case_images: PMC9051404_01
case_images: Chronological depiction from patient's initial presentation to current working diagnosis. Work-up prior to September was performed at outside institutions. In September, the patient was admitted to our institution for treatment. At no point during this course have lesions stopped progressing. In early February, the patient unfortunately passed away.
case_images: fmed-09-843793-g001.jpg
case_images: PMC9051404_01_fmed-09-843793-g001.jpg
case_images: F1
case_images: A 32-year-old female presented to her primary care physician with tender erythematous nodules on her bilateral lower extremities four weeks following her second Moderna COVID vaccination (Figure 1).
case_images: Lesion progression of left medial thigh over 3.5 months. (A) 8/27/21, (B) 9/11/21, (C) 9/27/21, (D) 10/26/21, (E) 11/16/21, (F) 11/30/21, (G) 12/1/21, taken immediately post debridement in operating room (H) 12/7/21.
case_images: fmed-09-843793-g002.jpg
case_images: PMC9051404_01_fmed-09-843793-g002.jpg
case_images: F2
case_images: In October, a diagnosis of cutaneous PAN was no longer favored due to evidence of ulcers eroding further into adipose tissue despite patient's steroid treatment (Figure 2).
case_images: Pathology images from incisional biopsy on left flank on 11/12/21 at 100x OM with (A). Widespread pannicular thrombotic vasculopathy with ischemic pannicular necrosis (H&E) (B). Negative for calcification on Von Kossa histochemistry with (C). A single subcutaneous arteriole with mural calcification at the biopsy base (H&E). (D) Pathology image from incisional biopsy 12/1/21 at 100x OM with H&E showing adipocyte calcification.
case_images: fmed-09-843793-g003.jpg
case_images: PMC9051404_01_fmed-09-843793-g003.jpg
case_images: F3
case_images: The biopsy results came back as diffuse small vessel thrombosis with rare small vessel calcification, suggesting a thrombotic vasculopathy (Figure 3).
case_images: Images of progressive necrotic ulcers taken 11/30/21 (other than C). (A) Right lateral thigh. (B) Right medial thigh. (C) Right flank (11/23/21). (D) Right anterior lower leg. (E) Left lateral thigh. (F) Left medial thigh. (G) Left flank. (H) Left posterior lower leg. Lesions not shown: right posterior lower leg, left anterior lower leg.
case_images: fmed-09-843793-g004.jpg
case_images: PMC9051404_01_fmed-09-843793-g004.jpg
case_images: F4
case_images: Wounds continued to progress (Figure 4), most notably on patient's bilateral flanks.