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Lichenoid eruptions accompanied by fever and pneumonia after measles vaccination

Dear Editor, Measles vaccine is a live attenuated vaccine routinely used in worldwide. It sometimes causes injection-site reactions, and less frequently, systemic side effects such as fever, encephalitis, and skin eruptions.1 Here, we report a case of lichenoid eruptions developed after a measles vaccination which was accompanied by fever and pneumonia. A 70-year-old Japanese man, who received a bone-marrow transplantation at the age of 55 for myelodysplastic syndrome, visited our clinic. He received a measles vaccine six weeks ago, and two weeks later, he noticed a moderate fever and hyperkeratotic erythema on the palms and soles. Another week later, he felt dyspnea and visited a local doctor. A chest radiograph revealed infiltrative shadows in bilateral lower lung fields (Figure 1a). The physician diagnosed him with pneumonia and prescribed a course of antibiotics; however, the fever continued and the skin eruptions spread to the trunk. He presented well-circumscribed keratotic erythema on the palms and soles (Figure 1b). Red-brown patches spread on the upper back area (Figure 1c). In addition, whitish erosions were found on the lips and oral cavity. Blood test showed slight increase of white blood cells (10.7 × 103/μL) and increased serum level of C-reactive protein (4.3 mg/ dL). Measles virus IgG-EIA titer was 2.9 before the vaccination and elevated to 24.4 afterwards. He still had moderate fever and pneumonia. Histological examination from the back skin revealed a band-like lymphocyte infiltration and a sawtooth-like acanthosis (Figure 1d). He had no history of new medications. Based on these findings, we diagnosed him with lichenoid eruptions induced by the measles vaccine and prescribed oral prednisolone (20 mg/day) and local steroid (clobetasol propionate). These treatments promptly improved the fever and pneumonia and the skin eruptions were ameliorated in 4 weeks. According to the national database,2 no case of vaccination-induced lichenoid reactions have been linked to systemic symptoms. However, fever and pneumonia, which were observed in our case, were frequently described after measles vaccination around 1970– 1980s,3 which is known as “atypical measles”. When persons who received “inactivated” measles vaccine were exposed to measles virus or live measles vaccine,4 they sometimes developed fever, pneumonia, and skin eruptions predominantly on the hands, feet, and back.5 The nature of eruptions observed in atypical measles was not reported as lichenoid, but its typical distribution resembles to our case. Due to the inducibility of atypical measles, the inactivated measles vaccine was abandoned in 1968 in Japan. It is unclear whether our patient had been vaccinated with the inactivated vaccine. We could not exclude the possibility of vaccination-induced graft-versus-host (GVH) reaction; however, we considered that atypical measles-“like” immune reaction might be induced in our case since characteristic systemic symptoms of atypical measles