Photo Quiz

Skin Inflammation After Immunization

 

Am Fam Physician. 2021 Jul ;104(1):81-82.

A 71-year-old patient sent a portal message through the electronic medical record with a picture showing a new rash on the arm. The patient had received the first dose of the mRNA-1273 vaccine against the SARS-CoV-2 virus, which causes COVID-19, in the affected arm about two weeks earlier. Initially, the patient had noticed a typical immune response reaction, with mild headache and muscle aches that lasted for about 48 hours. The rash developed suddenly two weeks after receiving the immunization.

On physical examination, the lateral aspect of the left upper arm was mildly warm and rough, with redness and pruritus (Figure 1). Over-the-counter hydrocortisone 1% cream provided some relief of the itching. The area was not painful, and the patient did not have a fever.

FIGURE 1


FIGURE 1

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Cellulitis.

  • B. Delayed local reaction.

  • C. Psoriasis.

  • D. Tinea corporis.

Discussion

The answer is B: delayed local reaction. Immediate injection site reactions are common following immunizations, but a delayed local reaction appears to be a phenomenon associated with the mRNA-1273 vaccine. In clinical trials for the vaccine, which is manufactured by Moderna, immediate site reactions were common (84% after the first dose), but delayed site reactions were rare (0.8% after the first dose and 0.2% after the second dose).1

Because this is a new vaccine against a novel coronavirus, there is little previous experience with possible reactions. A recent case series described 12 patients with similar delayed reactions.2 These patients developed an area of erythema and warmth around the injection site after systemic symptoms from the vaccine had resolved. Most of the rashes were large (greater than 10 cm in diameter). Patients were treated symptomatically with ice or antihistamines, and many received topical or oral corticosteroids. Symptoms resolved after a median of six days.2

This type of reaction is thought to be a delayed-type, T cell–mediated hypersensitivity. This patient questioned whether they should proceed with the second dose of the vaccine. However, neither initial nor delayed local reactions are considered contraindications to vaccination.3

Cellulitis is an infection involving the skin and underlying superficial soft

Address correspondence to Michael Grover, DO, at grover.michael@mayo.edu. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Baden LR, El Sahly HM, Essink B, et al. Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine. N Engl J Med. 2021;384(5):403–416....

2. Blumenthal KG, Freeman EE, Saff RR, et al. Delayed large local reactions to mRNA-1273 vaccine against SARSCoV-2. N Engl J Med. 2021;384(13):1273–1277.

3. Kelso JM, Greenhawt MJ, Li JT, et al. Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol. 2012;130(1):25–43.

4. Ramakrishnan K, Salinas RC, Agudelo Higuita NI. Skin and soft tissue infections. Am Fam Physician. 2015;92(6):474–483. Accessed May 17, 2021. https://www.aafp.org/afp/2015/0915/p474.html

5. Trayes KP, Savage K, Studdiford JS. Annular lesions: diagnosis and treatment. Am Fam Physician. 2018;98(5):283–291. https://www.aafp.org/afp/2018/0901/p283.html

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of Photo Quiz published in AFP is available at https://www.aafp.org/afp/photoquiz.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at https://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.

 

 

Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Sep 2021

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article