Rare systemic dermatologic reaction after pneumococcal vaccine administration. (Case Report).

Abstract: This case report describes a rare dermatologic reaction in a patient after administration of pneumococcal vaccine. A 65-year-old man developed an extensive dermatitis with pruritus, urticaria, and petechiae 1 week after receiving an intramuscular injection of the vaccine. The reaction resolved with application of topical steroids and oral diphenhydramine hydrochloride. This case report and others in the literature suggest the importance of recognizing the possibility of cutaneous adverse reactions with vaccines, such as the pneumococcal vaccine, which in general have a good safety profile.

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Streptococcus pneumoniae remains an important cause of morbidity and mortality in the United States and accounts for approximately 10 to 25% of all pneumonia, with an estimated 40,000 deaths annually. (1) Pneumococcal vaccine has been available for commercial use in the United States since 1977. Adverse reactions to the vaccine have usually been mild and of short duration and have consisted mainly of local discomfort at the site of injection and low-grade fever with frequencies of 50 and 15%, respectively. (2) According to the Centers for Disease Control and Prevention, the incidence of local side effects after primary vaccination was 50%. (3) Rodriguez and Dyer (4) reported that the incidence of local side effects after revaccination was 60%. The incidence of systemic symptoms was 4 to 8%, with minimal symptoms of fever, myalgias, and arthralgias, which were generally tolerated well and resolved within 72 hours. Examples of occasionally documented symptoms (<1%) included high fever (>38.5[degrees]C), extensi ve local reactions, headaches, nausea, photophobia, and death. (5-8) Only rarely have systemic adverse dermatologic reactions been described in the medical literature. Described in this report is an exceptionally rare systemic dermatologic reaction after pneumococcal vaccine administration. Information concerning such cutaneous reactions was sparse and scattered throughout the medical literature and is reviewed herein.

Case Report

A 65-year-old white man without known medical problems and not taking any oral prescription or nonprescription medications requested a 23 polyvalent pneumococcal vaccine, which contains 0.25% phenol in isotonic saline as a preservative. Unknown to the physician at that time was that the patient had received a pneumococcal vaccine 2 years before. At that time, the patient reported the occurrence of a localized reaction in the deltoid area with mild fever that resolved within 2 to 3 days. According to the patient, he had never received long-term medications for treatment of any chronic diseases and was unaware of any occurrence of pneumonia during his lifetime. Over the years and on several recent occasions, he had had a rash on his extremities after working in his garden, and he had treated the rash with phenolated calamine lotion, which contains 1% phenol. One day after injection in the deltoid area, local erythema and warmth with mild fever occurred but resolved in 3 to 4 days. During a period of 7 days, how ever, a diffuse maculopapular rash with pruritus, urticaria, and petechiae occurred on the entire abdominal and chest wall, with some extension to all extremities. Topical application of 1% hydrocortisone cream and oral diphenhydramine hydrochloride, 25 mg every 6 hours, led to resolution of the rash during a period of 10 days. Punch biopsy was not performed, and the patient refused skin testing. This individual had no known atopic history or allergy to medications.

Discussion

Nelson et al (9) described two cases of extensive erythematous edema and pruritus extending the length of the extremity after vaccination. Oral steroid therapy produced resolution within 5 days. Both of these individuals had had exposure to pneumococcal polysaccharide. One of them was a research technician at a laboratory in which patient specimens were tested for sensitivity to pneumococci. The second had received a pneumococcal vaccine 1 year before. Arthuslike reactions have occurred when a second dose of vaccine was administered within 3 years of the initial dose, and this reaction was hypothesized to be the response from local formation of antigen antibody complexes. (10) Rare cases of anaphylaxis that responded to standard treatment regimens have also been reported. (10)

Kelton (11) described two individuals with immune thrombocytopenia in whom three episodes of thrombocytopenia and cutaneous reactions occurred after three vaccinations, two of which were pneumococcal. The first person had received yearly influenza vaccinations without reaction and reported one episode of purpura and hemoptysis 2 weeks after administration of the vaccine. One year later and 2 weeks after the first pneumococcal vaccination, he had an abrupt onset of purpura and epistaxis. The second patient had an episode of epistaxis and generalized petechiae 10 days after the initial pneumococcal vaccination. The authors hypothesized that the close temporal relationship of the skin reactions after administration of the vaccines could have resulted from an increase in antiplatelet antibody production, leading to a relapse of their immune thrombocytopenia.

Jackson et al (7) recently showed that self-limited local injection site reactions occurred more frequently after revaccinations with pneumococcal vaccine than after first vaccinations (74 versus 57%). Most of these reactions occurred within 2 days of administration and resolved within 6 days, and the risk was not considered to be a contraindication to revaccination. However, two individuals developed adverse cutaneous reactions distant from the site of injection. In one of them, findings on punch biopsy were interpreted as superficial perivascular and interstitial dermatitis. The other individual had a maculopapular rash on the buttocks 1 week after revaccination; it spontaneously resolved, and punch biopsy was not performed.

The safety profile of this vaccine clearly has been established, but rare adverse systemic dermatologic reactions have been observed. Although the exact mechanism of the reaction in the present case was not fully determined, it was thought that, as in the cases of Nelson et al, (9) previous exposure to pneumococcal polysaccharide led to sensitization with subsequent reaction after rechallenge with this vaccine. The preservative phenol in the vaccine was not thought to be the cause of the reaction, because he had periodically used 1% phenolated calamine lotion to treat rashes that occurred on his extremities as a result of gardening.

In the two cases reported by Jackson et al, (7) as in this report, the rash occurred on the torso approximately 1 week after intramuscular injection, and the patient described here also had urticaria and petechiae. Fortunately, in this presentation as in others, the cutaneous reactions resolved with minimal intervention. Most likely, other systemic dermatologic reactions to pneumococcal vaccine have been observed but have not been reported in the medical literature. Thus, in consideration of the number of pneumococcal vaccinations and revaccinations administered yearly throughout the world, physicians should be aware of the risk of systemic cutaneous reactions to this vaccine, and recipients should be informed of such.

Accepted December 4, 2001.

References

(1.) Weaver M, Krieger J, Castorina J, Walls M, Ciske S. Cost-effectiveness of combined outreach for the pneumococcal and influenza vaccines. Arch Intern Med 2001;161:111-120.

(2.) Nichol KL, MacDonald R, Hauge M. Side effects associated with pneumococcal vaccination. Am J infect Control 1997;25:223-228.

(3.) Centers for Disease Control and Prevention: Pneumococcal polysaccharide vaccine. MMWR Morb Mortal Wkly Rep 1989;38(5):64-68, 73-76.

(4.) Rodriguez R, Dyer PD. Safety of pneumococcal revaccination. J Gen Intern Med 1995;10:511-512.

(5.) Ponka A, Leinonen M. Adverse reactions to polyvalent pneumococcal vaccine. Scand J Infect Dis 1982;14:67-71.

(6.) Overturf GD, Field R, Edmonds R. Death from type 6 pneumococcal septicemia in a vaccinated child with sickle-cell disease. N Engl J Med 1979;300: 143.

(7.) Jackson LA, Benson P, Sneller VP, et al. Safety of revaccination with pneumococcal polysaceharide vaccine. JAMA 1999;281:243-248.

(8.) Holdiness MR. Adverse cutaneous reactions to influenza vaccinations and chemotherapy. Int J Dematol 2001;40:427-430

(9.) Nelson K, Goldman JA, Perlino CA. Severe local reactions to Pneumococcal vaccine. South Med J 1980;73:264-265.

(10.) Hilleman MR, Carlson AJ Jr, McLean AA, et al: Streptococcus pneumoniae polysaccharide vaccine: Age and dose responses, safety, persistence of antibody, revaccination, and simultaneous administration of pneumococcal and influenza vaccines. Rev Infect Dig 1981;3(Suppl):S3I-S42.

(11.) Kelton JG. Vaccination-associated relapse of immune thrombocytopenia. JAMA 198l;245:369-370.

RELATED ARTICLE: Key Points

* A rare systemic dermatologic reaction to pneumococcal vaccination has been observed.

* The medical literature concerning adverse reactions of pneumococcal vaccines has been reviewed.

* With the exception of local discomfort at the site of intramuscular injection, in general the pneumococcal vaccine has a good safety profile.

From the Department of Internal Medicine, Lakeside Hospital, Metairie, LA.

Reprint requests to Mack R. Holdiness, MD, PhD, Lakeside Medical Office Building, Suite 207, 4720 I-10 Service Road, Metairie, LA 70001. Email: [e-mail]

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