“COVID-19/SARS-CoV-2 virus spike protein-related delayed inflammatory reaction to hyaluronic acid dermal fillers: a challenging clinical conundrum in diagnosis and treatment”

Abstract

We present the first reported cases of delayed inflammatory reactions (DIR) to hyaluronic acid (HA) dermal fillers after exposure to the COVID-19 spike protein. DIR to HA is reported to occur in the different scenarios including: secondary to poor injection technique, following dental cleaning procedures, following bacterial/viral illness, and after vaccination. In this report of 4 cases with distinct clinical histories and presentations: one case occured following a community acquired COVID-19 infection, one case occured in a study subject in the mRNA-1273 clinical phase III trial, one case occurred following the first dose of publically available mRNA-1273 vaccine (Moderna, Cambridge MA), and the last case occurred after the second dose of BNT162b2 vaccine (Pfizer, New York, NY). Injectable HA dermal fillers are prevalent in aesthetic medicine for facial rejuvenation. Structural modifications in the crosslinking of HA fillers have enhanced the products' resistance to enzymatic breakdown and thus increased injected product longevity, however, have also led to a rise in DIR. Previous, DIR to HA dermal fillers can present clinically as edema with symptomatic and inflammatory erythematous papules and nodules. The mechanism of action for the delayed reaction to HA fillers is unknown and is likely to be multifactorial in nature. A potential mechanism of DIR to HA fillers in COVID-19 related cases is binding and blockade of angiotensin 2 converting enzyme receptors (ACE2), which are targeted by the SARS-CoV-2 virus spike protein to gain entry into the cell. Spike protein interaction with dermal ACE2 receptors favors a pro-inflammatory, loco-regional TH1 cascade, promoting a CD8+T cell mediated reaction to incipient granulomas, which previously formed around residual HA particles. Management to suppress the inflammatory response in the native COVID-19 case required high-dose corticosteroids (CS) to suppress inflammatory pathways, with concurrent ACE2 upregulation, along with high-dose intralesional hyaluronidase to dissolve the inciting HA filler. With regards to the two vaccine related cases; in the mRNA-1273 case, a low dose angiotensin converting enzyme inhibitor (ACE-I) was utilized for treatment, to reduce pro-inflammatory Angiotensin II. Whereas, in the BNT162b2 case the filler reaction was suppressed with oral corticosteroids. Regarding final disposition of the cases; the vaccine-related cases returned to baseline appearance within 3 days, whereas the native COVID-19 case continued to have migratory, evanescent, periorbital edema for weeks which ultimately subsided.

Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases

“…1 These reactions may represent a delayed hypersensitivity to filler following the introduction of an immunologic trigger, 15 and have been previously noted after other viral illnesses 16 and influenza vaccines. 1,17 It is important to distinguish immediate hypersensitivity reactions, defined by the Centers for Disease Control and Prevention as including pruritus, urticaria, flushing, and angioedema occurring within the first 4 hours of an injection, from similar reactions that occur [4 hours after injection. 18 This distinction is particularly relevant for urticaria and angioedema, which are potential contraindications for a second vaccine dose.…”

The Immunogenicity of Hyaluronic Fillers and Its Consequences

“…Some authors also described a genetic predisposition underlying the reaction in individuals with the following subtypes: HLA B * 08 or DRB1 * 03.4 (a fourfold increase in the risk). 13,62 Diagnostics DIR-related lesions are of inflammatory nodular character. They should be differentiated with nodules caused by biofilm, abscesses (softening, fluctuance), granulomatous reactions (hard, inflammatory nodules).…”

“…1,33,49 Foreign body granulomas are not a typical allergic reaction, but they are caused by a sudden stimulation of macrophage memory. 62 The reasons for the development of severe inflammatory granulomatous processes have not been precisely elucidated. 49 It is not fully known why such a reaction only occurs in some patients (from 0.01% to 1.0%) and usually develops after 6-24 months at all injection sites at the same time.…”

BCG Scar Local Skin Inflammation as a Novel Reaction Following mRNA COVID-19 Vaccines in Two International Healthcare Workers

“…Munavalli et al [13] mention that even though the mechanism of action for the delayed reaction to HA fillers remains unknown and is likely to be of multifactorial nature, a potential mechanism of delayed inflammatory reactions (DIR) to HA fillers in COVID-19-related cases is the binding and blockade of angiotensin 2 converting enzyme receptors (ACE2), which are targeted by the SARS-CoV-2 virus spike protein to gain entry into the cell. Spike protein interaction with dermal ACE2 receptors favors a proinflammatory, loco-regional TH1 cascade, promoting a CD8+T cell-mediated reaction to incipient granulomas, which previously formed around residual HA particles [13].…”