer-BioNTech mRNA vaccine. Only 10
cases of SS induced by vaccine are published so far including: 3 with
seasonal influenza, 1 with influenza A, 2 with pneumococcal, 2
tuberculosis, 2 small pox4. SS is an acute
inflammatory skin disease associated with important infiltration of
neutrophils. Leukocytoclastic vasculitis could be present in
SS5. One case of SS in a patient receiving
pneumococcal vaccine showed the presence of dermal vasculitis associated
with infiltration of neutrophils6. In case of
anaphylactic reaction under SARS-CoV-2 Pfizer-BioNTech mRNA vaccine, the
risk of relapse with the Moderna SARS-CoV-2 mRNA vaccine or SARS-CoV-2
vaccines with an adenovirus carrier and protein subunit remains
unknown3, in case of SS even more.
To conclude we report the first case of SS induce by SARS-CoV-2
Pfizer-BioNTech mRNA vaccine confirmed by positive IDR.