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Recurrence of primary cutaneous CD30-positive lymphoproliferative disorder following COVID-19 vaccination

The reactogenicity profile of the Pfizer-BioNTech COVID19 vaccine approved by the U.S. Food and Drug Administration has demonstrated generally transient, mild-to-moderate local and systemic responses [1]. Shortterm axillary and cervical lymphadenopathy were reported in 0.3% of Pfizer-BioNTech vaccine recipients in the phase 2/3 trial data and was attributed to robust immune responses elicited by the vaccine [2]. Importantly, in the pivotal phase 3 trial, 22 patients (0.1%) with history of lymphoma received the PfizerBioNTech vaccine, providing limited safety data in this population. Here, we report a case of a new axillary lymphoid tumor developing after COVID-19 vaccination. A 79-year-old male presented with a 3-centimeter ulcerated tumor with surrounding erythema in the left axilla (Figure 1). The lesion appeared two days following initial vaccination with the Pfizer-BioNTech COVID-19 vaccine in the ipsilateral arm. The patient denied systemic symptoms in association with receiving the vaccine. Of historical significance, the patient was evaluated for an ulcerated plaque on the left supraclavicular skin in April 2019. Subsequent biopsy demonstrated a CD-30 positive lymphoproliferative disorder (CD30 LPD). Staging ruled out systemic disease and supported a diagnosis of primary cutaneous anaplastic large-cell lymphoma. The patient completed three fractions of 600 cGy localized radiation therapy in June 2019, after which the lesion resolved. He experienced no recurrence of disease in the interim period prior to presenting at our clinic following his COVID-19 vaccine. Biopsy of the current left axillary tumor revealed a CD30 LPD with numerous eosinophils (Figure 2), similar to pathology in 2019. A positive T-cell receptor gene rearrangement matching the 2019 clone was identified. Over the course of the next several weeks the tumor regressed significantly without treatment. Three weeks following his first dose, the patient received his second COVID-19 vaccine in the contralateral arm without developing significant side effects or new skin lesions. The close temporal association of our patient’s CD30 LPD relapse with administration of the COVID-19 vaccine raises suspicion for its potential contribution to his disease recurrence. This cannot be definitively ascertained, however, and the recurrence may represent possible coincidence. Skin-limited relapses occur commonly in patients with CD30 LPD [3], but none have been reported in association with COVID-19 vaccination. Current guidelines from the National Comprehensive Cancer Network advocate for vaccination of patients with active cancer, including lymphomas [4]. Given the paucity of data on COVID-19 vaccines in patients with a history of lymphoma, we recommend additional reporting of similar Figure 1. Biopsy-proven CD30þ lymphoproliferative disorder. A 3-centimeter ulcerated tumor with surrounding erythema in the left axilla. Photo taken 6 days after COVID-19 vaccination.