A 33-year-old white female presented to dermatology clinic with a three-month history of swelling and itching of blue-ink tattoos over each of her deltoid muscles. These symptoms began within one week of receiving intramuscular H1N1 vaccine (Sanofi-Pasteur, multidose vial containing 0.01% thimerosal, lot number UP005AA with expiration date March 15th 2011) into the right deltoid muscle superior to the tattoo on the right deltoid. These tattoos were placed eight years prior at different tattoo parlors. The patient denied past cutaneous eruptions or history of sarcoidosis or other vaccines or tattoos during this period. Past medical history included depression treated with depakote and haloperidol; hysterectomy with right oophorectomy and obesity. No medications had changed in the previous four months. Social history included occasional alcohol use but no tobacco or intravenous drug abuse. Physical examination showed induration confined to the blue-ink containing skin of two tattoos over the patient's deltoid muscles ( Figure 1). Other tattoos containing black, red and yellow ink were not affected.Histology of the punch biopsy specimen revealed noncaseating granulomas containing fine black granules (Figure 2). Staining revealed no evidence of acid-fast bacilli or fungi. Pathohistological differential diagnosis was sarcoidosis versus granulomatous reaction to pigment granules.Workup for sarcoidosis included chest X-rays, pulmonary function testing, ophthalmological examination and angiotensin converting enzyme serum levels. All studies were within normal limits except for pulmonary function testing which revealed a moderate restrictive lung defect. The patient declined further workup, as well as referral to a pulmonologist. A diagnosis was made of granulomatous reaction confined to blue-ink tattoos possibly triggered by H1N1 vaccine. After failing a trial of clobetasol ointment twice daily the patient is currently well-controlled with intralesional injections of triamcinolone acetonide. CommentNoncaseating granulomas in patients with edema and pruritus of tattoos have been attributed to both sarcoidosis and delayed type hypersensitivity reactions.1 Sarcoidosis cannot be excluded even if foreign pigment is found in a biopsy site [1].Sarcoidosis is a common disorder of the lungs and skin with AbstractNoncaseating granulomas occur due to a hypersensitivity reaction to an exogenous antigen. The introduction of the H1N1 vaccine has been successful in disease prevention but we expand the current literature on possible adverse reactions to the vaccine to include granulomatous reactions.
Objectives: Covid-19 epidemic has led to thousands of hospitalized patients and the fear of long-term pulmonary sequelae is real. This preliminary study aimed at describing the pattern of lung parenchymal lesions in patients at the time of clinical recovery. Methods Patients who were hospitalized for a severe Covid-19 pneumonia and who underwent a CTchest less at the time of discharge were included. CT scan parenchymal lesions were classified using international recommendations and compared to the diagnostic CT scan. Results We included 32 patients, median age 57 yo [26-89]. Out of them, 10 patients required ICU admission. The median hospital stay was 12 days [4-28]. All CT chest at discharge showed persistent parenchymal abnormalities regardless of the time of clinical recovery or ICU requirement. The main radiological pattern at admission was bilateral ground glass opacities in 28/30 (93.3%), associated in 12 patients (40%) with areas of consolidation, and organized pneumonia in 8 patients (27%). At discharge, the main radiological pattern remained bilateral ground glass opacities in 29/32 patients (91%) associated with consolidation in 3/32 patients (9%) and organized pneumonia in 25/32 patients (78%). There was no correlation between lesions extent and clinical severity, particularly ICU requirement. Conclusion CT-chest of patients recovering from severe covid-19 show parenchymal persistent abnormalities: careful consideration of the organisation of recovery of lung function follow-up is thus needed and the question of antifibrotic agent usefulness may be anticipated.Conclusion CT-chest of patients recovering from severe covid-19 show parenchymal persistent abnormalities : careful consideration of the organisation of recovery of lung function follow-up is thus needed and the question of antifibrotic agent usefulness may be anticipated.
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