Sex: F
Vaccine: COVID19
Symptoms: Cytomegalovirus test, Epstein-Barr virus test, HIV test, Hepatitis B, Hepatitis C
Clinical narrative: This is a literature report for the following literature source(s): "Acute vulvar ulcers and the COVID-19 booster vaccine", Case Reports, 2022. The authors presented a case of a 22-year-old patient who presented with acute vulvar ulcers that developed 2 days after they got the COVID-19 Pfizer booster. While these ulcers have historically been identified after a variety of triggers, more recently, reports have been made following the COVID-19 vaccination and infection. Here, they have identified a case following a Pfizer booster dose. Case Report: A 22-year-old adult presented to the dermatology clinic with an 11-day history of vulvar ulcers. The patient reported tenderness and swelling of the labia initially and subsequently noticed discrete, deeply erythematous lesions. These gradually coalesced into gray, tan exudates and pseudomembranous with continued extensive vulvar swelling. The patient also noted severe pain, particularly with urination, a fever, and axillary and supraclavicular lymphadenopathy with ulcer onset. Two days prior to symptom onset, the patient had received the Pfizer COVID-19 booster vaccine and had a negative COVID polymerase chain reaction test after the booster. The patient reported a history of 2 similar episodes, at age 13 years and approximately 6 months prior to presentation. The first episode was presumed to be trauma secondary to shaving, although they denied any history of shaving. The second episode was preceded by a viral upper respiratory illness. The patient noted a history of oral aphthous ulcer outbreaks 3 times per year. They denied any vaginal intercourse for over 2 years, new medications, personal care products, or inciting trauma. Testing for human immunodeficiency virus (HIV), gonorrhea, and chlamydia was all negative in the past and on repeat testing. Their recent pap smear was unremarkable. Prior to presenting to dermatology, the patient saw infectious disease and was prescribed amoxicillin/ clavulanate, doxycycline, and fluconazole as empiric therapy. A punch biopsy of the right labia minora showed epidermal ulceration with dense dermal mixed inflammation and favored an infectious etiology. Bacterial vulvar tissue culture and smear showed neutrophils and moderate mixed gram-positive organisms. Serologic testing revealed herpes simplex virus (HSV)-1 IgG. HSV-2, HIV, acid-fast bacilli, varicella zoster, hepatitis B, hepatitis C, cytomegalovirus, and syphilis testing were all negative. On examination, no oral ulcers were present, but vulvar edema and extensive ulceration were present bilaterally (left worse than right), with yellow, gray purulent drainage and pseudomembrane. A second punch biopsy of nonulcerated skin and tissue culture of the left vulva was completed. The patient was advised to continue oral antibiotics and to empirically start mupirocin and clobetasol ointment twice daily. The second punch biopsy of the left vulva showed dermal edema with vascular ectasia and sparse chronic inflammation and no signs of bacterial or fungal organisms. Tissue culture results showed Escherichia coli and rare candida, which were interpreted as asymptomatic colonization from GI/ GU flora. Antinuclear antibody, Epstein-Barr virus panel, Lyme, and thyroid cascade were negative. C3 and C4 complement were mildly elevated at 181 and 50, respectively, though noted to be insignificant. Approximately 1 week later, they noted improvement with topical clobetasol, but persistent pain. The patient started 60-mg oral prednisone with a 15-day taper. Two weeks after their first appointment, they noted improvement in discomfort and treatment was continued with prednisone taper, clobetasol ointment, and the mupirocin ointment. The patient was counseled that this may recur in the future. Discussion: This case of acute vulvar ulcers in a 22-year-old adult 2 days after receiving the COVID-19 Pfizer booster vaccine adds to the evolving compendium of COVID-19 vaccine related adverse reactions. Sender's Comments: Based on the known safety profile and information in the case report a casual association between reported event Vulval ulceration and the suspect drug BNT162B2 cannot be excluded. 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