Case Letter
Is there a link between guttate psoriasis and SARS-CoV-2? A series of three cases
Cláudia Brazãoa,
, Miguel Alpalhãoa,b,c, Marta Aguado-Loboa, Joana Antunesa,b, Luís Soares-de-Almeidaa,b,c, Paulo Filipea,b,c
Corresponding author
a Dermatology and Venereology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
b Dermatology and Venereology University Clinic, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
c Dermatology Research Unit, iMM João Lobo Antunes, University of Lisbon, Lisbon, Portugal
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Série de três casos" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "271" "paginaFinal" => "273" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 678 "Ancho" => 1505 "Tamanyo" => 119718 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Psoríase gutata e exacerbação de psoríase crônica em placas (caso 1). (A), Placas eritematosas semelhantes a gotas de psoríase gutata e placas eritematosas escamosas no tronco. (B), Placas eritematosas semelhantes a gotas de psoríase gutata nos membros superiores. 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(B) Guttate psoriasis drop-like erythematous plaques on the upper limbs; (C) Scaly erythematous plaques on the elbows.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Guttate psoriasis (GP) is an acute form of psoriasis that is associated with bacterial infections, mainly streptococcal, which cause superantigen-induced immune activation.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Viral upper respiratory infections may also be implicated, typically occurring two to three weeks before the onset of guttate lesions.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report three cases of GP following Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and BNT162b2 mRNA vaccine.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 42-year-old caucasian male with a history of chronic plaque psoriasis developed multiple erythematous scaly papules and plaques on the face, trunk, upper and lower limbs, and scaly erythematous plaques over the elbows and knees (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), one week after he was diagnosed with Coronavirus Disease 2019 (COVID-19). We established a clinical and histopathological (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) diagnosis of GP and a flare of plaque psoriasis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A 32-year-old caucasian female with a history of chronic plaque psoriasis developed multiple erythematous scaly papules and plaques on the trunk, upper and lower limbs, as well as scaly erythematous plaques over the elbows and knees (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), two weeks after she was diagnosed with COVID-19. We established a clinical diagnosis of GP and a flare of plaque psoriasis.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A 45-year-old caucasian male with a history of chronic plaque psoriasis presented with multiple erythematous scaly papules and small plaques on the trunk and upper limbs, one week following the first dose of COVID-19 BNT162b2 mRNA vaccine, with worsening after the second dose. A clinical diagnosis of GP was made.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The correlation between psoriasis and infection is well established, and viruses are recognized triggers. In one study of viral respiratory infections causing psoriasis flares, coronavirus was one of the most frequently detected pathogens.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">SARS-CoV-2 spike (S) protein exhibits a high-affinity motif for T-Cell Receptors (TCR) and may form a ternary complex with Major Histocompatibility Complex type 2 (MHC-II). Its binding epitope harbors a sequence motif that is very similar in sequence and structure to bacterial superantigens.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore, SARS-CoV-2 may favor psoriasis through superantigen modulation of the adaptive immune response. In fact, analysis of COVID-19 patients demonstrates that they exhibit TCR arrangements consistent with superantigen activation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> S protein may cause activation and polyclonal expansion of T-cells in the upper respiratory tract (namely the tonsils), causing them to differentiate and migrate to cutaneous tissue after acquiring skin-homing capacity through increased expression of Cutaneous Lymphocyte Antigen (CLA).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> These mechanisms may contribute to the inflammatory imbalance that underlies the pathophysiology of psoriasis, particularly acute forms such as GP.</p><p id="par0040" class="elsevierStylePara elsevierViewall">BNT162b2 COVID-19 vaccine consists of nucleoside-modified mRNA encoding the full-length spike protein, which will be massively produced and expressed on the surface of host cells, mimicking the structure and expression of the wild-type S protein during natural infection.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Thus, it is expected that the host immune responses to the vaccine will be similar to those during natural infection, explaining, through the abovementioned mechanism, how this vaccine could lead to acute forms of psoriasis in the absence of actual infection.</p><p id="par0045" class="elsevierStylePara elsevierViewall">These clinical cases demonstrate the importance of cutaneous abnormalities in patients with COVID-19, as well as possible dermatologic events in patients undergoing vaccination, and shed light on the potential immunologic underlying mechanisms.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Cláudia Brazão: Approval of the final version of the manuscript; critical literature review; data collection, analysis, and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; critical manuscript review; preparation and writing of the manuscript; study conception and planning.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Miguel Alpalhão: Approval of the final version of the manuscript; critical literature review; data collection, analysis, and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; critical manuscript review; preparation and writing of the manuscript; study conception and planning.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Marta Aguado-Lobo: Approval of the final version of the manuscript; critical literature review; data collection, analysis, and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; critical manuscript review; preparation and writing of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Joana Antunes: Approval of the final version of the manuscript; critical literature review; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; critical manuscript review; preparation and writing of the manuscript; study conception and planning.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Luís Soares-de-Almeida: Approval of the final version of the manuscript; critical literature review; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; critical manuscript review; preparation and writing of the manuscript; study conception and planning.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Paulo Filipe: Approval of the final version of the manuscript; Critical literature review; Data collection, analysis, and interpretation; Effective participation in research orientation; Intellectual participation in propaedeutic and/or therapeutic management of studied cases; Manuscript critical review; preparation and writing of the manuscript; Study conception and planning.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0085" 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" => "2021-05-21" "fechaAceptado" => "2021-07-16" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Dermatology and Venereology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1129 "Ancho" => 2507 "Tamanyo" => 257464 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Guttate psoriasis and chronic plaque psoriasis flare (case 1): (A) Guttate psoriasis drop-like erythematous plaques and scaly erythematous plaques on the trunk; (B) Guttate psoriasis drop-like erythematous plaques on the upper limbs; (C) Scaly erythematous plaques on the elbows.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1882 "Ancho" => 2507 "Tamanyo" => 933283 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Guttate psoriasis histopathologic aspects (case 1) (Hematoxylin & eosin ×100): Psoriasiform hyperplasia of the epidermis, featuring neutrophils overlying continuous parakeratosis and intracorneal micro-abscesses; absence of stratum granulosum; papillomatosis with vascular hyperplasia and perivascular lymphocytic infiltrate in the superficial dermis.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1905 "Ancho" => 2507 "Tamanyo" => 275202 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Guttate psoriasis and chronic plaque psoriasis flare (case 2): (A) Guttate psoriasis drop-like erythematous papules and plaques on the upper limbs; (B) Guttate psoriasis erythematous plaques on the upper limbs and erythematous scaly plaques on the elbows.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and Management of Cutaneous Psoriasis: A Review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 23 | 14 | 37 |
| 2024 October | 171 | 88 | 259 |
| 2024 September | 206 | 106 | 312 |
| 2024 August | 254 | 132 | 386 |
| 2024 July | 285 | 124 | 409 |
| 2024 June | 219 | 117 | 336 |
| 2024 May | 178 | 78 | 256 |
| 2024 April | 233 | 95 | 328 |
| 2024 March | 250 | 96 | 346 |
| 2024 February | 247 | 99 | 346 |
| 2024 January | 165 | 68 | 233 |
| 2023 December | 204 | 62 | 266 |
| 2023 November | 489 | 143 | 632 |
| 2023 October | 474 | 90 | 564 |
| 2023 September | 344 | 120 | 464 |
| 2023 August | 598 | 109 | 707 |
| 2023 July | 361 | 57 | 418 |
| 2023 June | 13112 | 67 | 13179 |
| 2023 May | 400 | 46 | 446 |
| 2023 April | 254 | 46 | 300 |
| 2023 March | 338 | 70 | 408 |
| 2023 February | 211 | 46 | 257 |
| 2023 January | 203 | 59 | 262 |
| 2022 December | 522 | 43 | 565 |
| 2022 November | 262 | 74 | 336 |
| 2022 October | 391 | 81 | 472 |
| 2022 September | 252 | 87 | 339 |
| 2022 August | 284 | 78 | 362 |
| 2022 July | 295 | 75 | 370 |
| 2022 June | 289 | 98 | 387 |
| 2022 May | 300 | 80 | 380 |
| 2022 April | 245 | 114 | 359 |
| 2022 March | 265 | 100 | 365 |
| 2022 February | 110 | 57 | 167 |
| 2022 January | 80 | 79 | 159 |
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