Age: 36.0
Sex: F
Vaccine: COVID19
Symptoms: Angular cheilitis, Antinuclear antibody negative, Basophil count normal, Blister, Blood thyroid stimulating hormone decreased
Clinical narrative: Within an hour of vaccine receipt, patient noted increased thirst with dry mouth and lips. She increased her water intake over the next 48 hours. Around 4 Apr, she noted cracking at the corners of her mouth. During that time, she applied lip balm and Chapstick to her lips almost constantly, with Neosporin applied to the areas cracking.  The following week (week of 5 Apr), she noted her labia were itchy and irritated; she denies vaginal irritation or discharge. No abdominal or pelvic pain. She applied an antifungal cream to the area with some relief of symptoms.  Also that week (week of 5 Apr), patient had itching and dry, flaking skin in her external ears; no discharge or pain from inner ear. She also noted that her taste buds were enlarged and red; they were irritated and they burned if she ate spicy food.  The following week (week of 12 Apr), patient noted her scalp was itching and flaking, so she started using Selsun shampoo. Then, her hands became very dry and itchy, and began to peel. Her feet developed small, itchy vesicles that dried and then peeled.  Patient attempted to be evaluated, but the first available face-to-face appointment was not until 3 May. At that time, exam of her skin noted:  macule seen on Palms of b/l hands- macular scaly lesions that are peeling.  b/l feet (near arch, lateral surface) small macular lesions w/o ulceration, nonvesicular nor pustular.  R corner of mouth- with small crack, no erythema or discharge.  - Scales were seen. Assessment/Plan: 1. Dermatitis, unspecified: Suspect flare of Atopic dermatitis.  2. Other specified disorders of the skin and subcutaneous tissue: Suspect angular chelitis of R corner of mouth She was prescribed Fluocinonide 0.05% and Ceramide creams to apply to her hands and feet. Mupirocin 2% ointment ((apply to lips) and Clotrimazole 1% vaginal cream were also prescribed.  Patient denies onset of facial swelling, swelling and itching of mouth and throat, difficulty swallowing or breathing, wheezing, watery eyes, cough, increased heart rate, lightheadedness, and GI-symptoms within the first 12 hours post-vaccine receipt.   Patient was feeling well on the day of vaccine receipt and denies any other possible exposures, including changes in foods and medications, and personal care products. She denies bug/insect bites, chemical exposure, exposure to plants, and exposures to sick contacts. She reports a negative health history for chronic or long-standing health conditions, except for a history of Atopic Dermatitis, with her last flare about 10 years ago. Patient also reports receipt of lip fillers 4 to 5 years ago. She denies a history of COVID infection; she has tested negative 3 times for SARS-CoV-2.  Recently, patient reports increased stressors and just initiated Bupropion. Otherwise, she takes no routine medications. She has a Mirena IUD. She has no known allergies to medication, food, latex, or insect stings.  Patient denies previous history of reactions following vaccine receipt. She has no history of similar rashes or dermatitis, except peeling of skin on hands and feet are similar to flares of atopic dermatitis).  Patient works as a dental hygienist. On 18 May, patient had noted near resolution of all oral-facial symptoms. Her other cutaneous symptoms had improved significantly, but she was still reporting pruritus of the scalp, feet, and hands. She had just initiated a Medrol Dosepak, Atarax, and Ketoconazole shampoo.