A young patient presents with a fever and rash: Is this an adverse effect of the mRNA vaccine, vasculitis, or rickettsiosis?

Abstract

The aetiology may be complex in patients presenting with fever and rash. The differential diagnosis may include coronavirus disease 2019 (COVID-19) infection, an adverse effect of the COVID-19 vaccine, infection, and vasculitis. We reported a patient who presented with fever and vasculitic rash, which we hypothesized was an adverse vaccine effect. A 35-year-old male patient presented to the emergency department reporting headache, fever, rash, weakness, and myalgia. The first dose of the mRNA vaccine, COVID-19, had been administered five days before his presentation. A nasopharyngeal severe acute respiratory syndrome coronavirus two-challenge test was negative. Antinuclear antibody, antineutrophil cytoplasmic antibody, rheumatoid factor, and cryoglobulin were negative. No hypocomplementemia was detected. Skin biopsy was predominantly lymphocytic, with a vasculitic reaction with a few neutrophils. The Rickettsia conorii immunoglobulin M test examined using enzyme-linked immunosorbent assay (ELISA) was positive. COVID-19 should be excluded in patients with fever, rash, and headache. Symptoms that occur after vaccination may indicate adverse reactions. Even though we are in the pandemic phase, rickettsiosis should not be forgotten. Key Points • COVID-19 is suspected first in the patient who applied to the emergency department with the complaints of fever and maculopapular rash during the pandemic era. • Although the COVID-19 vaccine is widely used, possible side effects of the vaccine may raise doubts among physicians and patients. • The preliminary diagnosis of a patient with a vasculitic rash who complains of fever and myalgia should be thought to be Rickettsiosis.

Keywords

• mRNA vaccine
• vasculitis
• rickettsiosis
• fever
• rash

References

1. COVID-19 coronavirus pandemic. Avaliable at: https://www.worldometers.info/coronavirus/. Accessed 22 October, 2021.
2. Elrobaa IH, New KJ. COVID-19: Pulmonary and extra pulmonary manifestations. Front Public Health. 2021 Sep 28;9:711616. doi: 10.3389/fpubh.2021.711616.
3. Almutairi N, Schwartz RA. COVID-19 with dermatologic manifestations and implications: An unfolding conundrum. Dermatol Ther. 2020 Sep;33(5):e13544. doi: 10.1111/dth.13544.
4. Mittal A, Elias ML, Schwartz RA, Kapila R. Recognition and treatment of devastating vasculopathic systemic disorders: Coronavirus disease 2019 and rickettsioses. Dermatol Ther. 2021 Jul;34(4):e14984. doi: 10.1111/dth.14984.
5. Muzumdar S, Rothe MJ, Grant-Kels JM. The rash with maculopapules and fever in adults. Clin Dermatol. 2019 Mar-Apr;37(2):109-18. doi: 10.1016/j.clindermatol.2018.12.004.
6. Anderson CW, Shah PA, Roberts JR. Adult-onset Still’s disease: Is this truly a diagnosis of exclusion? Hawaii J Med Public Health. 2017 Nov;76(11 Suppl 2):3-6.
7. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun. 2020 May;109:102433. doi: 10.1016/j.jaut.2020.102433.
8. Galván Casas C, Català A, Carretero Hernández G, Rodríguez-Jiménez P, Fernández-Nieto D, Rodríguez-Villa Lario A, Navarro Fernández I, Ruiz-Villaverde R, Falkenhain-López D, Llamas Velasco M, García-Gavín J, Baniandrés O, González-Cruz C, Morillas-Lahuerta V, Cubiró X, Figueras Nart I, Selda-Enriquez G, Romaní J, Fustà-Novell X, Melian-Olivera A, Roncero Riesco M, Burgos-Blasco P, Sola Ortigosa J, Feito Rodriguez M, García-Doval I. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. 2020 Jul;183(1):71-7. doi: 10.1111/bjd.19163.

9. Cohen SR, Prussick L, Kahn JS, Gao DX, Radfar A, Rosmarin D. Leukocytoclastic vasculitis flare following the COVID-19 vaccine. Int J Dermatol. 2021 Aug;60(8):1032-3. doi: 10.1111/ijd.15623.
10. World Health Organization. Coronavirus diseaese (COVID-19) pandemic [Internet]. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019?gclid=Cj0KCQjwnoqLBhD4ARIsAL5JedKWHzI1FP1nJxgYfvBgqnPcPJ-vL7KzKDjn8TOtkyjlr9wlIu--5SgaAlgWEALw_wcB. Accessed 25 October, 2021.
11. Soleimanpour S, Yaghoubi A. COVID-19 vaccine: where are we now and where should we go? Expert Rev Vaccines. 2021 Jan;20(1):23-44. doi: 10.1080/14760584.2021.1875824.
12. Coronavirus (COVID-19) Vaccinations [Internet]. Available at: https://ourworldindata.org/covid-vaccinations?country=TUR. Accessed 25 October, 2021.
13. Centers for Disease Control and Prevention-Safety of COVID-19 Vaccination [Internet]. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/safety-of-vaccines.html. Accessed 25 October, 2021.
14. Fritzen M, Funchal GDG, Luiz MO, Durigon GS. Leukocytoclastic vasculitis after exposure to COVID-19 vaccine. An Bras Dermatol. 2022 Jan-Feb;97(1):118-21. doi: 10.1016/j.abd.2021.09.003.
15. Bostan E, Gulseren D, Gokoz O. New-onset leukocytoclastic vasculitis after COVID-19 vaccine. Int J Dermatol. 2021 Oct;60(10):1305-6. doi: 10.1111/ijd.15777.
16. Walker DH, Ismail N. Emerging and re-emerging rickettsioses: endothelial cell infection and early disease events. Nat Rev Microbiol. 2008 May;6(5):375-86. doi: 10.1038/nrmicro1866.
17. Bechelli JR, Rydkina E, Colonne PM, Sahni SK. Rickettsia rickettsii infection protects human microvascular endothelial cells against staurosporine-induced apoptosis by a cIAP (2)-independent mechanism. J Infect Dis. 2009 May 1;199(9):1389-98. doi: 10.1086/597805.
18. Brouqui P, Parola P, Fournier PE, Raoult D. Spotted fever rickettsioses in southern and eastern Europe. FEMS Immunol Med Microbiol. 2007 Feb;49(1):2-12. doi: 10.1111/j.1574-695X.2006.00138.x.
19. Antón E, Font B, Muñoz T, Sanfeliu I, Segura F. Clinical and laboratory characteristics of 144 patients with mediterranean spotted fever. Eur J Clin Microbiol Infect Dis. 2003 Feb;22(2):126-8. doi: 10.1007/s10096-002-0879-x.