Sex: F
Vaccine: TDAP
Symptoms: Skin hyperpigmentation, Skin lesion, Tenderness, Type III immune complex mediated reaction
Clinical narrative: Arthus reaction; Erythema nodosum; Nodule; Peripheral swelling; Pruritus; Skin hyperpigmentation; Skin lesion; This case was reported in a literature article and described the occurrence of arthus reaction in a 39-year-old female patient who received DTPa (Reduced antigen) (dTpa vaccine).   On an unknown date, the patient received dTpa vaccine. On an unknown date, 1 day after receiving dTpa vaccine, the patient experienced arthus reaction (serious criteria GSK medically significant), erythema nodosum, nodule, peripheral swelling, pruritus, skin hyperpigmentation and skin lesion. The subject was treated with ibuprofen, antihistamine, corticosteroid nos (Corticosteroids Nos), fexofenadine and prednisone. On an unknown date, the outcome of the arthus reaction, erythema nodosum, nodule, peripheral swelling, pruritus, skin hyperpigmentation and skin lesion were recovered/resolved.   The reporter considered the arthus reaction, erythema nodosum, nodule, peripheral swelling, pruritus, skin hyperpigmentation and skin lesion to be related to dTpa vaccine.  Additional details were provided as follows: This case was reported in a literature article and described the occurrence of pruritus and swelling on distal lower extremities, erythema nodosum, arthus like phenomenon, skin lesion, nodule and macular hyperpigmentation in a 39-year-old female patient, who was vaccinated with unspecified tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) (manufacturer unknown) for prophylaxis. This case corresponds to supplementary table 1 (Table S1) reported in this literature article. The VAERS ID was 567730. Initial report received from literature on 17 May 2014. The patient was a part of the study that aimed to describe trends in spontaneously reported Arthus reactions following tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines (Tdap) and to assess the risk of this phenomenon in persons receiving Tdap repeatedly. The goal of this literature review was to identify published studies of Tdap vaccines administered in adolescents and adults who received a tetanus toxoid-containing vaccine less than or equal to 5 years previously. [It was reviewed Arthus reports in the Vaccine Adverse Events Reporting System (VAERS), 1990-2018. A systematic literature review was conducted in database for any Arthus cases reported in Tdap clinical trials and observational studies published between 2000 and 2019. Of the total of 619,479 reports in VAERS, it was identified 192 records coded with the "Type III immune complex mediated reaction" MedDRA term. All but one had vaccination dates between 2000 and 2018. The reports mentioned 35 different vaccines administered alone or coadministered in various combinations. The most frequently reported vaccine types, i.e., mentioned in more than 10 reports, were inactivated influenza vaccine (n = 39), pneumococcal polysaccharide vaccine (n = 39), Tdap (n = 36), measles mumps rubella (n = 20), inactivated polio vaccine (n = 17), Td (n = 16), hepatitis A vaccine (n = 14), meningococcal conjugate vaccine (n = 14), and varicella vaccine (n = 14). 36 (thirty-six) reports mentioning Tdap were received between 2006 and 2018. The Vaccine Adverse Events Reporting System (VAERS) received spontaneous reports of adverse events after vaccination from healthcare providers, patients, parents, vaccine manufacturers, and others. It was searched for the MedDRA preferred term "Type III immune complex mediated reaction" in reports submitted to VAERS between 11 June 1990 (the start of VAERS system database) and 14 December 2018]. The patient's current illness was unknown. The patient's preexisting condition and medical history was unknown. The patient had not received any concomitant. The patient's other medication was unknown. No information on patient's family history, or concomitant medication was provided. On an unspecified date, the patient received unspecified tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) (Site: UN/ Route: UN; dosage unknown; Lot: not provided). [Tetanus toxoid-containing vaccines included pediatric diphtheria and tetanus toxoids vaccine (DT), tetanus toxoid vaccine (Ttox), adult tetanus toxoid reduced diphtheria toxoid vaccine (Td), and Tdap. Tdap was administered alone in 22 of these cases. In 14 persons it was coadministered with other vaccines, such as inactivated influenza, hepatitis B, hepatitis A, human papilloma virus, meningococcal conjugate, measles-mumps-rubella, and pneumococcal polysaccharide vaccines]. On an unspecified date, within 24 hours of receiving TDAP vaccine, the patient noted several areas of pruritus and swelling on her distal lower extremities. During the next 24 hours, these areas enlarged and developed into tender red nodules. The painful nodules persisted and the patient sought dermatologic medical attention. Correlation of the patient's medical history, clinical symptoms, and lesion morphology were compatible with a diagnosis of Tdap vaccine-related erythema nodosum; however, the differential diagnosis also included an Arthus like phenomenon induced by immunization and erythema nodosum secondary to another etiology with immunization being associated by chance. Several circumstances favored Tdap vaccine-related erythema nodosum. Specifically, the patient had not been receiving any topical or systemic medications. Also, the patient had no recent streptococcal pharyngitis or systemic conditions such as Crohn's disease, sarcoidosis, or tuberculosis. Therefore, the temporal association between the patient's recent Tdap vaccination and the development of the skin lesion suggested that the development of erythema nodosum was related to the patient's receiving Tdap vaccine. On cutaneous examination, 7 day after receiving Tdap vaccine, revealed tender erythematous nodules on her legs. There was a large, 12 by 8 cm, erythematous nodule on distal pretibial left leg. Multiple, individual and grouped, nodules were present on her right leg; they were located on the distal lateral thigh (4.0 by 2.5 cm), the proximal lateral calf (6.0 by 3.5 cm), the distal lateral calf (2.0 by 2.0 cm), and the distal lateral leg proximal to the ankle (each of 3 lesions measuring 2.5 by 2.5 cm). Symptomatic treatment was initiated oral ibuprofen 600 mg four times daily. Since a drug induced etiology was suspected, daily oral systemic therapy with an antihistamine and a corticosteroid, 180 mg of fexofenadine and prednisone (60 mg for 4 days, followed by 40 mg for 3 days, and followed by 20 mg for 2 days). The patient's symptoms began to improve and the nodules started to flatten within 3 days. One of the nodules proximal to her right ankle was smaller, yet palpable with mild erythema of the skin. All other nodules had completely flattened and there was macular hyperpigmentation at the sites. [MedDRA PT terms: Erythema nodosum, Nodule, Peripheral swelling, Pruritus, Skin hyperpigmentation, Skin lesion, Type III immune complex mediated reaction]. [Most reports provided very limited information on the clinical course and laboratory workup. There were no cases of severe sequelae, such as skin necrosis. One report represented a literature case of erythema nodosum in temporal association with Tdap vaccination (VAERS captures cases and case-series of adverse events published in the literature as spontaneous reports). Arthus reaction was mentioned in the manuscript as one of several differential diagnoses (the final diagnosis being vaccine-associated erythema nodosum). No reports mentioned the use of Tdap during pregnancy. Between 2011 and 2018, approximately 169,000,000 doses of Tdap vaccines were distributed. During the same time, 24 presumed Arthus reaction cases following Tdap were reported to VAERS, for an estimated reporting rate of 0.1 per million doses distributed]. At the time of this report the patient was recovered from the event. The patient had no ER or doctor visit. The author commented, "Since the 1980s, literature reports and reviews of Arthus reaction following tetanus-containing vaccines have become rare. This is probably due to a wider acceptance by vaccine providers of the general recommendation not to re-administer tetanus vaccines more frequently than every 10 years. Other factors are undoubtedly improvements in standardization and purity of modern tetanus toxoid-containing vaccines. In this review, we found that the risk of Arthus reactions following vaccines used in the past two decades is extremely low. Only 36 reports were found in the VAERS database following Tdap booster. Several studies identified in our literature review support the idea that Tdap vaccines do not noticeably increase the risk of injection site reactions, when administered following a recent dose of tetanus toxoid-containing vaccine. The safety of multiple doses of Tdap vaccine administered in pregnant women was evaluated in a retrospective large database study. Cases were reported after a wide variety of pediatric and adult vaccines. Most reactions reported were mild and self-limiting without treatment. The review confirmed that overall incidence of Arthus reactions was very low. No information related to Tdap vaccine was presented in the review. The authors stressed the need for the standard definition and diagnostic criteria of the reaction. Arthus reaction following vaccination is difficult to study, because of its rarity. The prescribing information documents for all tetanus toxoid-containing vaccines used provide a warning about the use of these products in persons who have experienced an Arthus-type hypersensitivity following a prior dose of a tetanus toxoid-containing vaccine. They state that such persons usually have a high level of tetanus antitoxin and that they should not receive tetanus toxoid-containing vaccines unless at least 10 years have elapsed since the last dose. Providers who suspect an Arthus reaction in adult patients receiving a tetanus toxoid- containing vaccine, including Tdap, should consider serology testing for tetanus and diphtheria antibodies. Very high concentrations measured in the patient's blood within a few days after vaccination would support the diagnosis. Other conditions and reactions that may present similar symptoms and complaints (e.g., sterile abscess, cellulitis, SIRVA, etc.) may need to be ruled out. Accurate diagnosis and confirmation of Arthus reaction is important, and, ideally, it should be a histological diagnosis with demonstration of a vasculitis. Confusing an expected injection site reaction (not Type III hypersensitivity) for Arthus reaction with the subsequent recommendation to avoid tetanus or diphtheria toxoid-containing vaccines may have negative consequences for the individual. Limitations of our study include those inherent to passive surveillance systems, such as VAERS, including over- or underreporting, biased reporting, inconsistency in quality and completeness of reports, and, in general, inability to assess the causality." The author concluded, "In conclusion, the risk of Arthus reaction following Tdap vaccine administration appears to be extremely low. This should provide reassurance to vaccine providers considering the increasing use of Tdap vaccines in the adult population, including in pregnant women. Future research into Arthus reaction following immunization would benefit from the development of a standard case-definition." This article corresponding to this case is not available for regulatory submission due to copyright restriction. This is 1 of the 10 valid cases reported in the same literature article.; Sender's Comments:  US-GLAXOSMITHKLINE-US2020GSK143477:Same reporter