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vaccine&#46; She complained of acute onset of burning pain in labia majora and swelling 24<span class="elsevierStyleHsp" style=""></span>hours after receiving the vaccine&#44; accompanied by fever and body aches&#46; Physical examination revealed multiple millimetric&#44; shallow&#44; purple-red&#44; painful ulcerations in labia majora&#44; labia minora&#44; and vaginal introitus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The patient had no previous history of genital ulcers&#46; Oral mucosa and oropharynx were clear&#46; At 24<span class="elsevierStyleHsp" style=""></span>hours follow up she reported worsening symptoms complaining of difficulty sitting down&#46; Upon examination&#44; the patient had more ulcerations with yellow and gray covering with surrounding erythema and edema&#44; some with the purulent center&#46; A biopsy of one ulcer was taken and tissue PCR for Herpes Simplex Virus &#40;HSV&#41; 1&#47;2&#44; Varicella-Zoster Virus &#40;VZV&#41;&#44; and cytomegalovirus was negative&#44; as well as serologic IgG and IgM for HSV 1&#47;2 and VZV&#46; HIV serology was not reactive&#44; genital swab culture&#44; VDRL&#44; COVID antigen test&#44; and antinuclear antibodies were all negative&#46; The biopsy showed epithelium ulceration&#44; spongiosis&#44; and dense inflammatory infiltrate of lymphocytes and histiocytes&#44; there was no trace of vasculitis or viral infection &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The patient was diagnosed with vulvar aphthous ulcers&#46; She was treated with hydrocortisone 1&#37; and pain control&#46; Ulcers resolved within 9 days&#46; At the 6 month follow-up&#44; she had not presented a recurrence of the lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Although the exact etiology of Lipsch&#252;tz ulcer remains unclear&#44; it likely involves an immunologic response to an infection or other source of inflammation&#46; Most cases are idiopathic with a negative infectious workup&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> There are six case reports of vulvar aphthous ulcers following COVID-19 vaccination&#44; four after Pfizer-BioNTech and one after AstraZeneca&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> This is the second one reported in the literature after the AstraZeneca vaccination&#46; The diagnosis was challenging since the patient was sexually active&#46; Sexually transmitted diseases were tested for and excluded&#46; After discarding infectious diseases&#44; the main differential diagnosis was Beh&#231;et syndrome&#44; however&#44; the biopsy did not show signs of vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Lipsch&#252;tz&#8217;s ulcers were firstly attributed to virgin women&#44; and later to patients with an absence of sexual contact in the previous three months&#46; However&#44; in a study conducted in Brazil&#44; 86 out of 98 patients were diagnosed with Lipsch&#252;tz ulcers when expanding criteria to any age and sexual activity&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Another retrospective analysis of 33 cases found that 84&#46;8&#37; of the patients had had their sexual debut&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Several cutaneous reactions to the COVID-19 vaccination have been reported&#46; This case demonstrates a potential association between this vaccine and the development of a vulvar aphthous ulcer&#46; Clinicians&#44; especially dermatologists&#44; gynecologists and pediatricians should be aware of the possible risk of this disease after COVID-19 vaccination&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Maria Bracho-Borro&#58; Writing of the manuscript or critical review of important intellectual content&#59; effective participation in the research guidance&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Graciela Guzm&#225;n-Perera&#58; Writing of the manuscript or critical review of important intellectual content&#59; effective participation in the research guidance&#44; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Mario Maga&#241;a&#58; Data collection&#44; analysis&#44; and interpretation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Clinical
Lipschütz ulcers after AstraZeneca COVID-19 vaccination
Maria Bracho-Borroa,
Autor para correspondência
mbrachoborro@gmail.com

Corresponding author.
, Graciela Guzmán-Pererab, Mario Magañac
a Dermatology Department, General Hospital of Mexico Dr. Eduardo Liceaga, Mexico City, Mexico
b Dermatology Department, Hospital Ángeles del Pedregal, Mexico City, Mexico
c Dermatology Department, General Hospital of Mexico Dr. Eduardo Liceaga, Mexico City, Mexico
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Biopsy of one ulcer stained with Hematoxylin &#38; eosin&#44; 40x&#46; &#40;A&#41; Vulvar mucosa ulceration and spongiosis&#46; &#40;B&#41; Dense mixed inflammatory infiltrate of lymphocytes&#44; histiocytes&#44; and scarce monocytes in all the stroma&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute vulvar aphthous ulceration or Lipsch&#252;tz ulcer is a rare non-sexually acquired condition which is characterized by the sudden onset of painful genital ulcers&#46; It doesn&#8217;t have a clear etiology&#59; therefore&#44; its diagnosis is challenging&#46; The usual course is self-resolution without relapses and scarring&#46; There have been six cases reported following COVID-19 vaccination&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 27-year-old healthy&#44; sexually active woman received her third dose of the COVID-19 vaccine&#44; the first two were Pfizer-BioNTech and this one was AstraZeneca &#40;Vaxzevria&#41; vaccine&#46; She complained of acute onset of burning pain in labia majora and swelling 24<span class="elsevierStyleHsp" style=""></span>hours after receiving the vaccine&#44; accompanied by fever and body aches&#46; Physical examination revealed multiple millimetric&#44; shallow&#44; purple-red&#44; painful ulcerations in labia majora&#44; labia minora&#44; and vaginal introitus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The patient had no previous history of genital ulcers&#46; Oral mucosa and oropharynx were clear&#46; At 24<span class="elsevierStyleHsp" style=""></span>hours follow up she reported worsening symptoms complaining of difficulty sitting down&#46; Upon examination&#44; the patient had more ulcerations with yellow and gray covering with surrounding erythema and edema&#44; some with the purulent center&#46; A biopsy of one ulcer was taken and tissue PCR for Herpes Simplex Virus &#40;HSV&#41; 1&#47;2&#44; Varicella-Zoster Virus &#40;VZV&#41;&#44; and cytomegalovirus was negative&#44; as well as serologic IgG and IgM for HSV 1&#47;2 and VZV&#46; HIV serology was not reactive&#44; genital swab culture&#44; VDRL&#44; COVID antigen test&#44; and antinuclear antibodies were all negative&#46; The biopsy showed epithelium ulceration&#44; spongiosis&#44; and dense inflammatory infiltrate of lymphocytes and histiocytes&#44; there was no trace of vasculitis or viral infection &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The patient was diagnosed with vulvar aphthous ulcers&#46; She was treated with hydrocortisone 1&#37; and pain control&#46; Ulcers resolved within 9 days&#46; At the 6 month follow-up&#44; she had not presented a recurrence of the lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Although the exact etiology of Lipsch&#252;tz ulcer remains unclear&#44; it likely involves an immunologic response to an infection or other source of inflammation&#46; Most cases are idiopathic with a negative infectious workup&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> There are six case reports of vulvar aphthous ulcers following COVID-19 vaccination&#44; four after Pfizer-BioNTech and one after AstraZeneca&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> This is the second one reported in the literature after the AstraZeneca vaccination&#46; The diagnosis was challenging since the patient was sexually active&#46; Sexually transmitted diseases were tested for and excluded&#46; After discarding infectious diseases&#44; the main differential diagnosis was Beh&#231;et syndrome&#44; however&#44; the biopsy did not show signs of vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Lipsch&#252;tz&#8217;s ulcers were firstly attributed to virgin women&#44; and later to patients with an absence of sexual contact in the previous three months&#46; However&#44; in a study conducted in Brazil&#44; 86 out of 98 patients were diagnosed with Lipsch&#252;tz ulcers when expanding criteria to any age and sexual activity&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Another retrospective analysis of 33 cases found that 84&#46;8&#37; of the patients had had their sexual debut&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Several cutaneous reactions to the COVID-19 vaccination have been reported&#46; This case demonstrates a potential association between this vaccine and the development of a vulvar aphthous ulcer&#46; Clinicians&#44; especially dermatologists&#44; gynecologists and pediatricians should be aware of the possible risk of this disease after COVID-19 vaccination&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Maria Bracho-Borro&#58; Writing of the manuscript or critical review of important intellectual content&#59; effective participation in the research guidance&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Graciela Guzm&#225;n-Perera&#58; Writing of the manuscript or critical review of important intellectual content&#59; effective participation in the research guidance&#44; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Mario Maga&#241;a&#58; Data collection&#44; analysis&#44; and interpretation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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