AZD-1222/prednisone

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 60-year-old man developed chronic spontaneous urticaria (CSU) following administration of AZD-1222 for COVID-19 vaccination. Additionally, he developed rebound effect manifested as pruritic rash and angioedema secondary to prednisone for CSU [routes not stated].

The man who had medical history of potential anaphylactic reaction to unspecified immunotherapy (for environmental allergies 30 years previously), asthma received first dose of AZD-1222 [AstraZeneca/Oxford COVID-19] on 15 March 2021. He had been receiving unspecified antihistamine for environmental allergies. After five days of AZD-1222 administration, he developed erythema on his palms, cheeks followed by a pruritic rash on scalp, face, neck, shoulders and armpits. Thereafter, he visited pharmacist, who suggested bilastine and started receiving bilastine. On 2 April 2021, he visited family doctor, who suggested to continue bilastine and betamethasone and hydrocortisone topical cream was added to the therapy without success. Thus lack of efficacy to betamethasone and hydrocortisone was considered. After 14 days, he received prednisone and his symptoms resolved; however, after discontinuation of prednisone, he developed a generalised pruritic rash with wax and wane along with angioedema. Thus, angioedema secondary to rebound effect of prednisone was considered. Thereafter, he took frequent cold showers and continued bilastine. On 4 May 2021, he visited dermatologist and switched his therapy to rupatadine, in addition to hydroxyzine and restarted prednisone with taper. After discontinuation of prednisone, the mild rash reappeared. Eventually, in June 2021, he achieved remission. On 23 June 2021, he visited immunology clinic. Images of his rash revealed red wheals demonstrating characteristic of urticaria. His blood workup was unremarkable. Protein electrophoresis and immunofixation was also unremarkable. He was therefore diagnosed with CSU associated with AZD-1222. On 2 July 2021, he received second dose of tozinameran. He received bilastine before receiving the second dose; however, he developed pruritus of the palms, in addition to similar rash on his scalp and neck. His symptoms resolved after 5 days with continuation of bilastine.