Post-vaccination COVID Toes (Chilblains) Exacerbated by Rituximab Infusion Suggests Interferon Activation as Mechanism

Abstract

Coronavirus disease (COVID) toes are pernio-like skin lesions associated with severe acute respiratory syndrome coronavirus 2. We observed pernio-like skin findings presenting after a Pfizer BioNTech vaccine, which significantly worsened after an infusion of rituximab. This suggests that the mechanism for COVID toes is interferon activation. Military providers may avoid unnecessary referrals for this self-limiting condition by anticipating this adverse effect.

Cutaneous Complications of mRNA and AZD1222 COVID-19 Vaccines: A Worldwide Review

“…Pernio-like lesions and purpuric eruptions have been reported post-COVID-19 vaccination ( Figure 5 ). Of the 41 cases described in 11 observational studies [ 1 , 2 , 21 , 23 , 24 , 27 , 51 , 52 , 53 , 54 , 55 , 56 ], 25 (61.0%) were associated with BNT162b2, 9 (22.0%) with ADZ1222, and 7 (17.1%) with mRNA-1273 vaccination ( Table 1 ). In a series of 16 patients, purpuric manifestations appeared at a mean of 7.6 days after COVID-19 vaccination and lasted a mean of 15.7 days [ 2 ].…”

Post-SARS-CoV-2 vaccination COVID toes and fingers

“…(2021) suffered from Sjögren’s syndrome and rheumatoid arthritis. After application of rituximab for her rheumatologic disorders, she experienced a worsening of the post-vaccination COVID toes within hours [ 9 ]. While most cases have been reported after mRNA vaccination, recently, the case of a woman developing such lesions after the first shot of an adenoviral vector-based COVID vaccination (AZD1222; Oxford/AstraZeneca) was reported [ 10 ].…”

Self-limiting pernio-like ‘Covid-Toe’ reaction following oxford-astrazeneca vaccination in a renal transplant patient

“…Our patient's lack of reaction during a subsequent SARS-CoV-2 infection may support this theory. Additionally, there has been documented exacerbation of the reaction following Rituximab infusions which suggests an immune-mediated process [9].…”