The patient is a 30 yo male who received JE #1 lot #JEV13H43E on 14 July 2015. He reports the next day he developed a generalized pruritic exanthem that initially presented to his face then spread to his trunk and peripherally to all extremities to the elbow and knees, but not more distal. The lesions do not resolve and develop new ones. He states the lesions are discrete and erythematous, but has difficulty describing them further. He denies vesicles or pustules. He denies oral lesions. He states he fells well and has felt well. The dermatitis has improved after therapy. The pruritus has improved after therapy. He denies any immediate symptom reaction including shortness of breath, hives, or facial/oral swelling. He denies any local site reaction of redness, swelling or pain. He denies systemic symptoms of fever, chills, malaise, cough, chest pain, nausea, emesis, diarrhea, myalgias or arthralgias. He denies any pre-vaccine symptoms of illness including fever, chills, malaise, nasal stuffiness, cough, chest pain, nausea, emesis, diarrhea. He denies any history of eczema or atopy. No history of adverse reactions to drugs. No history of adverse reactions to hymenoptera stings. No history consistent with food intolerance. No history consistent with latex intolerance. Current medication including OTC meds, vitamins, herbals, etc. ZYRTEC, hydroxyzine. Past medical/surgical history reported: Medical: Reported medical history none. Surgical / Procedural: Surgical / procedural history appendectomy age 6-7. Personal history Social history reviewed does not smoke or drink. Engineer. Family History Family medical history mother age 53 healthy, father age 55 healthy, no family hx atopy. Review of systems: GENERAL: no night sweats or weight loss HEENT: no ear, or throat pain, no nasal blockage or discharge HEART: no chest pain RESP: no shortness of breath or cough GI: no abdominal pain, constipation GU: no urgency, dysuria, frequency, back pain. Physical findings General: Physical examination speech clear thought cogent and organized. A/P Last updated at 03 Aug 2015 1458 EDT 1. SKIN DISORDER EXANTHEM: The patient is a 30 yo male who received JE vaccine IXARIO #1 lot #JEV13H43E on 14 July 2015 and developed a generalized pruritic exanthem, per chart review lesions were papular and monomorphic, appearing 1 day later. This is inconsistent with a hypersensitivity reaction. Per patient lesions have improved but not resolved after 20 days with treatment with oral and IM steroids, and currently oral cetirizine and hydroxyzine. He was seen by Allergy clinic who contacted office for consideration of vaccine induced exanthem, with specific consideration for Gianotti-Crosti Syndrome. The differential diagnosis includes cutaneous drug eruption, a number of viral induced dermatoses, and vasculitides. Vaccine induced adverse reactions are generally a diagnosis of exclusion. The patient had no other symptoms of illness suggesting a viral etiology. JE is the only vaccine the patient received and his dermatitis onset is temporally consistent. Japanese encephalitis vaccine has been associated with dermatitis in pretrial studies 0.8% of adults, however the product literature is not more specific on the type of dermatoses seen. Per UpToDate Gianotti-Crosti is a papular acrodermatitis which historically described three cardinal manifestations of the acral dermatitis, lymphadenopathy and acute hepatitis, although the lymphadenopathy and hepatitis need not be present for the diagnosis. It is most common in children and associated with viral illness, although it has been associated with vaccine receipt. There is a case report associated with JE-VAX, the JE vaccine prior to IXARIO in a child. Treatment is symptomatic supportive care and the course is benign. A review of VAERS reports provided 35 reports of Gianotti-Crosti that is temporally vaccine associated, none of which were JE. It should be noted this is a passive reporting system and the reports do not establish any causality. 2. Patient Counseling: I discussed the differential, and possible vaccine reactions with the patient and address his concerns there is no risk for communicability if it is vaccine related. Per literature if it is viral in origin transmission would be related to the virus transmission, but that is still unlikely. I recommend: Continue current supportive plan of care. Followup as planned with Allergy clinic. Consider biopsy of lesions if they continue to persist. Consider Serologic evaluation of LAE, HBV, CMV to rule out other causes of GCS. Consider evaluate for lymphadenopathy and for hepatomegaly, consider further hepatic evaluation if present LFTs and hep B. Per his vaccine record he has only received hep B #1, although most accessions complete this series. Consider CBC to evaluate for eosinophilia which may be seen in drug eruptions, although this is suggestive but not diagnostic. I recommend exemption from all vaccines until symptoms resolve unless an alternate etiology is identified. I recommend permanent exemption from JE #2 and education on insect precautions. In a immunogenicity pre-licensing evaluation 39.8 % of recipients achieved adequate titers at day 28 post dose #1 vaccine receipt, although long term immunity is unknown. I also recommend exemption from smallpox vaccine for now due to association with GCS with atopy. I provided my contact numbers to the patient for any further questions and will continue to follow.