Sex: M
Vaccine: COVID19
Symptoms: Biopsy skin, Blood culture, Chlamydia test, HLA-B*27 assay, Investigation
Clinical narrative: GPP after COVID-19 infection and vaccination/ resulting in flare of his GPP-like eruption; This is a literature report.  A 45-year-old male with a 2-year history of HLA-B27-negative spondyloarthropathy (previously diagnosed as ankylosing spondylitis), well-controlled on biweekly 40 mg adalimumab and followed by rheumatology, presented to the dermatology clinic with a 1-week history of a new pustular rash that started on his left palm and slowly spread over his hands, arms, trunk and legs. He had a past dermatologic history of eczema and a family history of ankylosing spondylitis in his brother and father. He had no known drug allergies and was a former smoker. The patient's long-standing medication list included 100 mg vitamin C, 1000-unit vitamin D3, 20 mg omeprazole, and 550 mg rifaximin, which he took for chronic abdominal bloating concerning for irritable bowel syndrome or small intestinal bacterial overgrowth. Four weeks prior to presentation, the patient had contracted COVID-19 infection with respiratory symptoms that resolved without issue; no acute dermatologic findings were noted during the course of his COVID-19 illness. During his COVID-19 course, he self-discontinued his adalimumab given its immunosuppressive effects. Four weeks after COVID-19 infection, the patient noticed tender, painful skin lesions with moderate pruritus; he had never had such lesions before. He initially presented to his primary care provider who prescribed a 7-day course of 100 mg doxycycline twice daily for suspected infection with no improvement. Over the course of the next week, new pustular lesions appeared on his proximal arms, legs, trunk and groin. On exam, there were multiple areas of pustular lesions focally coalescing into larger plaques with involvement of the bilateral hands (left greater than right sided) and fingers. Pustular lesions were also scattered on the groin, bilateral shins, back, arms and left dorsal foot (Clinical photographs of the pustular lesions focally coalescing into larger plaques with several isolated pustules distributed on the left palm, left proximal arm, right shin and trunk, respectively. Similar lesions were seen on the right palm, groin, right shin and left dorsal foot). Microbiological data were notable for negative blood culture, and negative nucleic acid amplification tests for gonorrhoea and chlamydia. Given the desire for a broad-based skin sample and to obtain a full intact blister, a shave biopsy was performed which revealed florid subcorneal aggregates of neutrophils (A biopsy of an ill-defined yellow pustule on the left palm was taken to determine diagnosis. Haematoxylin and eosin staining (10 magnification) demonstrated a well-defined dense intraepidermal neutrophilic infiltrate consistent with subcorneal pustular dermatosis, compatible with palmoplantar pustulosis). Overall, the clinicopathologic findings were in line with a diagnosis of palmoplantar pustulosis with more diffuse involvement beyond acral sites, suggestive of a GPP-like eruption. The patient was subsequently diagnosed with psoriatic arthritis, replacing the prior diagnosis of ankylosing spondylitis. Given the suspected inflammatory nature of his rash, the patient was started on topical 0.05% clobetasol ointment daily for the first month, increased to twice-daily due to recurrent flares and new focal, painful pustular lesions and plaques on his leg and groin. One month after initiating treatment, he developed a gout and psoriatic arthritis flare and was placed on a 2-week taper of prednisone starting at 40 mg daily and restarted adalimumab 40 mg biweekly, both of which somewhat helped his pustulosis. He was also started on calcipotriene ointment and clindamycin 1% lotion, which were quickly discontinued due to lack of response. Over the course of the next year, the GPP-like rash improved, but did not resolve. New pustular lesions formed on his central scalp and upper back, prompting an increase in frequency of adalimumab from 40 mg biweekly to weekly. After 6 weeks of inadequate response on weekly adalimumab, methotrexate (MTX) 10 mg weekly was added with positive effect (Clinical photographs after several weeks of adalimumab and methotrexate combination therapy with near-complete resolution of generalized pustular psoriasis-like rash on the leg and trunk). Over the course of the following year, the patient had minimal flares. In Jan2022, he received a booster COVID-19 vaccination and self-held his adalimumab dosage, resulting in flare of his GPP-like eruption. The patient contracted COVID-19 in Jun2022 with minimal flare of his cutaneous disease and has since remained without flare.  In this patient's case, given the temporality of the COVID-19 infection with the patient's symptoms, as well as his symptom flares during COVID-19 vaccination and reinfection, a viral or post-viral inflammatory contribution to his eruption was strongly suspected. Furthermore, the cessation of his biologic medication and his underlying predisposition to autoimmune disease provided a unique substrate for disease development. We cannot know for certain the relative effects of these aetiologies on the development of his rash. However, his flares were more extreme when he discontinued adalimumab with initial COVID-19 infection and vaccination, and less severe when he continued adalimumab and was reinfected by COVID-19. Thus, we suspect that the discontinuation of adalimumab was contributory to his GPP-flares, biologically "priming" his body to develop his first psoriatic rash, which may have been precipitated by a viral immune response that triggered this autoinflammatory eruption.  No follow-up attempts are possible.; Sender's Comments: Based on the temporal relation, the association between the event Pustular Psoriasis and the suspect product cannot be completely ruled out.The impact of this report on the benefit/risk profile of the Pfizer drug is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees, and Investigators, as appropriate.