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CASE REPORT
Year : 2022 | Volume
: 26
| Issue : 2 | Page : 96-98
Saudi adolescent present with new-onset vitiligo post-COVID-19 vaccination: Case report
Abdullah A Alnaim1, Amnah N Al-Mulhim2, Mohammed M Al-Momen1, Lenah Y Shaikh2
1 College of Medicine, King Faisal University, Hofuf, Saudi Arabia
2 Department of Medicine, Section of Dermatology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
Correspondence Address:
Dr. Abdullah A Alnaim
King Faisal University, Hofuf
Saudi Arabia
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jdds.jdds_35_22
Coronavirus disease of 2019 (COVID-19) is a relatively new pandemic; the first reported case was in late 2019, and the first vaccine was given in December 2020. To this date, multiple side effects have been reported with COVID-19 vaccines. Nonetheless, autoimmune (AI) diseases with the COVID-19 vaccine have rarely been associated. We described herein a case of sudden onset of vitiligo occurring after the first dose of the COVID-19 vaccine. To date, there are less than 10 reported cases of vitiligo post-COVID-19 vaccine. This report aims to recognize AI disease presentation with vaccines, specifically COVID-19.
Keywords: Autoimmune, COVID-19, vaccine, vitiligo
Coronavirus disease of 2019 (COVID-19) is a relatively new pandemic; the first reported case was in late 2019, and the first vaccine was given in December 2020. To this date, multiple side effects have been reported with COVID-19 vaccines. Nonetheless, autoimmune (AI) diseases with the COVID-19 vaccine have rarely been associated. We described herein a case of sudden onset of vitiligo occurring after the first dose of the COVID-19 vaccine. To date, there are <10 reported cases of vitiligo post-COVID-19 vaccine. This report aims to recognize AI disease presentation with vaccines, specifically COVID-19.
Case ReportWe describe the case of an 18-year-old Saudi male known to be medically free who presented with hypopigmented patches over the face and extremities about 2 weeks after receiving the first dose of COVID-19 messenger ribonucleic acid vaccine (Pfizer) [Figure 1]. Skin lesions gradually became lighter, eventually presenting with depigmented patches. The patient's medical history was unremarkable, and he did not take any medication. He had a positive family history of vitiligo in a first-degree relative (brother) and AI thyroid disease in the mother. The patient presented to our dermatology clinic 18 weeks after the first dose (1 week before the second dose) with the complaint of having multiple depigmented patches over the face, right arm, and right leg. Examination under Wood's lights showed accentuation of the patches with a chalky white color [Figure 2]. The white patches were clinically consistent with vitiligo and examination under Wood's lamp has confirmed the diagnosis. A week later (19 weeks post the first vaccine), the patient took the second dose of the COVID-19 vaccine (Moderna); the patient reported worsening of those lesions in the form of an increase in the number of existing lesions are brighter in color, and increase sizes of preexisting lesions.
Figure 1: (a) Well-demarcated bizarre-shaped depigmented patches over the right temple measuring around 5 cm in largest diameter – another circular depigmented patch over the angle of the right eye measuring around 3 cm in largest diameter. (b) Black arrow: single well-defined bizarre-shaped depigmented patch with a smooth surface measuring around 2 cm × 3.5 cm in diameter just below the sternum. Blue arrows: multiple discrete ill-defined round hypopigmented macules with smooth surface, each measuring around 0.5 cm diameter around the left nipple. (c) Multiple well-defined geographic-shaped hypopigmented macules and patches over the posterolateral side of the right leg. (d) Multiple well-defined geographic-shaped hypopigmented macules and patch with a smooth surface on the right anterior upper leg
Figure 2: Lesions under the Wood's lights show accentuation of the lesions with a chalky-white appearanceSince vitiligo is an AI disease, in addition to positive family history of AI diseases, the patient was screened for other AI conditions. All laboratories were normal apart from antinuclear antibodies which were positive (1:640).
Moreover, the patient had neck swelling noticed 1 week after receiving the first dose of the COVID vaccine persisting for 4 months not accompanied by fever, weight loss, night sweats, or cough. Systemic review at that time was unremarkable. The soft-tissue swelling was therefore investigated and found to be cervical lymph node enlargement; after further investigation, the diagnosis of nasopharyngeal carcinoma was revealed. However, we believe that it is not related to vitiligo, nonetheless, the possibility of vitiligo being triggered by an underlying neoplasm cannot be excluded although it has rarely been reported. Furthermore, an association between the neoplasm and the vaccine is undetermined.
Our patient has started on topical clobetasol propionate ointment twice daily for 2 weeks, tacrolimus twice daily for 3 months accompanied with the excimer laser, also high sun protection cream was prescribed 3 months later, [Figure 3] and [Figure 4]. During the follow-up, lesions on the face mildly improved, lesions on the chest and abdomen were the same, and there were new lesions over the left foot.
Figure 3: (a) Depigmented lesion at presentation. (b) After 3 months of treatment, the lesion is smaller in size and erythema and follicular repigmentation. (c) Depigmented lesion under Wood's light at presentation. (d) After 3 months of treatment show a decrease in size and shape of depigmentation
Figure 4: After 3-month follow-up: (a and b) new lesion has appeared. (c and d) Stable lesions with the treatment Discussion Several cases have reported a possible association between the COVID-19 vaccine and cutaneous diseases, first described a 58-year-old man presenting a week after receiving the first dose of Pfizer-BioNTech COVID-19 vaccine with symmetrically distributed white macular plaques across the face. The patient was a known case of ulcerative colitis which is maintained with azathioprine and sulfasalazine with no family history of vitiligo. After Wood's lamp examination, the diagnosis of vitiligo was confirmed.[1]
The second reported case was about a 61-year-old female presenting 3 days after the first dose of Moderna COVID-19 vaccine with very faint hypopigmented macules on the anterior neck; she did not seek treatment till she received the second dose and those lesions progressed in size and color, accompanied with new and widespread macule on other parts of the body. She has no personal or family history of vitiligo or other AI diseases. Upon Wood's lamp examination, accentuated milky-white appearance was noted which is consistent with the diagnosis of vitiligo.[2]
The third case reported is about a 33-year-old female who never had vitiligo before present 1 week after BioNTech COVID-19 vaccine with multiple white macules over the upper trunk, after Wood's lamp test, it was consistent with vitiligo.[3]
Similarly, a 67-year-old woman presented to the dermatology clinic for new onset of skin discoloration of the bilateral hands that started several months ago. Two weeks after receiving Moderna COVID-19 vaccination, the patient started to have these skin patches. Physical examination revealed multiple depigmented patches primarily located in bilaterally dorsal hands. With no significant past medical history for AI disease, no topical or systemic treatment has been used is considered to cause drug-induced vitiligo. Wood's lamp examination was consistent with the diagnosis of vitiligo.[4]
Severe adverse effects of vaccine have low-incident delayed large local reactions were most common, followed by local injection site reaction, and morbilliform eruptions urticaria, chilblain-like lesions are the main reactions. In addition, there were less common reactions which included cosmetic filler reactions, pernio/chilblains, zoster and herpes simplex flares, and pityriasis rosea-like reactions.[3],[5]
It is unknown whether AI diseases can be triggered by COVID-19 vaccination, but with the lack of explanation of how the vaccine could induce or at least contribute to autoimmunity. Genetic susceptibility may play a role in the induction of AI diseases in such cases, taking into consideration that it could be just a coincidence[3],[6]
Vitiligo is a common nonlife-threatening pigmentary disorder afflicting 0.5%–2% of the world population.[7] This could result in a significant challenge for a patient's psychosocial well-being, especially for people with darker skin whose disease could be more noticeable. Millions have received the vaccine with no adverse effects, with several cases that highlighted a possibility of such a reaction.[2],[7]
In conclusion, we present this case with the consideration of previous reports that have been published in addition to the many unrecognized nonreported adverse event, to be acquainted with the possible rare dermatologic COVID-19 vaccine reaction. Even though our patient might be genetically predisposed to AI disease, we believe that the COVID vaccine is a trigger, supported by the clinical exacerbation after the second dosage of the vaccine. Thus, patients shall be counseled regarding these possible complications. More organized studies should be done to demonstrate the potential of the COVID-19 vaccine to cause vitiligo and other dermatologic diseases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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