Sex: M
Vaccine: COVID19
Symptoms: Alanine aminotransferase, Anion gap, Aspartate aminotransferase, Blood albumin, Blood alkaline phosphatase
Clinical narrative: COVID-19 infection/ The patient was fully vaccinated prior to infection which, at the time, constituted a total of three vaccine doses; COVID-19 infection/ The patient was fully vaccinated prior to infection which, at the time, constituted a total of three vaccine doses; Aquagenic Syringeal Keratoderma; This is a literature report for the following literature source(s):  A 24-year-old male with a history of food allergy anaphylaxis, infection-induced asthma, and atopic dermatitis pruritis presented with a subacute (approximately 2-week) onset of bilateral palmar edema with whitish-colored papules following brief local exposure to water or sweat. The patient denied excessive handwashing. The patient had no history of daily nonsteroidal anti-inflammatory drug (NSAID) use but had a recent 2-week prior history of pm re nata (PRN) ibuprofen use. There was no known family history of atopy, renal disease, pulmonary disease, AF508 cystic fibrosis transmembrane conductance regulator (CFTR) allele mutation, or breast cancer (BRCA) gene mutation. The patient was convalescent for Coronavirus disease 2019 (COVID- 19) 3 months prior, which was successfully treated with a full course of ritonavir-boosted nirmatrelvir (PAXLOVIDTM, Pfizer), resulting in complete recovery without any COVID-19-related hospitalization. The patient was  fully vaccinated prior to infection which, at the time, constituted a total of three vaccine doses. Post-COVID self-administered rapid COVID-19 viral antigen tests were negative. The patient denied any post-COVID-19 conditions, also known as post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PASC) or long COVID.  Prior to presentation, the patient obtained photographic documentation of ASK on 2 separate occasions. On presentation, both palms appeared unremarkable; however, upon brief exposure to water for 2 minutes, the clinical signs of ASK became apparent with moderate involvement of the thumb and index fingers. There was no pedal involvement or involvement of other areas. The patient denied pain, discomfort, pruritis, and burning sensation. The patient declined therapeutic intervention, including topical steroids, topical aluminum chloride solution, and antihistamines.  Workup for associated conditions was negative. A comprehensive metabolic panel (CMP) was also unremarkable, excluding nephrotic syndrome or other associated renal involvement. Sodium - 139 mmol/L [Standard range (SR): 135-146 mmol/L], Potassium - 4.7 mmol/L (SR: 3.5-5.3 mmol/L), Chloride 103 mmol/L (SR: 98-110 mmol/L), CO2 - 30 mmol/L (SR: 21-31), BUN - 12 mg/dL (SR: 8-24 mg/dL), Glucose - 89 mg/dL (SR: 70-99 mg/dL), Creatinine - 1.04 mg/dL (SR: 0.70 - 1.30 mg/dL), Calcium - 9.4 mg/dL (SR: 8.5-10.5 mg/dL), Total protein - 7.1 g/dL (SR: 6.4 - 8.9 g/L), Albumin - 4.6 g/dL (SR: 3.5 - 5.7 g/L), Total bilirubin - 0.3 mg/dL (SR: 0.0 - 1.0 mg/dL), Alkaline phosphatase - 57 IU/L or U/L (SR: 34 - 104 IU/L or U/L), AST (SGOT) - 18 IU/L (SR: 13 - 39 IU/L or U/L), ALT (SGPT) - 32 IU/L or U/L (SR: 7 - 52 IU/L or U/L), Anion gap - 6 mmol/L (SR: 4 - 14 mmol/L), Est. CFR - >90 ml/min/l.73 m2. Subsequent CFTR gene sequencing and single-gene deletion/duplication analysis returned negative. No pathogenic, likely pathogenic, or variants of uncertain significance on the CFTR gene were identified.   Two months later, ASK appeared to have resolved. It could no longer be elicited by exposure to water or sweat, despite numerous attempts. The patient noted disappearance of white plaques and wrinkling after water exposure. Photographs of the improvement were not obtained. No known lifestyle, dietary, or medication-related changes contributed to ASK resolution.  One month later, however, ASK returned, initially characterized by palmar edema after water exposure with absence of white plaques and papules. Soon, ASK progressed in severity with development of white plaques and increased palmar area involvement. Physical discomfort with episodes of pruritis was noted. Treatment with 12% topical aluminum chloride to promote palmar anhidrosis did not lead to improvement despite 4 weeks of nightly treatment. As a result, the patient was treated with bilateral palmar botulinum toxin injections. Within 2 weeks following botulinum toxin treatment, complete resolution of ASK occurred. The affected phalangeal surfaces also resolved despite no direct injection to these locations.  Conclusions: The authors present a case of ASK in an adult male months following COVID-19 infection without a history of excessive handwashing. Near resolution 2 months after ASK onset was followed by recurrence 1 month later. The patient may have had a predisposition to recurrent ASK due to his history of atopy including atopic dermatitis and food allergy anaphylaxis combined with prior COVID-19 infection and sporadic, short-term NSAID use. It is possible that ASK may be a newly identified condition comprising PASC or long COVID. Clinicians should maintain heightened awareness of ASK in their patients and continue to document cases of this rare and poorly understood condition to improve clinical knowledge, treatment strategies, and future patient outcomes.  Amendment: This follow-up report is being submitted to amend previous information: Case was reassessed from invalid to valid.; Sender's Comments: A causal relationship to the suspect drug BNT162B2 NOS cannot be excluded for the event vaccination failure. Aquagenic Syringeal Keratoderma could be secondary to underlying contributory factors including COVID-19 infection. This case will be reassessed upon receipt of additional information.   The impact of this report on the benefit/risk profile of the Pfizer product 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.