Combined Reduced-Antigen Content Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccine-Related Erythema Nodosum: Case Report and Review of Vaccine-Associated Erythema Nodosum
A healthy 39-year-old Japanese woman visited her primary care physician for an annual examination. She had received all of her childhood vaccinations without any complications. She did not have any history of preceding infections, sore throat or diarrhea. She also had no prior or current skin or systemic diseases and her laboratory studies were normal. There was no personal or family history of tuberculosis. Her physician recommended prophylactic vaccination with combined tetanus-diphtheria-pertussis (Tdap) vaccine since her booster immunization was due. Informed consent was obtained from the patient for being included in the study and for the publishing of photographs. This article does not contain any studies with human subjects performed by the author.\nWithin 24 h of receiving Tdap vaccine, she noted several areas of pruritus and swelling on her distal lower extremities. During the next 24 h these areas enlarged and developed into tender red nodules. The painful nodules persisted and she sought dermatologic medical attention.\nCutaneous examination, 7 days after receiving Tdap vaccine, revealed tender erythematous nodules on her legs (Fig. ). There was a large, 12 by 8 cm, erythematous nodule on distal pretibial left leg (Fig. ). 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) (Fig. ).\nCorrelation of her 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, she had not receiving any topical or systemic medications. Also, she had no recent streptococcal pharyngitis or systemic conditions such as Crohn’s disease, sarcoidosis, or tuberculosis. Therefore, the temporal association between her recent Tdap vaccination and the development of the skin lesion suggested that the development of her erythema nodosum was related to her receiving Tdap vaccine.\nSymptomatic 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 was started: 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). Her symptoms began to improve and the nodules started to flatten within 3 days.\nFollow-up examination occurred 2 weeks after her initial visit. Her symptoms had completely resolved. One of the nodules proximal to her right ankle was smaller, yet palpable with mild erythema of the skin. All of her other nodules had completely flattened and there was macular hyperpigmentation at the sites.