Sex: M
Vaccine: MMR
Symptoms: Asthenia, Biopsy skin abnormal, Erythema, Fungal test negative, Gram stain negative
Clinical narrative: Cutaneous Granulomas;   This literature marketed report has been received from authors of the literature article entitled as stated above referring to an approximately 4 years old male patient with common variable immunodeficiency disorder (CVID) and NOD2 mutation.   On an unknown date (reported as during his childhood, before his immunodeficiency diagnosis), the patient was vaccinated with the first dose of (1 of 2) measles, mumps, and rubella (wistar RA 27-3) virus vaccine, live (manufacturer unknown) (strength, route, batch/lot# and expiration date were unknown) for prophylaxis.   On an unknown date (reported as seventeen years before presentation, at around 4 years old), the patient's clinical image of face showed scattered pink depressed papules coalescing into plaques, some areas with honey-colored crusting, and telangiectasias. On an unknown date (reported as fifteen years before presentation), clinical image showed greater involvement of the face with larger and more indurated pink to bright red papules and plaques. On an unknown date, at the age of 21 years old, the patient presented with an approximately 15-year history of progressive disfiguring and scarring changes of the face, left upper arm, and right posterior lower leg. The patient was previously followed up by an outside dermatologist for chronic granulomatous dermatitis and received infliximab for 4 consecutive years with poor-to-moderate response. The patient has a complex medical history including recurrent and chronic sinopulmonary infections, microcephaly with severe global and developmental delay, seizure disorder, as well as other major pulmonary, gastrointestinal, and musculoskeletal conditions (onset dates unspecified). At presentation, the patient was receiving intravenous immunoglobulin infusions monthly, gabapentin, albuterol, budesonide, cetirizine, pseudoephedrine, metoclopramide, and omeprazole. The patient was noted to be wheelchair-bound, frail, small statured, nonverbal, and nonresponsive. On the central face, right upper arm, and left posterior calf, there were large, telangiectatic, sclerotic, red, stellate plaques with scattered 28 mm hemorrhagic crusts, scale, and erosions. The clinical image at presentation also showed there was a 1.5-cm yellowish firm nodule on the right lower forehead at the level of the eyebrow. It was reported that all his skin lesions had been slowly progressive over time. A punch biopsy obtained from the left arm showed palisaded granulomatous dermatitis in the reticular dermis, with central necrobiotic collagen and multinucleated giant cells. Special stains including gram, Grocott's methenamine silver, and acid-fast bacilli stains for bacteria, fungi, and mycobacteria, respectively, were negative. Considering the clinical findings and history, the histopathology was compatible with CVID-associated granulomatous dermatitis. To further investigate the unusual lack of response to therapy and the severity of the cutaneous granulomas, the biopsy specimen was sent for immunofluorescence microscopy, which showed the presence of rubella vaccine capsid proteins in M2 macrophages within the granuloma. RV, a core component of the universally utilized measles, mumps, and rubella vaccine was considered to be a causative agent for cutaneous granulomas. The reporter considered the event of granulomatous dermatitis to be related to measles, mumps, and rubella (wistar RA 27-3) virus vaccine, live (manufacturer unknown). The outcome of granulomatous dermatitis was unknown.  A copy of the published article is attached as further documentation of the patient's experience.