Saturday, December 25, 2021

Myocarditis and COVID-19: for some people the risk may be higher following vaccination than infection

COVID-19 is a known cause of cardiac complications such as myocarditis and systolic dysfunction. Vaccine associated myocarditis was described following smallpox vaccination, streptococcal pneumonia and influenza vaccine. In some cases, autoimmune/inflammatory syndrome induced by adjuvants used in the vaccine have been also implicated. 

Associations of COVID-19 vaccination and myocarditis have been proposed in multiple publications, but the consensus was that the benefits of vaccine are worth the increased risk even though more personalized approach seems warranted by the evidence.

A new study presents data about the risk of myocarditis increasing with each subsequent dose of mRNA vaccines, especially mRNA-1273. Moreover, in younger males the risk of myocarditis was higher following vaccination than infection. Another study presents a case of fatal breakthrough infection in an older male who experienced myocarditis-like symptoms after his COVID-19 vaccine. Retrospective cohort study of 196,992 adults in Israel did not observe an increased incidence of neither pericarditis nor myocarditis in unvaccinated adult patients recovering from COVID-19 infection. See example case reports


Martina Patone, Winnie Xue Mei, Lahiru Handunnetthi, Sharon Dixon, Francesco Zaccardi, Manu Shankar-Hari, Peter Watkinson, Kamlesh Khunti, Anthony Harnden, Carol AC Coupland, Keith M. Channon, Nicholas L Mills, Aziz Sheikh, Julia Hippisley-Cox Risk of myocarditis following sequential COVID-19 vaccinations by age and sex  medRxiv 2021.12.23.21268276; doi:

Kim HW, Jenista ER, Wendell DC, Azevedo CF, Campbell MJ, Darty SN, Parker MA, Kim RJ. Patients with acute myocarditis following mRNA COVID-19 vaccination. JAMA cardiology. 2021 Oct 1;6(10):1196-201.

Lazaros G, Anastassopoulou C, Hatziantoniou S, Kalos T, Soulaidopoulos S, Lazarou E, Vlachopoulos C, Vassilopoulos D, Tsakris A, Tsioufis C. A case series of acute pericarditis following COVID-19 vaccination in the context of recent reports from Europe and the United States. Vaccine. 2021 Oct 29;39(45):6585-90.

Hendren NS, Carter S, Grodin JL. Severe COVID-19 vaccine associated myocarditis: Zebra or unicorn?. International journal of cardiology. 2021 Nov 15;343:197-8.


Thursday, December 16, 2021

Cutaneous manifestations of SARS-CoV-2 and COVID-19 vaccines

 COVID-19 is associated with a wide range of skin signs. 

The following six main clinical patterns have been proposed for such manifestations most recently: (i) urticarial rash, (ii) confluent erythematous/maculopapular/morbilliform rash, (iii) papulovesicular exanthem, (iv) chilblain-like acral pattern, (v) livedo reticularis/racemosa-like pattern, and (vi) purpuric "vasculitic" pattern. Livedo or necrosis - blotchy red or blue appearance with a net-like pattern - was associated with increased disease severity while measles-like (morbilliform) rash was generally seen in patients with moderate to severe infection (like in the patient shown on the left who died) and pseudo-chilblains, a late sign of COVID-19, was associated with decreased severity and more likely to happen for younger patients. The median duration of chiblain-like acral pattern, however, was significantly longer that all other patterns. One study of 200 patients found the following frequencies of these signs: 10.2% for Urticarial rash; 25.7% for confluent erythematous/maculo-papular/morbilliform rash; 15.5% for papulovesicular exanthem, 24.6% for a chilblain-like acral pattern; 2.1% for a livedo reticularis/racemosa-like pattern; and 6.9% for a purpuric vasculitic pattern. 15% of skin patterns were not clearly classified while 6.5% had more than one pattern present.

The prevalence of cutaneous involvement was 7.8% in a binational Chinese-Italian cohort of 678 hospitalized adults with laboratory-confirmed disease. Dermatologic reactions after COVID-19 vaccines have been also reported and can mimic SARS-CoV-2 infection itself (eg, pernio/chilblains). The prevalence was the highest after the 2nd dose of mRNA-1273 (over 12% in Moderna), although only 1-2% experienced it with ChAdOx1 nCov-19 vaccine (AstraZeneca).

Delayed large local reactions were most common among vaccinees, followed by local injection site reactions, urticarial eruptions, and morbilliform eruptions. In a study of 414 people, forty-three percent of patients with first-dose reactions experienced second-dose recurrence. Additional less-common reactions included pernio/chilblains, dyshidrotic eczema, psoriasiform dermatitis, cosmetic filler reactions, zoster, herpes simplex flares, and pityriasis rosea-like reactions. 

Some of more serious reactions could be exacerbation of Erythema multiforme. It mostly happens in mild form of a sudden rash that goes away in a few weeks but could progress to larger raised patches that look like a target or "bulls-eye" and may have a blister or crust. Relapses of autoimmune bullous disease have been also reported as well as new onset Lichen planus, immune complex vasculitis or flares of subacute cutaneous lupus erythematosus, psoriasis and atopic dermatitis. 

Morphologic misclassification is, however, possible. 


Tan SW, Tam YC, Oh CC. Skin manifestations of COVID-19: A worldwide review. JAAD international. 2021 Mar 1;2:119-33.

Slimani Y, Abbassi R, El Fatoiki FZ, Barrou L, Chiheb S. Systemic lupus erythematosus and varicella‐like rash following COVID‐19 in a previously healthy patient. Journal of Medical Virology. 2021 Feb;93(2):1184-7.

Genovese G, Moltrasio C, Berti E, Marzano AV. Skin manifestations associated with COVID-19: current knowledge and future perspectives. Dermatology. 2021 Jan 1:1-2. 

Marzano AV, Genovese G, Moltrasio C, Gaspari V, Vezzoli P, Maione V, Misciali C, Sena P, Patrizi A, Offidani A, Quaglino P. The clinical spectrum of COVID-19–associated cutaneous manifestations: An Italian multicenter study of 200 adult patients. Journal of the American Academy of Dermatology. 2021 May 1;84(5):1356-63. 

Bogdanov G, Bogdanov I, Kazandjieva J, Tsankov N. Cutaneous adverse effects of the available COVID-19 vaccines. Clinics in Dermatology. 2021 Apr 27.

Rice SM, Ferree SD, Mesinkovska NA, Kourosh AS. The art of prevention: COVID-19 vaccine preparedness for the dermatologist. International journal of women's dermatology. 2021 Jan 12.

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