Case Report of Subcutaneous Nodules and Sterile Abscesses Due to Delayed Type Hypersensitivity to Aluminum-Containing Vaccines

Abstract

Routine childhood immunizations have resulted in great reductions in vaccine-preventable infectious diseases. Vaccine-related adverse events, albeit rare, can be of significant consequence. Although anaphylaxis, or type I hypersensitivity, is recognized as a potential reaction after vaccination, delayed type hypersensitivity or type IV reactions are less so. We present a case of persistent subcutaneous nodules and sterile abscesses in the setting of delayed type hypersensitivity to aluminum, confirmed by patch testing and recurrence on re-exposure. We review sources of aluminum in common immunizations, principles for treatment, and strategies for management of future vaccinations for this patient.

Delayed‐type hypersensitivity to vaccine aluminum adjuvant causing subcutaneous leg mass and urticaria in a child

“…Injection‐associated granulomas are a rare side effect of immunizations, with reported frequencies of 0.35%‐1.18% . Although this reaction is more commonly reported in young children, probably because of their frequent vaccination schedule, adults have presented with similar findings after allergen immunotherapy and human papilloma virus vaccination, which both contain aluminum adjuvants . It has been hypothesized that subcutaneous granuloma formation may occur secondary to unintentional superficial deposition of an intramuscular vaccine .…”

Sonographic features of vaccination granulomas in children with delayed‐type hypersensitivity to aluminum

“…The coat variability would reflect the entity of the follicular infiltrate, which increases in the phases of swelling and pruritus, usually triggered by intercurrent infections and consequent lymphocytes activation. In this model, a priming of the antigen presenting cells may have occurred, and explains the reasons for the Al sensitization at patch tests.…”

“…High potency topical steroids (clobetasol propionate 0.05% ointment) were prescribed once daily for flares, and gradually tapered or replaced with self‐adhesive betamethasone valerate 0.1% patches over a few week period, according to the sonographic evaluation. Hydrocolloid dressings, topical capsaicin, intralesional corticosteroids could be considered as valid therapeutic alternatives to control scratching and to reduce inflammation …”

“…The clinical presentation changes over time, as it usually manifests with one or more palpable subcutaneous pruritic nodules with associated local skin changes, including erythema with papulovesicular elements (mimicking relapsing eczema), hypertrichosis, bluish discoloration, and excoriations . The natural evolution of VG is rather peculiar and is characterized by a delayed onset after vaccination (weeks to months) and a prolonged course, often flared up by upper respiratory infections or subsequent vaccine administrations .…”

“…The clinical presentation changes over time, as it usually manifests with one or more palpable subcutaneous pruritic nodules with associated local skin changes, including erythema with papulovesicular elements (mimicking relapsing eczema), hypertrichosis, bluish discoloration, and excoriations . The natural evolution of VG is rather peculiar and is characterized by a delayed onset after vaccination (weeks to months) and a prolonged course, often flared up by upper respiratory infections or subsequent vaccine administrations . A1 hydroxide or, less frequently, A1 phosphate salts are used as adjuvants in vaccines against diphtheria, tetanus, pertussis, hepatitis B, human papilloma virus (HPV), and tick‐borne encephalitis (TBE), in pneumococcal and meningococcal conjugate vaccines and in several vaccine formulations against hepatitis A …”