EBA skin lesions recurred after COVID-19 vaccination: Case report

Researchers say vaccine may have reactivated autoantibodies in patient's blood

Andrea Lobo, PhD avatar

by Andrea Lobo, PhD |

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Lesions in the skin and mucosa in a 20-year-old woman with epidermolysis bullosa acquisita (EBA) came back years later, after a COVID-19 vaccination, according to a case report.

While rapid development of skin disease after receiving vaccinations had been reported, this is the first case of possible EBA with autoantibodies (self-reactive antibodies), in which lesions recurred shortly after a COVID-19 vaccination.

The study, “Case report: A case of epidermolysis bullosa acquisita with IgG and IgM anti-basement membrane zone antibodies relapsed after COVID-19 mRNA vaccination,” was published in the journal Frontiers in Medicine.

EBA is an autoimmune disorder characterized by skin blistering, mostly in mucous membranes — which line body cavities, such as the mouth, nose, and eyes — as well as in the hands, feet, knees, elbows, and buttocks.

It is caused by antibodies generated against a protein called type VII collagen, a major structural protein of anchoring fibrils, which ensure the connection of the epidermis (the top layer of the skin) with the dermal layer underneath.

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Recurrence of lesions happened two days after vaccination

Here, researchers in Japan reported the case of a young woman who showed a recurrence of skin and mucosa lesions two days after a COVID-19 vaccination using messenger RNA (mRNA) technology (which includes the Pfizer-BioNTech and the Moderna vaccines).

The patient, who had no relevant medical history, first presented at age 16 with erosions — a breakdown of the outer layer — of the lips. A physical examination revealed blisters, erosions, and erythema (redness) in the face, lips, back, shoulders, and arms.

Further analysis revealed blisters just below the epidermis (subepidermal), and deposits of antibodies (IgG, IgM, and C3) in the basement membrane zone, the fine sheet that lies between the epidermis and the dermis, and attaches these layers together.

She was diagnosed with EBA, with IgM antibodies against an unknown target protein and IgG antibodies (the most abundant antibody class in humans) against collagen type VIII. Treatment with oral prednisolone at 30 mg/day was initiated, which gradually eased the skin and oral mucosa symptoms. Prednisolone is a corticosteroid, an anti-inflammatory therapy that works by suppressing the immune system.

However, skin lesions could not be effectively treated, and the patient stayed on prednisolone for four years until recurrence, when she was receiving prednisolone at 2 mg/day.

The patient experienced fever after the first dose of a COVID-19 mRNA vaccine and skin lesions two days later.

Piece of mRNA introduced during vaccination

mRNA vaccines introduce a piece of mRNA, an intermediate molecule between genes and the proteins they produce, that corresponds to a viral protein, usually a small piece of the virus’s outer membrane.

A physical examination at the hospital revealed the same skin symptoms as on the first visit. Also as seen before, she had subepidermal blisters and IgG, IgM and C3c antibody deposits in the basement membrane zone.

After increasing the prednisolone dose from 2 to 15 mg/day, the lesions resolved in a week.

“This case showed the recurrence only 2 days after vaccination, and therefore it may be difficult to conclude that the recurrence of the skin lesions is attributed to vaccination,” the team wrote. “Indeed, 2 days are too short for pathogenic [disease-related] plasma cells to produce autoantibodies.”

Among the possible reasons for the quick skin lesion recurrence in this case, the scientists said that the autoantibodies persisted in the patient’s blood and might have been reactivated by vaccination.

The researchers noted previous studies reported skin lesions in patients with various autoimmune skin diseases about one week after COVID-19 vaccination. Thus, the investigators considered that this case might be a recurrence of the previous autoimmune skin disease after the vaccination.

“Clinicians should be aware that [autoimmune bullous diseases, AIBDs], including EBA … might be developed after COVID-19 mRNA vaccination,” the researchers concluded. “However, because corticosteroid treatment might have a beneficial effect on COVID-19, abrupt termination or quick dose reduction of systemic [body-wide] corticosteroids should be avoided in severe AIBDs.”