Generalized bullous fixed drug eruption after influenza vaccination, simulating bullous pemphigoid.

A 90-year-old woman was seen with a generalized bullous eruption. She did not remember suŒering from similar lesions previously. She had hypertension treated for more than one year with hydrochlorothiazide and valsartan (Co-diovanâ ). Six weeks before the start of cutaneous lesions, nimodipine (Nimotopâ ) and ginko biloba (Tanakeneâ ) had been added to her therapy. In October 2000 she received an in ̄ uenza vaccination. She denied intake of paracetamol or any other new drug. Twelve hours after administration of the in ̄ uenza vaccine, she noticed pruritus in her genital area and legs. Twenty-four hours after the vaccination, well-demarcated erythematous macules and large bullae appeared on these areas, and later on the trunk, hands and face (Figs. 1 and 2). Some lesions had a darker centre. She had oral and genital erosions. Systemic symptoms were absent. Suspecting the diagnosis of bullous pemphigoid, a cutaneous biopsy was taken, and therapy was started with 30mg of prednisone. Histology of a skin lesion showed a prominent subepidermal bulla with scarce perivascular mixed in ̄ ammatory in® ltrates, focal hydropic degeneration of the basal layer, pigmentary incontinence, dyskeratotic keratinocytes with pyknotic nuclei in the epidermis and papillary dermis, and areas of con ̄ uent Fig. 1. Erosions after the rupture of large bullae. epidermal necrosis. Direct and indirect immuno ̄uorescence were negative. Ten days after its institution, prednisone and systemic symptoms, the spontaneous resolution in 2 weeks the rest of her therapy were withdrawn. Bullae disappeared in without recurrence (but leaving persistent pigmentedmacules), 2 weeks, and no new lesions had appeared after 10 months, and the characteristic histology and negative immuno ̄uorebut residual pigmentedmacules persisted. She remained normoscence. The lack of a history of previous localized lesions tensive on a low-sodium content diet. According to the manucould be an argument against this diagnosis. However, in an facturer, in ̄ uenza vaccine (Vacuna antigripal Pasteurâ ) is an old patient with some cognitive disturbances minor lesions inactivated subunit split vaccine that contains hemagglutinin, could easily remain unnoticed. Moreover, the diagnosis of neuraminidase, and residual internal viral structural proteins, ® xed drug eruption can be made on the ® rst episode (4). as well as thiomersal, formaldehyde, neomycin, phosphate Generalized bullous ® xed drug eruption diŒerential buŒered saline and octoxinol-9. 2000-01serotypes were diagnosis includes toxic epidermal necrolysis and bullous A/Moscow/10/99 (H3N2), A/New Caledonia/20/99 (H1N1) pemphigoid. The ® nding, in some cases, of C3 and IgM and B/Beijing/184/93. Standard patch tests, including all the deposition along the basement membrane during the early components (except for octoxinol-9), and patch test with the phases of ® xed drug eruption, can make the distinction from vaccine `̀ as is’ ’ , in previously aŒected skin, gave negative bullous pemphigoid more di cult (5). results. Temporal criteria led us to consider in ̄ uenza vaccination as the trigger of this patient eruption. The latent period after DISCUSSION the supposed trigger for ® xed drug eruption is characteristically very short (5, 6). In ̄ uenza vaccination was the only drug We made the diagnosis of generalized bullous ® xed drug started shortly before the eruption. Taking into account the eruption on the basis of the clinical picture of well-demarcated severity of her lesions, we considered it unethical to perform polycyclic lesions aŒecting the face and mucosae, the lack of