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 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 32-34

Pityriasis rosea like eruption possibly due to anti-rabies vaccine administration in a young man: A rare case report

Department of Dermatology, Venereology and Leprosy, Hindu Rao Hospital and NDMC Medical College, New Delhi, India

Date of Web Publication27-Jun-2017

Correspondence Address:
Akhilesh Vilaskumar Thole
2nd Floor OPD Building, Department of Dermatology, Venereology and Leprosy, Hindu Rao Hospital, New Delhi - 110 007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdd.ijdd_13_16

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Pityriasis rosea (PR) is an acute, self-limited skin disease thought to be a viral exanthem caused by reactivation of HHV-7 and HHV-6 viruses; although, numerous studies have explored various pathogens. Several reports associate PR with drugs and vaccines. We report a typical case of PR in a 26-year-old male following intradermal anti-rabies vaccine (ARV). There are reports of vaccine-induced pityriasis like eruptions due to various vaccine. However, PR-like eruptions due to ARV is rarely reported. This case represents a new side effect of an already existing vaccine and throws light on varied etiologies of vaccine-induced PR.

Keywords: Adverse reaction, anti-rabies vaccine, pityriasis rosea

How to cite this article:
Thole AV, Khurana VK, Misri RR, Gupta VK. Pityriasis rosea like eruption possibly due to anti-rabies vaccine administration in a young man: A rare case report. Indian J Drugs Dermatol 2017;3:32-4

How to cite this URL:
Thole AV, Khurana VK, Misri RR, Gupta VK. Pityriasis rosea like eruption possibly due to anti-rabies vaccine administration in a young man: A rare case report. Indian J Drugs Dermatol [serial online] 2017 [cited 2021 Apr 11];3:32-4. Available from: https://www.ijdd.in/text.asp?2017/3/1/32/209034

  Introduction Top

Pityriasis rosea (PR) is a common acute self-limited skin eruption that tends to favor otherwise healthy adolescents and young adults.[1] It is a papulosquamous disorder characterized by a distinctive skin eruption and associated with minimal constitutional symptoms and is normally lasting for about 4–10 weeks.[2] There are several reports associating PR and PR-like eruptions with drugs and vaccines. We report a case of PR in a 26-year-old male following intradermal anti-rabies vaccine (ARV). This case represents a new side effect of an already existing vaccine and throws light on varied etiologies of vaccine-induced PR.

  Case Report Top

A 26-year-old male patient presented to our outpatient dermatology department with pruritic papulosquamous rash on trunk and proximal extremities for the past 3 days. He had a dog bite 10 days back for which he was administered intradermal ARV from (ARV clinic) of our Institute (verocell vaccine schedule: Day 0, 3, 7, and 28). He received two more doses of ARV on day 3 and 7. On further enquiry, the patient said that he had first developed a large patch on the left arm [Figure 1] 24 h after the third dose (day 7 dose) and the remaining patches gradually appeared. He was otherwise healthy and had no accompanying fever, cough, or coryza. There was no history of any drug intake in the recent past. Patient did not have a history of similar reactions in the past.
Figure 1: Herald patch on left arm with peripheral collarette of scales.

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On examination, there were multiple oval to round papules and plaques ranging in size from 0.5 to 3 cm, symmetrically distributed; predominantly on abdomen, arms and sparingly involving the lower back [Figure 2]. The surface of the plaques was topped with fine semi-adherent scaling in the center with peripheral collarette of scales. Auspitz's sign was negative. Mucosal and nail examination revealed no abnormality.
Figure 2: Multiple oval to round plaques on abdomen with fine semi-adherent scaling in center and peripheral collarette of scales.

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Differential diagnosis of PR, psoriasis, secondary syphilis, drug rash was kept and investigations were sent. Venereal disease research laboratory and enzyme-linked immunoabsorbent assay testing for HIV were negative. His complete blood counts and liver and renal function tests were within normal limits. Histopathological examination of the section from the representative lesion revealed focal parakeratosis, focal mild spongiosis [Figure 3] of the epidermis associated with exocytosis of lymphocytes. Dermis showed mild perivascular mononuclear inflammatory infiltrate with extravasation of red blood cell in papillary dermis [Figure 4].
Figure 3: Parakeratosis and spongiosis (H and E, ×400).

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Figure 4: Mild perivascular mononuclear inflammatory infiltrate with extravasation of red blood cells in papillary dermis (H and E, ×400).

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The histopathologic and clinical features were consistent with PR and final diagnosis of PR like eruption was made. Patient showed symptomatic relief with oral levocetrizine 5 mg once daily and with topical calamine lotion. He was advised to complete his vaccination due to the benign nature of PR-like eruption as compared to life-threatening rabies disease. The lesions resolved in 2 weeks after the last dose of rabies vaccine.

  Discussion Top

PR is an acute, self-limited skin disease which usually begins as an oval, salmon-colored, scaly herald patch followed by a secondary phase manifesting as similar patches distributed symmetrically on the trunk and limbs in a typical Christmas tree pattern.[1]

Numerous studies over the past 50 years have explored various pathogens. There is a scientific evidence that PR is a viral exanthem associated with reactivation of either HHV-7 or HHV-6 virus.[3]

There are several reports associating PR and PR like eruptions with drugs and vaccines. The rashes caused by arsenic, bismuth, gold, lithium, and methopromazine may have been atypical lichenoid reactions.[4] Other drugs implicated include metronidazole, barbiturates, clonidine, captopril, ketotifen, clozapine, bupropion, adalimumab, and imatinib mesylate.[5] In some reports, the resemblance of the eruption to PR has not been close, and in others coincidence might explain the association. Thus, while drug eruptions may somewhat resemble the condition, there is no convincing evidence that typical PR can be caused by drugs.[4]

PR and PR-like eruptions have been rarely reported after vaccination against yellow fever, influenza, streptococcus pneumonia, hepatitis B virus, tuberculosis, human papilloma virus.[6],[7],[8],[9] However, not reported following ARV to the best of our knowledge. When associated with drugs, the eruption may present with smaller number of itchy larger scaly lesions that do not have the classic Christmas tree distribution and may have bullous or purpuric lesions. Drug induced PR is more common in older individuals and usually shows the absence of initial single herald patch, is more pruritic and is said to be more bright or violaceous or red. Histologically, it shows more infiltrate of eosinophils in the skin or blood.[10] The lesions may also have a protracted course and evolve rarely into lichenoid dermatitis.[8] In our patient, rash was pruritic, but numerous eosinophils were not seen. Hence, it is difficult to know whether PR-like rash was due to ARV vaccine as a drug or vaccine virus was the triggering or etiological factor in the causation of the disease as in conventional cases of PR.

According to the National Guidelines for Rabies Prophylaxis and intradermal Administration of Cell Culture Rabies Vaccines (2007) - modern cell culture vaccines are now being used and are widely accepted as the least “reactogenic” rabies vaccines available as of today. The general adverse reactions include sore arm, headache, malaise, nausea, fever, and localized edema at the site of injection. No other major dermatological disorder has been reported with rabies vaccine apart from erythema multiforme [11] and erythema nodosum. In our patient, a causal relationship is highly suggestive as the skin rash developed within 1 week of vaccination and regressed after completion of all vaccine doses. The patient also presented with highly itchy lesions. The drug eruption had some similarities with typical PR which had a herald patch, and erythematous maculopapular eruptions with a central collarette of scale, although it did not have the classic “Christmas tree” distribution. The lesions were not purpuric or bullous, not refractory, and did not evolve into lichenoid dermatitis. By Naranjo's method for estimating the possibility of drug reactions the score in our case is 4, leading to a possible association between ARV and PR.[12]

The precise mechanism leading to PR after vaccination is unknown. Vaccination-induced immune stimulation may trigger the reactivation of latent infectious agents such as HHV-6 or HHV-7 leading to PR. Another hypothesis is cell-mediated immune response related to a molecular mimicry with a viral epitope, but there is currently no evidence to support such theory.[6]

Based on data on vaccine utilization, approximately 3 million people receive postexposure treatment in the country. Non dermatologist physicians are usually unaware regarding the clinical presentation and many a times vaccination history may be overlooked by dermatologists when PR like eruptions are encountered in clinical practice. Hence, further studies are required to confirm the association between ARV and PR considering the huge magnitude of vaccination in our country. The treating physicians and health workers should be educated regarding the benign and self-limiting nature of the disease and informed that this should not warrant discontinuation of vaccine as it is lifesaving in a case of rabies.

There have been no reports of ARV associated with PR in the published literature to the best of our knowledge. We report this rare case of PR-like eruptions following ARV as a novel and possible association with the vaccine.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chuh A, Lee A, Zawar V, Sciallis G, Kempf W. Pityriasis rosea – An update. Indian J Dermatol Venereol Leprol 2005;71:311-5.  Back to cited text no. 1
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Blauvelt A. Pityriasis rosea. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, editors. Fitzpatrick's Dermatology in General Medicine. 8th ed. New York: McGraw Hill; 2014. p. 458-63.  Back to cited text no. 2
Drago F, Broccolo F, Rebora A. Pityriasis rosea: An update with a critical appraisal of its possible herpesviral etiology. J Am Acad Dermatol 2009;61:303-18.  Back to cited text no. 3
Sterling JC. Virus infections. In: Burns T, Breathnach S, Griffiths C, Cox N, editors. Rook's Textbook of Dermatology. 8th ed. West Sussex: Wiley-Blackwell; 2010. p.33.79  Back to cited text no. 4
Verma P, Singal A, Sharma S. Imatinib mesylate-induced cutaneous rash masquerading as pityriasis rosea of gilbert. Indian J Dermatol 2014;59:311-2.  Back to cited text no. 5
[PUBMED]  [Full text]  
Chen JF, Chiang CP, Chen YF, Wang WM. Pityriasis rosea following influenza (H1N1) vaccination. J Chin Med Assoc 2011;74:280-2.  Back to cited text no. 6
Sasmaz S, Karabiber H, Boran C, Garipardic M, Balat A. Pityriasis rosea-like eruption due to pneumococcal vaccine in a child with nephrotic syndrome. J Dermatol 2003;30:245-7.  Back to cited text no. 7
Oh CW, Yoon J, Kim CY. Pityriasis rosea-like rash secondary to intravesical bacillus calmette-guerin immunotherapy. Ann Dermatol 2012;24:360-2.  Back to cited text no. 8
Drago F, Ciccarese G, Rebora A, Parodi A. Pityriasis rosea following human papillomavirus vaccination. Braz J Infect Dis 2015;19:224-5.  Back to cited text no. 9
Panda M, Patro N, Jena M, Dash M, Mishra S. Pityriasis rosea like drug rash-A need to identify the disease in childhood. J Clin Diagn Res 2014;8:YD01-2.  Back to cited text no. 10
Wiwanitkit S, Wiwanitkit V. Erythema multiforme after rabies vaccination. Pediatr Dermatol 2013;30:e299.  Back to cited text no. 11
Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-45.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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