Case Letter
Pityriasis lichenoides et varioliformis acuta following anti-tetanus and diphtheria adult vaccine
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"etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Natália Parente" "apellidos" => "Bicudo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Mariangela Esther Alencar" "apellidos" => "Marques" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:4 [ "nombre" => "Silvio Alencar" "apellidos" => "Marques" "email" => array:1 [ 0 => "silvio.marques@unesp.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pathology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1286 "Ancho" => 855 "Tamanyo" => 137729 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">PLEVA: multiple hemorrhagic vesicles and papules with hematic crusts. Pre-treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pityriasis lichenoides (PL) is a rare cutaneous inflammatory disease of unknown etiology consisting of three clinical forms: pityriasis lichenoides et varioliformis acuta (PLEVA), pityriasis lichenoides chronica and the severe febrile Mucha-Habermann's disease.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> PL affects mainly children and young adults. There is a relationship with response to extrinsic antigens, such as medications, infections, radiocontrast and vaccines. We present a very rare report of PLEVA associated with double-dose adult vaccine.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 26-year-old male patient, previously healthy, complained of malaise, arthralgia, exanthema and 38<span class="elsevierStyleHsp" style=""></span>°C fever appearing two days after reinforcement with anti-tetanus and diphtheria adult vaccine (double-dose adult vaccine). Five days later, a dermatological examination revealed a polymorphous rash with generalized exanthema, associated with erythematous papules with adherent necrotic crusts and multiple hemorrhagic vesicles (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The remainder of the physical examination was normal. Despite the patient's past medical history of varicella the diagnostic hypotheses were of hemorrhagic varicella and PLEVA. Serologies for HIV, HBV and HCV were negative. Tzanck test did not show multinucleated giant cells.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The histopathological examination revealed necrosis of the epidermis, suggestive signals of lymphocytic vasculitis and extravasation of red blood cells, supporting the clinical diagnosis of PLEVA (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). With the diagnosis of severe PLEVA, we started treatment with prednisone 1<span class="elsevierStyleHsp" style=""></span>mg/kg/day plus potassium permanganate wet dressing. As no improvement was obtained, methotrexate (15mg/week) was added a week later. A considerable and fast improvement was observed with this regimen. In the follow-up, corticosteroid was tapered and, two months later, methotrexate was discontinued. Achieving clinical cure, although with multiple residual varioliform scars.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">PLEVA is characterized by a polymorphous eruption of erythematous macules that rapidly evolve into 2–3<span class="elsevierStyleHsp" style=""></span>mm papules, vesicles, and vesicopustular or hemorrhagic lesions, which undergo necrosis with overlapping crusts. It can result in varioliform scars. Symptoms include burning and itching. The Mucha–Habermann subtype is an intense, varicella-like, ulceronecrotic cutaneous disease associated with systemic repercussions, fever and impairment of clinical condition. Our case would be situated between the two acute subtypes of the disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">PL is caused either by an inflammatory reaction triggered by extrinsic factors or has lymphoproliferative origin, as an inflammatory response secondary to a T-cell dyscrasia; or, yet, immune complex mediated hypersensitivity vasculitis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In this case, the first hypothesis seems to be more plausible. In an extensive literature review, we found only three reports associating PLEVA with triple viral vaccine and vaccine against influenza.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–4</span></a> To the best of our knowledge, our patient is the first to show the association of PLEVA and double-dose adult vaccine. The double-dose adult vaccine is composed of a combination of diphtheria and tetanus toxoid, aluminum hydroxide or phosphate as an adjuvant, and thimerosal as a preservative, administered intramuscularly deep in the deltoid.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Treatments for PL are based on uncontrolled case series or case reports. First-line therapy includes topical corticosteroids, tetracycline, erythromycin, and various types of phototherapy. In severe and/or fulminant cases, the use of systemic corticosteroids, methotrexate or ciclosporin may be necessary.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> We emphasize the favorable response to the established therapy in this case.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Maira Renata Merlotto: Conception and planning of the study; elaboration and writing of the manuscript; review of the literature; critical review of the manuscript.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Natália Parente Bicudo: Approval of the final version of the manuscript; obtaining, analysis, and interpretation of the data; review of the literature; critical review of the manuscript.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Mariangela Esther Alencar Marques: Approval of the final version of the manuscript; obtaining, analysis, and interpretation of the data; critical review of the manuscript.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Silvio Alencar Marques: Approval of the final version of the manuscript; elaboration and writing of the manuscript; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-02-01" "fechaAceptado" => "2019-06-14" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Merlotto MR, Bicudo NP, Marques MEA, Marques SA. Pityriasis lichenoides et varioliformis acuta following anti-tetanus and diphtheria adult vaccine. An Bras Dermatol. 2020;95:259–60.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1286 "Ancho" => 855 "Tamanyo" => 137729 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">PLEVA: multiple hemorrhagic vesicles and papules with hematic crusts. Pre-treatment.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1286 "Ancho" => 855 "Tamanyo" => 135354 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">PLEVA: papulonecrotic lesions and papules with necrotic crusts. Treatment with metotrexate and systemic corticosteroids.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 642 "Ancho" => 855 "Tamanyo" => 178237 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">PLEVA: histopathological examination reveals necrosis of the epidermis, suggestive signals of lymphocytic vasculitis and large number of extravasated red blood cells (Hematoxylin & eosin, x200).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pityriasis lichenoides and its subtypes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. 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Mossa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1440-0960.2011.00781.x" "Revista" => array:6 [ "tituloSerie" => "Australas J Dermatol" "fecha" => "2012" "volumen" => "53" "paginaInicial" => "e76" "paginaFinal" => "e78" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23157791" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pityriasis lichenoides chronic after measles-mumps-rubella vaccination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D. Gil Bistes" 1 => "N. Kluger" 2 => "D. Bessis" 3 => "B. Guillot" 4 => "N. 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Weinberger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/cei.12822" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Immunol" "fecha" => "2017" "volumen" => "187" "paginaInicial" => "93" "paginaFinal" => "99" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27279025" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009500000002/v1_202004180640/S0365059620300453/v1_202004180640/en/main.assets" "Apartado" => array:4 [ "identificador" => "82769" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000002/v1_202004180640/S0365059620300453/v1_202004180640/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620300453?idApp=UINPBA00008Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 13 | 33 |
| 2024 October | 128 | 78 | 206 |
| 2024 September | 163 | 80 | 243 |
| 2024 August | 164 | 114 | 278 |
| 2024 July | 147 | 118 | 265 |
| 2024 June | 139 | 106 | 245 |
| 2024 May | 119 | 61 | 180 |
| 2024 April | 149 | 86 | 235 |
| 2024 March | 164 | 67 | 231 |
| 2024 February | 145 | 82 | 227 |
| 2024 January | 114 | 45 | 159 |
| 2023 December | 140 | 65 | 205 |
| 2023 November | 136 | 76 | 212 |
| 2023 October | 119 | 77 | 196 |
| 2023 September | 134 | 76 | 210 |
| 2023 August | 104 | 42 | 146 |
| 2023 July | 83 | 34 | 117 |
| 2023 June | 101 | 42 | 143 |
| 2023 May | 121 | 14 | 135 |
| 2023 April | 127 | 24 | 151 |
| 2023 March | 110 | 49 | 159 |
| 2023 February | 82 | 30 | 112 |
| 2023 January | 95 | 27 | 122 |
| 2022 December | 125 | 26 | 151 |
| 2022 November | 98 | 51 | 149 |
| 2022 October | 157 | 66 | 223 |
| 2022 September | 66 | 62 | 128 |
| 2022 August | 79 | 35 | 114 |
| 2022 July | 79 | 58 | 137 |
| 2022 June | 83 | 41 | 124 |
| 2022 May | 83 | 49 | 132 |
| 2022 April | 61 | 40 | 101 |
| 2022 March | 66 | 65 | 131 |
| 2022 February | 91 | 31 | 122 |
| 2022 January | 96 | 73 | 169 |
| 2021 December | 67 | 53 | 120 |
| 2021 November | 54 | 54 | 108 |
| 2021 October | 102 | 77 | 179 |
| 2021 September | 77 | 50 | 127 |
| 2021 August | 54 | 43 | 97 |
| 2021 July | 58 | 44 | 102 |
| 2021 June | 33 | 56 | 89 |
| 2021 May | 52 | 72 | 124 |
| 2021 April | 125 | 206 | 331 |
| 2021 March | 133 | 51 | 184 |
| 2021 February | 38 | 23 | 61 |
| 2021 January | 52 | 16 | 68 |
| 2020 December | 42 | 25 | 67 |
| 2020 November | 54 | 12 | 66 |
| 2020 October | 39 | 8 | 47 |
| 2020 September | 42 | 10 | 52 |
| 2020 August | 41 | 6 | 47 |
| 2020 July | 36 | 12 | 48 |
| 2020 June | 20 | 20 | 40 |
| 2020 May | 41 | 19 | 60 |
| 2020 April | 3 | 1 | 4 |
| 2020 March | 0 | 4 | 4 |
| 2020 February | 0 | 1 | 1 |
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