Localized bullous fixed drug eruption following yellow fever vaccine
Authors: Eric Y. Sako, Ashley Rubin, Lorraine C. Young
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: Yellow fever is a potentially fatal, mosquito-borne disease endemic to areas of South America and Africa. The yellow fever vaccine is recommended to those traveling to high-risk areas and is considered one of the safest and most effective vaccines ever developed. The vaccine is a live attenuated version of the 17D strain grown in egg embryos and imparts durable immunity for 10 years. Reported dermatologic side effects of the vaccine include mild injection site reactions, urticaria, and anaphylaxis.1Barbaud A. Deschildre A. Waton J. Raison-Peyron N. Trechot P. Hypersensitivity and vaccines: an update.Eur J Dermatol. 2013; 23: 135-141PubMed Google Scholar We report a case of an injection site reaction followed by a localized bullous fixed drug eruption after the administration of the yellow fever vaccine. Hours after receiving the vaccine, a painful edematous plaque developed at the injection site in a healthy 56-year-old woman. Four days later, she reported development of large, asymptomatic bullae localized to her nose. The lesions increased in size and eventually ruptured with minimal crust. She presented to our clinic 10 days after receiving the vaccine. The patient had no known allergies to medications, eggs, or vaccines, and denied a history of herpes or changes to her medication regimen. She reported no insect bites, trauma, or burns to the area. On exam, there was a 1.2-cm erythematous, circular, superficial erosion with desquamative scale overlying the left nasal ala with scant hemorrhagic and serous crust (Fig 1). Superficial erosions were also appreciated on the columella. An erythematous patch surrounded the injection site on the upper right arm. Biopsy, culture, and direct immunofluorescence were deferred given the benign exam. Because the lesions were healing, no specific treatment was indicated. The eruption cleared 2 days later without scarring or dyspigmentation. The history and clinical findings were consistent with the yellow fever vaccine producing a mild injection site reaction and subsequent bullous fixed drug eruption on the left nasal ala. Herpes simplex, herpes zoster, and arthropod bites, while considered with findings of bullae, were unlikely here given the history, time course, and lack of symptoms. The possibility of bullous impetigo was also weighed but the characteristic turbid vesicular fluid and yellow crusting were not present and the patient did not possess risk factors such as sick contacts. Autoimmune blistering diseases were not favored due to the localized and self-limited nature of the lesions. Although rare, various bullous eruptions have been described following vaccination. Bullous pemphigoid has been reported to occur most commonly after receipt of the influenza vaccine, as well as after receipt of the diphtheria-tetanus-pertussis vaccine.2Sezin T. Egozi E. Hillou W. Avitan-Hersh E. Bergman R. Anti—laminin-332 mucous membrane pemphigoid developing after a diphtheria tetanus vaccination.JAMA Dermatol. 2013; 149: 858-862Crossref PubMed Scopus (16) Google Scholar Influenza and human papillomavirus vaccinations have triggered the appearance of linear IgA bullous disease.3Alberta-Wszolek L. Mousette A.M. Mahalingam M. Levin N.A. Linear IgA bullous dermatosis following influenza vaccination.Dermatol Online J. 2009; 15: 3PubMed Google Scholar, 4Ikeya S. Urano S. Tokura Y. Linear IgA bullous dermatosis following human papillomavirus vaccination.Eur J Dermatol. 2012; 22: 787-788PubMed Google Scholar Generalized bullous fixed drug eruption has developed after receipt of the flu vaccine.5Garcia-Doval I. Roson E. Feal C. De la Torre C. Rodriguez T. Cruces M.J. Generalized bullous fixed drug eruption after influenza vaccination, simulating bullous pemphigoid.Acta Derm Venereol. 2001; 81: 450-451Crossref PubMed Scopus (28) Google Scholar Unlike our patient's limited and self-resolved eruption, these eruptions were widespread, generally requiring systemic therapy and an autoimmune workup. This localized, yet distant, bullous fixed drug reaction to the injection site in our patient likely represents a benign, idiosyncratic reaction to the vaccine that requires no treatment.