Letter - Clinical
Lipschutz’s vulvar ulcer in an adolescent after Pifzer COVID-19 vaccine
Juan-Manuel Morón-Ocaña
, Ana-Isabel Lorente-Lavirgen, Isabel-María Coronel-Pérez, María-Luisa Martínez-Barranca
Corresponding author
Department of Dermatology, Hospital Universitario Virgen de Valme, Sevilla, Spain
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Clinical</span>" "titulo" => "Lipschutz’s vulvar ulcer in an adolescent after Pifzer COVID-19 vaccine" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor,</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "125" "paginaFinal" => "126" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Juan-Manuel Morón-Ocaña, Ana-Isabel Lorente-Lavirgen, Isabel-María Coronel-Pérez, María-Luisa Martínez-Barranca" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Juan-Manuel" "apellidos" => "Morón-Ocaña" "email" => array:2 [ 0 => "juamoroca@gmail.com" 1 => "juanm.moron.sspa@juntadeandalucia.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Ana-Isabel" "apellidos" => "Lorente-Lavirgen" ] 2 => array:2 [ "nombre" => "Isabel-María" "apellidos" => "Coronel-Pérez" ] 3 => array:2 [ "nombre" => "María-Luisa" "apellidos" => "Martínez-Barranca" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Hospital Universitario Virgen de Valme, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1272 "Ancho" => 955 "Tamanyo" => 163931 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fibrinous kissing ulcers on the vulva.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Lipschütz’s acute vulvar ulceration is a non-sexually acquired condition, which is characterized by a sudden onset of a few necrotic and painful genital ulcers. Self-resolution without scarring and relapses is the usual course.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The underlying pathogenesis of vulvar aphthous ulcers is unclear. Numerous case reports have described aphthous ulcers as a dysregulated immune response associated with a variety of infections including Cytomegalovirus (CMV), influenza, mumps virus, salmonella, mycoplasma and most notably Epstein Barr Virus (EBV).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Over 334,000,000 doses of the Moderna, Pfizer and Johnson & Johnson vaccines have been administered since December 2020. Side effects are common and have been widely reported. Most of the systemic side effects after receiving the Pfizer COVID-19 vaccine as headache, fatigue, chills, diarrhea, fever and myalgias are well-known.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, skin manifestations are not as well studied.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In this brief report, the authors present the case of a patient presenting with vulvar aphthous ulcer following Pfizer COVID-19 vaccination.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 13-year-old girl, with no relevant personal history, started with fever, myalgias, and intense pain in her genitals 48<span class="elsevierStyleHsp" style=""></span>hours after having been vaccinated with the second dose of the COVID-19 vaccine (Pfizer).</p><p id="par0020" class="elsevierStylePara elsevierViewall">After being explored, fibrinous kissing ulcers were observed on the vulva (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient denied initiation of sexual intercourse and had had the menarche a year ago with regular menstruations that did not coincide with the ulcers.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Exudated cultures and PCRs for herpes viruses 1 and 2, treponema, and mycoplasma of the vulva were negative. Serological tests including HIV, Epstein Barr virus and antinuclear antibodies were also negative. The patient also presented a negative nasopharyngeal test for SARS-CoV-2 infection.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Empirical treatment with topical antibiotics and corticosteroids was started. In 15 days, the patient was reevaluated with a complete resolution of the injuries.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The case was reported to the Spanish pharmacovigilance system. According to its casualty algorithm, the vulvar ulcer was considered as possibly related to the vaccine.</p><p id="par0045" class="elsevierStylePara elsevierViewall">One of the rare side effects of the COVID-19 vaccine may be the appearance of ulcers on the vulva. In fact, among the 1,128,289 cases of adverse effects by the Pfizer COVID-19 vaccine that the pharmacovigilance database of the European Medicine Agency (eudravigilance) has reported up to 24/09/22; 47 cases were vulvar ulcers.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">If the authors compare with other vaccines against COVID-19 disease, 9 cases of vulvar ulcers have been described with the Moderna vaccine, 19 with the Astrazeneca vaccine and 1 with the Janssen vaccine up to 24/09/22.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">This is one case report to describe a potential relationship between the development of vulvar aphthous ulcers and COVID-19 vaccination. Our patient had typical clinical features of aphthous ulcer including an influenza-like prodrome and characteristic dermatologic manifestations which occurred after receiving the second dose Pfizer COVID vaccine.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Vulvar aphthous ulcers are thought to be precipitated by physiologic stress from a variety of insults, most notably viral infections. The Pfizer BioNTech (BNT162b2) COVID-19 vaccine, which our patient received, is a lipid nanoparticle-formulated nucleoside-modified mRNA that encodes the receptor binding domain of the SARS-CoV-2 spike glycoprotein. The spike glycoprotein is a popular target in COVID-19 vaccine development as it mediates the entry of SARS-CoV-2 into host cells by binding the angiotensin-converting enzyme 2 receptor.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The temporal relationship of our patient’s symptoms to Pfizer BioNTech (BNT162b2) vaccination in the context of a negative test for SARS-COV-2 RNA, as well as other infectious etiologies, suggest that her systemic symptoms and vulvar aphthous ulcer may have occurred secondary to an immune response precipitated by the vaccine.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In summary, this case highlights a potential novel association between mRNA Pfizer BioNTech (BNT162b2) COVID-19 vaccination and vulvar aphthous ulcer. One proposed mechanism for the study is to investigate how the immune system’s response to vaccination recapitulates the pro-inflammatory response associated with vulvar aphthous ulcers secondary to a viral illness.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the case of our patient, the immune response could be triggered by the virus proteins of the Pfizer COVID-19 vaccine after no other underlying cause was found.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author's contribution</span><p id="par0085" class="elsevierStylePara elsevierViewall">Juan Manuel Morón Ocaña: Preparation and writing of the manuscript; critical literature review.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Ana Isabel Lorente Lavirgen: Approval of the final version of the manuscript; manuscript critical review.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Isabel María Coronel Pérez: Approval of the final version of the manuscript; manuscript critical review.</p><p id="par0100" class="elsevierStylePara elsevierViewall">María Luisa Martínez Barranca: Approval of the final version of the manuscript; manuscript critical review.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0105" 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" => "Author's contribution" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-02-05" "fechaAceptado" => "2023-03-08" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Department of Dermatology, Hospital Universitario Virgen de Valme, Sevilla, Spain.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1272 "Ancho" => 955 "Tamanyo" => 163931 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fibrinous kissing ulcers on the vulva.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vulvar ulcers in young females: a manifestation of aphthosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 28 | 6 | 34 |
| 2024 October | 236 | 88 | 324 |
| 2024 September | 272 | 93 | 365 |
| 2024 August | 281 | 118 | 399 |
| 2024 July | 217 | 103 | 320 |
| 2024 June | 192 | 82 | 274 |
| 2024 May | 178 | 87 | 265 |
| 2024 April | 286 | 106 | 392 |
| 2024 March | 1062 | 96 | 1158 |
| 2024 February | 831 | 111 | 942 |
| 2024 January | 791 | 99 | 890 |
| 2023 December | 112 | 74 | 186 |
| 2023 November | 98 | 93 | 191 |
| 2023 October | 85 | 94 | 179 |
| 2023 September | 74 | 104 | 178 |
| 2023 August | 2 | 0 | 2 |
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