key: cord-0722819-nsflioqd
authors: Bailly-Caillé, Barbara; Jouen, Fabienne; Dompmartin, Anne; Morice, Cécile
title: A Case Report of Anti-P200 Pemphigoid Following COVID-19 Vaccination
date: 2022-03-15
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2022.03.011
sha: fa64547138cfd5b7133622a8d2e16577c60e6e9c
doc_id: 722819
cord_uid: nsflioqd

nan

Anti-p200 pemphigoid is a rare autoimmune subepidermal bullous disease characterized by 46 autoantibodies to laminin γ1 (p200). A few rare cases of autoimmune bullous dermatoses, mainly 47 bullous pemphigoid, have been reported following COVID-19 vaccination. 1,2 Only one case of anti-48 p200 pemphigoid postvaccination has been reported after a pneumococcal vaccination. 3 We report a 49 case of anti-p200 pemphigoid subsequent to COVID-19 vaccination. Colchicine (1 mg/day) and daily application of a topical corticosteroid led to a significant 74 improvement after a delay of 15 days. Colchicine was stopped after 2 months because of hepatic 75 cholestasis, and the use frequency of the topical corticosteroid was decreased over 4 months. 76

Remission was sustained for 6 months after the treatment. 77 78

A broad spectrum of cutaneous adverse events has been described after mRNA COVID-19 80 vaccination, including subepidermal bullous disease such as bullous pemphigoid (BP). The most 81 frequently reported adverse effects were local injection site reactions, urticaria, morbilliform rashes, 82 and pityriasis rosea-like reactions. 2,4 It seems that after the second dose, less than 50% relapse. 5 83 Some cases of BP following COVID-19 vaccination have been described recently, 84 highlighting the potential triggering role of the mRNA COVID-19 vaccine in autoimmune 85 subepidermal bullous disease initiation. Our anti-p200 pemphigoid case seems to be different from 86 other BP cases not only by these features but also by its evolution. Indeed, the majority of described 87 BP following COVID-19 vaccination began after the second dose with a median onset on Day 7. 1 In 88 our clinical case, we noticed the first eruption 10 days after the first dose, with a more intense and 89 rapid relapse after the second dose, and remission after 6 months, corresponding with a decrease in 90 COVID-19-specific antibodies following immunization. The close temporal relationship between 91 vaccination and the onset of anti-p200 pemphigoid in our patient reinforced the potential triggering 92 role of the COVID-19 vaccine. 93

We suggest that vaccination may be the triggering factor of autoimmune subepidermal bullous 94 diseases by stimulating the immune system with an unexplained mechanism. Indeed, vaccination could 95 unmask subclinical disease defined by the presence of antibodies before clinical symptoms 6 through 96 the immunostimulatory process of the vaccine and initiate rapid lesions after the first dose. In patients 97 with more delayed kinetics, it could reflect a period of antibody production. COVID-19 vaccination is 98 the first use of mRNA vaccines in humans and additional studies will be needed to understand the 99 J o u r n a l P r e -p r o o f 

Subepidermal blistering eruptions, including 138 bullous pemphigoid, following COVID-19 vaccination

Clinical and 141 histopathological spectrum of delayed adverse cutaneous reactions following COVID-19 142 vaccination

immunoglobulin G antibodies to BP180 C-terminal domain and laminin-γ1 (p200) developed 145 after pneumococcal vaccination

Delayed Large Local Reactions to mRNA-1273

Vaccine against SARS-CoV-2

Cutaneous reactions reported after Moderna 149 and Pfizer COVID-19 vaccination: a registry-based study of 414 cases

A retrospective 152 review of autoimmune bullous disease antibody positivity before clinical symptoms

Clinical and immunological features and 155

The authors are grateful to Fabien Chaillot, Caen University Hospital, for his

potential role of COVID-19 vaccination in initiating the development of autoimmune subepidermal 100 bullous diseases. 101 Epidermolysis bullosa acquisita should be considered in the differential diagnosis, which was 102 ruled out thanks to immunoblot and by lack of autoantibodies targeting type VII collagen. The 103 diagnosis of anti-p200 pemphigoid can be challenging, as it shares clinical and histopathologic 104 characteristics with other blistering diseases. Some cases of anti-p200 pemphigoid closely looked like 105 epidermolysis bullosa acquisita, with lesions on extremities. Mucosal involvement was also described. The authors suggest that these different developments may reflect different pathophysiological 116 mechanisms: BP-like disease and BP unmasked by vaccination, which require stronger treatment. 117