Development of Dermatomyositis after Pfizer BioNTeh COVID-19 Vaccine: A Case Report

INTRODUCTION

The Coronavirus Disease 2019 (COVID-19) pandemic led to the fast development of vaccines, which is considered a medical advance in healthcare. With the extensive vaccination campaign performed worldwide, many adverse events following immunization (AEFI) were reported. Most of them were flu-like symptoms, mild and self-limiting. However, serious adverse events, such as dermatomyositis (DM), an idiopathic autoimmune connective tissue disease, have also been reported.

CASE PRESENTATION

In this report, we describe a case of skin erythema, edema, and diffuse myalgia attributed at first to Pfizer BioNTeh, COVID-19 vaccination, given the temporal relationship and the absence of significant medical history. The causality assessment score was I1B2. However, after completing the etiological assessment, an invasive breast carcinoma was identified, and we retained the diagnosis of paraneoplastic DM.

CONCLUSION

This study underlines the importance of completing the etiological assessment before attributing any adverse reaction to vaccination to maintain optimal patient care.

Statin Associated Muscular Adverse Effects

BACKGROUND

Statins are widely used in the treatment of hyperlipidemia and in the prevention of cardiovascular diseases. However, they may induce muscular adverse effects that range from asymptomatic elevation of creatine kinase to life threatening rhabdomyolysis.

OBJECTIVE

The aim of the study was to describe epidemiological and clinical characteristics of patients with muscular adverse effects.

METHODS

We conducted a retrospective and descriptive study over a ten-year period from January 2010 to December 2019. We included all cases of statin associated muscular adverse effects notified to the Tunisian National Centre of Pharmacovigilance during this period.

RESULTS

The study involved 22 muscular adverse effects related to statins (28% of all adverse events reported with statins during this period). Patient's mean age was 58.7 years and the sex ratio was 1.6. There were 12 cases of isolated creatine kinase elevation, 5 cases of myalgia, 3 cases of myopathy, one case of myositis and one case of rhabdomyolysis. Muscular adverse effects occurred 7 days to 15 years after starting this drug. In all cases, the statin was withdrawn after muscular adverse effects and resolution of symptoms was observed within 10 days to 18 months. In seven cases, creatine kinase persisted elevated for 18 months. Involved statins were atorvastatin, simvastatin, rosuvastatin and fluvastatin.

CONCLUSION

Early recognition of muscle symptoms is required to prevent rhabdomyolysis. Further researchare needed to completely elucidate the pathophysiology of statin-induced muscular adverse effects.

Cutaneous adverse effects of antiepileptic drugs

Antiepileptic drugs (AED) are widely used in therapy. They are mainly indicated in the treatment of epilepsy and some psychiatric pathologies as well as for their analgesic action. Their cutaneous adverse effects (CAE) are common, often mild but sometimes serious. The aim of this work was to study the epidemiological and clinical features of CAE occurring in adults and elderly patients (aged over 20 years-old) and to identify the most implicated AED. We conducted a descriptive retrospective study over a period of five years from January 2017 to December 2022 about CAE of AED in adults and elderly patients notified to The National Center Chalbi Belkahia of Pharmacovigilance (Tunis,Tunisia). All cases were analyzed according to the updates French methods of imputability. We collected 71 cases of patients aged over 20 years old who presented CAE to AED. The age ranged from 20 to 79 years (mean age=44.8 years). The sex ratio F/M was 0.7. AED were indicated for neurological pathology in 70.5% of cases, for psychiatric pathology in 15.9% of cases and for their analgesic action in 12.9% of cases. Epilepsy was the first indication (51.1% of cases). The most notified CAE in our study were drug reaction with eosinophilia and systemic symptoms (DRESS syndrome; 34% of cases), maculopapular exanthema (MPE; 26% of cases), erythematous rash (8% of cases) and photosensitivity in 5% of cases. Severe cutaneous adverse reactions were accounted for 37% of all CAE. The most implicated AED were carbamazepine (52%), phenobarbital (24%) and lamotrigine (18%). However, further study with a larger number of patients and in collaboration with prescribing physicians are needed to better clarify features of CAE associated with AED intake and specify the risk factors, specific to our Tunisian population.

Erythema multiforme reactions following Pfizer/BioNTech (tozinameran) vaccination: two case-reports with positive rechallenge and review of the literature

AIM

Pfizer/BioNTech (BNT162b2) is a COVID-19 vaccine with a reassuring safety profile. The main adverse reactions are mild local reactions. Cutaneous reactions are generally minor. The most common cutaneous reaction reported was a local injection-site reaction.

CASE STUDY

Here we present 2 cases of erythema multiform (EM) following BNT162b2 vaccination with positive rechallenge. The 1st case was about a 51-year-old woman who developed 5 days after the 1st dose of the mRNA Pfizer/BioNTech (BNT162b2) a macular, erythematous, round-shaped lesions on the hands, knees and soles. She experienced a positive rechallenge one month later. In the 2nd case, a 55-year-old man presented 6 days following the 2nd shot of the mRNA Pfizer/BioNTech (BNT162b2), targetoid eruption on the upper and lower members. The patient reported that he had the same skin lesions in ankles and soles few days following the 1st shot of the same vaccine.

CONCLUSION

Few cases of EM following COVID-19 vaccination were reported in the literature and positive rechallenge in only one case. Rechallenge was not performed in most cases. Our two cases are particular because of the positive rechallenge in both patients. This is the gold standard to confirm that the vaccine was the culprit agent in inducing EM.

Guillain-Barré syndrome after COVID-19 vaccines: A Tunisian case series

As the COVID-19 vaccination campaign progresses worldwide, Guillain-Barré syndrome (GBS) vaccine-related cases have been reported. We carried out a retrospective, descriptive study of GBS patients following COVID-19 vaccine, submitted to the National Pharmacovigilance Center of Tunis during the period between March 2021 and May 2022. Our study aimed to identify epidemiological and clinical features of COVID-19 vaccine-associated GBS. We found 9 cases of GBS post COVID-19 vaccination; 5 of them were excluded due to the lack of information, whereas 4 cases were included in this study. Men represented 75% (3/4) of the cases. The most frequently reported vaccine type was ChAdOx1 nCoV-19 vaccine (n = 2 reports [50%]), Ad26.COV2.S vaccine and BNT162b2 vaccine in 1. The mean time interval from vaccination to symptom onset was 15.3 days. Clinical manifestations were different: classical GBS in two cases and GBS with unilateral facial palsy in the other 2 cases. All patients were treated with a course of intravenous immunoglobulin for 5 days. Three patients reported clinical improvement while one case (25%) showed treatment-related fluctuations. Our observations suggest that COVID-19 vaccines may be associated with GBS. Continuous surveillance and further studies are warranted to assess the significance of the association.

DRESS Syndrome Associated with Liposomal Amphotericin-B in a Kidney Transplant Patient: A Case Report

INTRODUCTION

Liposomal amphotericin B is a widely used broad-spectrum antifungal drug. It was developed to reduce nephrotoxicity and maximize the therapeutic utility of amphotericin B in the treatment of invasive fungal infections. Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a severe drug-induced hypersensitivity syndrome commonly associated with aromatic antiepileptic drugs. Liposomal amphotericin-B was associated with DRESS syndrome in only one case.

CASE REPORT

We report an exceptional case of possible DRESS syndrome associated with liposomal amphotericin B in a 31-year-old male renal transplant recipient. Seventeen days after starting liposomal amphotericin B for visceral leishmaniosis, he developed a skin rash with elevated liver tests. Liposomal amphotericin B was then discontinued. A favourable outcome was slowly observed in one month.

RESULTS AND CONCLUSION

This case scored two (possible case) based on the criteria adopted by the European group RegiSCAR. The Naranjo score for liposomal amphotericin B was four (possible).

Myocarditis following Coronavirus vaccination

Introduction

Myocarditis is an adverse reaction discovered after the marketing of SARS-CoV-2 mRNA vaccines. Nevertheless, this effect is not mentioned as an adverse reaction in the summary of product characteristics of other types of vaccines against this disease.

Objective

In this work, we aim to present the cases of myocarditis after vaccination against COVID-19 reported to the national Tunisian centre of pharmacovigilance.

Method

We present the cases of myocarditis reported after the COVID-19 vaccination. All cases are diagnosed according to Brighton's case definition of myocarditis. The vaccines causality assessment was estimated by the French imputability updated method of Bégaud et al.

Results

We included five patients. The sex ratio (M/F) was 4. The mean age was 30 years. All patients had no notable cardiovascular history and did not report any significant past medical history. The onset of symptoms was two days post-vaccination in three patients. The predominant reported symptoms are chest pain and dyspnea in the five cases. Cardiac magnetic resonance imaging (MRI) confirmed the myocarditis diagnosis in four patients (not performed for one patient).All cases were classified as definitive cases according to the Brighton case definition of myocarditis. No patient required hospitalization in a cardiac intensive care unit. All the patients recovered from acute myocarditis within a few days.

Conclusion

Reported cases of myocarditis post-COVID-19 vaccination in our population are rare, not severe, and have a quick favorable outcome.

Seizures after vaccines

Immunization plays an important role in achieving global health goals. Thus, vaccination is one of the essential means of preventing infectious and viral diseases. The onset of adverse events following immunization (AEFI) is common and most of the time it is a mild effect. However, stimulating the immune system during critical periods of brain development can lead to neurological effects. Among the neurological effects, we were interested in this work by seizures appearing following vaccination.

Hand-foot syndrome induced by chemotherapy drug: Case series study and literature review

INTRODUCTION

Chemotherapy drugs can be responsible of several side effects such as hand-foot syndrome (HFS). This syndrome is also called "palmar-plantar erythrodysesthesia" and "acral erythema." Without proper management, it can deteriorate the quality of life of a patient, leading to temporary or definitive stop of chemotherapy.

AIM OF THIS STUDY

To identify the epidemiological and clinical characteristics of patients, the risk factors for occurrence and worsening of this syndrome, and the drugs most likely to be responsible of HFS.

METHODS

Our study was retrospective, including 42 patients with HFS secondary to a chemotherapy drug. These cases were notified to the National Center of Pharmacovigilance over 7 years. The severity of HFS has been classified according to the NCI-CTCAE v4.0 classification.

RESULTS

Our population was composed of 40 women and 2 men. The mean age was 51 years. Docetaxel was the main drug associated with this adverse effect. Hands were involved in all cases and were sometimes associated with other skin surfaces apart from feet. Erythema of the hands and/or feet was present in all patients; it was associated with edema in more than half of the cases. The distribution of different grades according to the NCI-CTCAE classification among the patients was almost equal: 28% Grade 1, 36% Grade 2, and 36% Grade 3. HFS occurred mainly after the first course of chemotherapy with a mean period of 3-4 days. The regression of HFS occurred more rapidly for Grade 1 and Grade 2 compared with Grade 3, especially when assisted by symptomatic treatment. The recurrence rate of HFS for those patients with decreased doses, spacing of cures, and/or symptomatic and prophylaxis treatment was 25%.

CONCLUSION

An early detection of HFS, associated with preventive measures, enables patients to continue the chemotherapy.

Skin tests for the exploration of hypersensitivity reactions associated with iodinated contrast media

BACKGROUND

Iodinated contrast media (ICM) are responsible for multiple side effects, especially hypersensitivity reactions. These reactions can either be authentic allergies, or non-allergic hypersensitivity reactions. Skin tests (prick and intradermal tests) are simple to perform and can be of great help, especially if the ICM need to be re-used. The aim of the study was to assess the characteristics of the patients in whom skin tests were performed, and the results of these tests.

METHODS

This is a retrospective study from June 2014 to June 2019. All included patients had at least one episode of hypersensitivity reaction to ICM and underwent skin tests.

RESULTS

We included 35 patients aged 18 to 85 years. The iopromide was the most implicated ICM. The reactions were mainly cutaneous (n=30) and immediate (n=27). The skin tests were negative, except for two patients. The reuse of ICM occured in 11 patients: 9 with an ICM other than the one suspected and two patients with the same ICM. Among these patients, 5 did not have any premedication. Two of them had a second hypersensitivity reaction, the first with another ICM and the second with the same ICM.

CONCLUSION

One of the main pillars of allergic exploration is ICM skin testing, not only to prevent recurrence, but also to allow patients to benefit from ICM reuse, which are sometimes essential.

Drug reaction with eosinophilia and systemic symptoms in pediatric patients: A clinicopathological study of 16 cases in the National Center of Pharmacovigilance of Tunisia

INTRODUCTION

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse drug reaction (SCAR) that can affect the pediatric population. However, data on its characteristics in this age group are limited. This study aims to evaluate clinical and pathological features of cases of DRESS in children reported to the national center of pharmacovigilance of Tunisia.

METHODS

We conducted a descriptive retrospective study on the cases of children with DRESS reported to the National Center of Pharmacovigilance of Tunisia between January 2011 and December 2017. We used for the diagnostic the criteria suggested by the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR).

RESULTS

There were 16 patients with a diagnosis of DRESS. Mean age was six years. The most common offending drugs were anticonvulsants (68.75%). The mean latency period from using the culprit drug to the onset of drug reaction was 21 days. Skin lesions and internal organ involvement were present in all patients. Hepatitis was the most common visceral involvement. Eosinophilia (>1500 cells/μL) was present in 10 patients (62.5%). The outcome was favorable for all patients after drug withdrawal and symptomatic treatment.

CONCLUSION

Clinical features of DRESS in Tunisian children provide clinical information that could be useful for the early detection and the outcome improvement of this severe adverse reaction.

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) Syndrome Induced by Imatinib

INTRODUCTION

Imatinib is the treatment of choice in patients with locally advanced or metastatic gastrointestinal stromal tumours (GIST). Clinical tolerance of imatinib is excellent except for the common adverse drug reaction (ADR). Drug rash with eosinophilia and systemic symptoms (DRESS syndrome) is a severe, potentially life-threatening drug-induced hypersensitivity reaction, characterized by cutaneous eruptions, fever, diffuse lymphadenopathy, along with eosinophilia, and elevated liver function tests. This ADR is rarely reported with imatinib. Only four cases of DRESS syndrome associated with imatinib have already been published.

CASE REPORT

We report an exceptional case of DRESS syndrome associated with imatinib in a 46 year-old woman with GIST. Two weeks after she had started imatinib therapy, she developed a skin rash, with eosinophilia and elevated liver tests. Plasma level of imatinib was within the therapeutic range. Imatinib was immediately discontinued. A favourable outcome was slowly observed after the drug had been stopped.

RESULTS AND CONCLUSION

This case was scored three according to the European Registry of Severe Cutaneous Adverse Reactions Study Group (RegiSCAR). The Naranjo score for imatinib was five (probable).

Plantar Psoriasis Associated with Olmesartan

BACKGROUND

Psoriasis is a chronic inflammatory skin disorder that may be initiated or exacerbated by some drug intakes. Some of the most common medications known to trigger or worsen existing psoriasis include lithium, gold salts, beta blockers and antimalarials.

CONCLUSION

We report an exceptional case of plantar psoriasis in a woman who was treated by olmesartan for 3 years.

Eyelid and feet edema induced by pemetrexed

Pemetrexed is an anti-metabolite that targets multiple enzymes in folate pathway. The main toxicities associated with pemetrexed are asthenia, nausea, diarrhea, myelosuppression, and rash. Few cases of pemetrexed induced cutaneous adverse event have been reported, mainly periorbital-facial edema and edema of the limbs. We report a case of pemetrexed-induced edema of the eyelid and feet in a patient with adenocarcinoma of the lung.

Hydroxychloroquine-induced acute generalized exanthematous pustulosis with positive patch-testing

Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction, mostly induced by drugs. Hydroxychloroquine have been rarely reported in literature as a causative drug of this reaction. We report a case of AGEP induced by hydroxychloroquine with systemic involvement and confirmed by positive patch testing.

Probable disseminated BCG infection in a 10-month-old child after BCG vaccination

The disseminated BCG infection is a rare and serious complication of bacillus Calmette-Guerin (BCG) vaccine. We report a case of probable disseminated BCG infection in a 10-month-old child who had been vaccinated by BCG vaccine at birth. No incident was noted on the first days of vaccination. At the age of 40 days, she developed left supra clavicular and axillar abcessed lymph nodes. She was treated by surgical flattening of the lymph adenopathy. The same lymph node recurred at the age of 6 months and was treated with surgery. Few weeks after the second episode, cutaneous ulcerative lesions appeared. Cutaneous biopsy was performed and showed lesions compatible with tuberculosis. X-rays showed osteolysis of P1 of the middle finger in the left hand. She was treated by anti-tuberculosis antibiotics.

Bullous Eruption Associated With Dihydropyridines With Cross Reactivity

The spectrum of cutaneous eruptions associated with dihydropyridines is extensive, varying from exanthemas to severe adverse events. We report a case of bullous eruption, one month after starting nicardipine and lercanidipine. The same symptoms recurred few days after taking nitrendipine.

Facial hyperpigmentation during imatinib therapy for gastrointestinal stromal tumor

We report a rare case of facial hyperpigmentation during imatinib therapy for a gastrointestinal stromal tumor.

[Fixed pigmented erythema antihistamine H1: about 2 cases and review of the literature]

We describe two cases of fixed drug eruptions induced by pheniramine (1(st) case) and loratadine (2(nd) case).

Lichen associated with metformin

We report an exceptional case of bullous lichen induced by metformin in a patient with diabetes mellitus.

Meprobamate-induced fixed drug eruption

Meprobamate is usually a safe drug prescribed for anxiety disorders. Fixed drug eruption (FDE) is an exceptional cutaneous adverse effect of this drug. We report a case of FDE induced by meprobamate with positive patch test. A 22-year-old woman was prescribed for depression meprobamate, aceprometazine, valpromide and lorazepam. On the second day of treatment, the patient presented red erythematous and pruriginous plaques in the limbs and the face. After stopping the previous treatment, the patient's lesions resolved completely within 3 weeks with residual pigmentation. One month later, patch tests were performed and were positive to meprobamate. Exceptional cases of FDE were reported in literature with meprobamate. None has reported the use of patch test to confirm the diagnosis.

Cardiac arrhythmia induced by interferon beta-1a

Cardiac adverse effects have never been reported with interferon (INF) beta. We report a case of left bundle branch block in a 35-year-old woman treated with INF beta-1a for multiple sclerosis. Five years after INF therapy, she presented loss of consciousness, retrosternal pains, short breath and lowered tolerance of effort. ECG and Holter 24-h ECG monitoring revealed permanent complete left bundle branch block. Nine months after stopping INF, no abnormalities were found at ECG and echocardiogram examination.

Fatal liver injury associated with clopidogrel

Clopidogrel, an adenosine diphosphate receptor blocker, is widely used as an adjunctive antiplatelet therapy in acute coronary syndrome and percutaneous coronary stenting. It appears to be a safe drug with few occurrences of liver side-effects that usually resolved after drug withdrawal. We report a serious liver injury with fatal outcome in a 63-year-old man developed 19 days after starting clopidogrel for percutaneous coronary stenting.

[Photosensitivity induced by metformin: a report of 3 cases]

BACKGROUND

Metformin is an oral antihypoglycemic drug. Its cutaneous side effects are rare and photosensitivity had not been reported.

AIM

Case report.

CASE REPORT

We report 3 cases (a man and two women) of photosensitivity induced by metformin, notified to the Tunisian National Centre of Pharmacovigilance. Onset of the reaction was respectively 22 days, 4 months and 4 years. Daily dose of metformin varied from 1 to 2 tablets. Cutaneous lesions were located in sun-exposed sites in all cases with extension to the back in one case. Lesions were eczematous in two cases and erythematous in one case. Lesions healed after stopping metformin in all cases with positive rechallenge in the 1st case.

CONCLUSION

In patient treated by metformin, occurrence of photosensitivity can be related to this drug.

Recurrent dysosmia induced by pyrazinamide

Pyrazinamide can have adverse effects such as hepatic toxicity, hyperuricemia or digestive disorders. In rare cases, alterations in taste and smell function have been reported for pyrazinamide when combined with other drugs. We report a case of reversible olfactory disorder related to pyrazinamide in a woman, with a positive rechallenge. The patient presented every day a sensation of smelling something burning 15 min after drug intake. Dysosmia disappeared completely after pyrazinamide withdrawal and recurred after its rechallenge. The case was reported to the Tunisian Centre of Pharmacovigilance.