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Case Report

An 8-year-old boy presented to o ur outpa tient

clinic with a two-da y history of a m ildly pruritic

disseminated eruption. He had been treated

with steroids for six months for nephrotic syn-

drom e. Four mo nths prior to h is admission, he

had discontinued the intake of corticosteroids.

H e received o ne d ose of synth etic hepatitis B

(G enH evac B Pasteur, Pa steur Mrieux, Lyon ,

France) and polyvalent pneumococcal vaccine

(P neum o 23, Pasteur Mrieux, Lyon , France) 15

days prior to his admission. There had been no

drug in take during the previous four mon ths.

On physical examinat ion, the pat ient ap-

peared well. There were multiple, erythema tous,

oval, papulosqua mous lesions distributed o n th e

trunk and extremities, many of which ha d pe-

ripheral scales (Fig. 1). The long axis of each le-

sion was parallel to skin lines, giving the firtree d istribution pa ttern, which is chara cteristic

of pityriasis rosea. Examina tion o f mucosa an d

nails revealed no abnormalities. When ques-

tioned about prodromal symptoms for viral in-

fections, the patient denied any history of pre-

ceding illness. In vestigation of scrapin gs using

potassium hydroxide failed to show any evi-

dence of fun gal infection.

Serologic tests for syphilis, results of com plete

blood coun t, blood smear, and measurement of

Received May 23, 2002; accepted for publication

Jan uary 21, 2003.

Departments of Dermatology, *Pediatrics, **Path-

ology, Faculty of Medicine, Kahramanmaras, Turkey.

***Department of Pediatric Nephrology, Faculty

of Medicine, G aziantep U niversity, Gazian tep, Turkey.

Reprint requests to: Dr. Sezai Sasmaz, Kahraman-

maras Sutcuimam Universitesi, Tip Fakultesi Derma-

tolo ji Ana bilim Da li, 46050 Kah ram an mar as, Turkey.

The Journa l of DermatologyVol. 30: 245247, 2003

Short reports

Pityriasis Rosea-Like Eruption Due to Pneumococcal

Vaccine in a Ch ild with Nephrotic Syndrome

Sezai Sasmaz, H amza Karabiber*, Cetin B oran **,

Mesut Garipardic* and Ayse Balat***

Abstract

A pityriasis rosea-like eruption can occur a s a con seq uence o f treatm ents with go ld co m-

pounds and capto pril. It has rarely been repor ted to have an association with vaccination s

such as smallpox, BCG , hepatitis B, an d d iphtheria to xoid. It h as not previously been d oc-

umented to d evelop after pneum ococcal vaccination. We repor t a case of pityriasis rosea-

like eruption that developed fo llowing pn eumoco ccal vaccination in a child with nephrot-

ic synd rome.

Key words: pityriasis rosea; pn eumoco ccal vaccine; n ephro tic synd rome

Fig. 1. Clinical appearance of the eruptions on

the upper extremity

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Sasmaz et a l

erythrocyte sedimen tation rate were all nega tive

or within normal limits. The skin biopsy showed

a mononuclear perivascular infiltrate in the

upper dermis, which invaded the epidermis fo-

cally. In the epidermis, there were spongiosis,

patchy parakeratosis, and irregular acanthosis.

Scattered extravasated erythrocytes were seen in

the papillary dermis (Fig. 2). These anamnestic,

clinical and h istopath ologic find ings verified the

diagnosis of pityriasis rosea-like eruption .

The patient was treated symptomatically with

oral loratadine an d topical steroid, and the le-

sions disappeared within two weeks. The patient

received only two doses of hepatitis B vaccine

one month and six months after the first dose.

Recurrence of eruption was not seen following

these vaccinations.

Discussion

Pityriasis rosea is a unique disorder thatusually begins as a single, large, round or

oval pinkish patch known as the herald

pat ch. This is followed in about 2 weeks by a

blossoming of small, flat , round or oval,

scaly patches of similar color, each with a

central collarette scale, usually distributed

in a fir tree pattern o ver the trunk and , to

a lesser degree, the extremities. However, in

dr ug-ind uced p ityriasis rosea, th e her ald

patch is usually absent, an d th e eruption will

often no t follow the classic pattern . Pityriasis

rosea-like eruptio ns h ave been report ed

with ca ptopril, metronida zole, isotretinoin ,

D-penicillamin e, levamisole, bismuth , go ld,

barbitura tes, ketotifen, clonidin e, arsenic,and certain vaccinations such as smallpox,

BCG , and diphth eria toxoid (13). A single

case has been reported with hepatitis B vac-

cine (4). The literature do es not include

an y men tion of a p ityriasis rosea-like erup-

tion as a side effect of pneumococcal vacci-

nation.

In our case, the eruption was most likely

caused by pneumococcal vaccine for several

reasons: (i) there was a strong corr elation

between th e time course of th e reaction an d

the administration of pneumococcal vac-

cine, (ii) no recurrence of eruptions was

seen after second an d third do ses of vacci-

na tion when th e patient received hepatitis B

alone, and (iii) the ab sence of herald patch

in our case just like in most of the drug in-

duced pityriasis rosea ca ses.

Pneumococcal vaccine is occasionally

given to patien ts with a risk of immun e defi-

ciency. In ad dition to preservatives an d ad ju-

vant agents, it contains a ba cterial an tigen

with a po lysaccha ride structure. Cutaneo usside effects of this vaccine are not frequent.

Reports have been published describing

Sweets syndrome (5), acute exanthematous

pustular dermatit is (6) and keratoacan-

thoma (7) after pneumococcal vaccination.

Moreover, Kikuchi et al. reported a case of

generalized eruption and nephrotic syn-

drom e following the pn eumococcal vaccina-

tion, and blamed th e cellular immune reac-

tion on the vaccine (8).

We are n ot a ware of a ny case of an associ-ation between P R and nephrotic synd rome

in the literature and do not know if, in our

patient, it was fortuitous or not. In fact ,

pityriasis rosea is not an unco mmo n d isease

and may coincide by chan ce with a num ber

of internal disorders. Nevertheless, both

nephrotic syndrome and pityriasis rosea are

known to be induced by immune mecha-

nisms or infectious agents similarly. In the

pathogenesis of both diseases, the role of T

246

Fig. 2. Superficial perivascular infiltrate of lym-

phocytes that exten d to the epidermis where

irregular acanthosis and spongiosis are seen

(H & E,

100).

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Pit yriasis Rosea-Like Erupt ion

cell-mediated hypersensitivity is stressed

owing to th e fact that the population of T

lymph ocytes increases in the glomeru li in

neph rotic synd rome and in the lesiona l skin

in pityriasis rosea (3, 9). In addition to this,another finding to support the coexistence

of both diseases is the higher occurrence of

the prevalence of allergic symptoms in the

patients with n ephrotic synd rome (10). So,

the un derlying cause of eruption in o ur case

could be a bacterial antigen in pneumococ-

cal vaccin e itself or T cell-med iated patho lo-

gy.

Our case is the first from two points of

view: (i) it occurred following the adminis-

tration o f pneumo coccal vaccine, an d ( ii) it

had an association with nephrotic syn-

drome.

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