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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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 20 | 13 | 33 |
| 2024 Outubro | 128 | 78 | 206 |
| 2024 Setembro | 163 | 80 | 243 |
| 2024 Agosto | 164 | 114 | 278 |
| 2024 Julho | 147 | 118 | 265 |
| 2024 Junho | 139 | 106 | 245 |
| 2024 Maio | 119 | 61 | 180 |
| 2024 Abril | 149 | 86 | 235 |
| 2024 Março | 164 | 67 | 231 |
| 2024 Fevereiro | 145 | 82 | 227 |
| 2024 Janeiro | 114 | 45 | 159 |
| 2023 Dezembro | 140 | 65 | 205 |
| 2023 Novembro | 136 | 76 | 212 |
| 2023 Outubro | 119 | 77 | 196 |
| 2023 Setembro | 134 | 76 | 210 |
| 2023 Agosto | 104 | 42 | 146 |
| 2023 Julho | 83 | 34 | 117 |
| 2023 Junho | 101 | 42 | 143 |
| 2023 Maio | 121 | 14 | 135 |
| 2023 Abril | 127 | 24 | 151 |
| 2023 Março | 110 | 49 | 159 |
| 2023 Fevereiro | 82 | 30 | 112 |
| 2023 Janeiro | 95 | 27 | 122 |
| 2022 Dezembro | 125 | 26 | 151 |
| 2022 Novembro | 98 | 51 | 149 |
| 2022 Outubro | 157 | 66 | 223 |
| 2022 Setembro | 66 | 62 | 128 |
| 2022 Agosto | 79 | 35 | 114 |
| 2022 Julho | 79 | 58 | 137 |
| 2022 Junho | 83 | 41 | 124 |
| 2022 Maio | 83 | 49 | 132 |
| 2022 Abril | 61 | 40 | 101 |
| 2022 Março | 66 | 65 | 131 |
| 2022 Fevereiro | 91 | 31 | 122 |
| 2022 Janeiro | 96 | 73 | 169 |
| 2021 Dezembro | 67 | 53 | 120 |
| 2021 Novembro | 54 | 54 | 108 |
| 2021 Outubro | 102 | 77 | 179 |
| 2021 Setembro | 77 | 50 | 127 |
| 2021 Agosto | 54 | 43 | 97 |
| 2021 Julho | 58 | 44 | 102 |
| 2021 Junho | 33 | 56 | 89 |
| 2021 Maio | 52 | 72 | 124 |
| 2021 Abril | 125 | 206 | 331 |
| 2021 Março | 133 | 51 | 184 |
| 2021 Fevereiro | 38 | 23 | 61 |
| 2021 Janeiro | 52 | 16 | 68 |
| 2020 Dezembro | 42 | 25 | 67 |
| 2020 Novembro | 54 | 12 | 66 |
| 2020 Outubro | 39 | 8 | 47 |
| 2020 Setembro | 42 | 10 | 52 |
| 2020 Agosto | 41 | 6 | 47 |
| 2020 Julho | 36 | 12 | 48 |
| 2020 Junho | 20 | 20 | 40 |
| 2020 Maio | 41 | 19 | 60 |
| 2020 Abril | 3 | 1 | 4 |
| 2020 Março | 0 | 4 | 4 |
| 2020 Fevereiro | 0 | 1 | 1 |
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