Post COVID-19 Vaccination Vulvar Aphthous Ulcers: An Unpopular Case Series

      Background: Vulvar aphthous ulcers have been described since the early 1900s. These non-sexually acquired genital ulcers typically appear in the perimenarchal population as 1-3 painful ulcers that spontaneously resolve within 21 days. Etiology is not completely understood but there is believed to be a large immunologic component given a high association with a recent viral infection. With the COVID-19 pandemic, our institution saw COVID associated aphthous ulcers. After increased use of the Pfizer vaccine in those 12 years old and over, our institution also saw a series of post vaccination aphthous ulcers.
      Case: At our tertiary care children's hospital the division of pediatric and adolescent gynecology saw three patients from 6/2021 through 9/2021 presenting with vulvar aphthous ulcers all of whom were recently given their second COVID-19 Pfizer vaccination. Patients ranged from age 12 to 15 years old and were both pre- and post-menarchal. None of the patients to their knowledge had a history of COVID or a recent COVID exposure. In addition, there were no recent symptomatic viral illnesses. Of those who agreed to cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) testing, all were negative. These patients had all received their first dose of the Pfizer vaccine without complications and were all 2 days post second vaccine when they first noticed pain. On average, they presented to the emergency room within 24-48 hours of presentation of symptoms and had gynecologic follow-up within 48 hours. Physical exam was consistent with a diagnosis of vulvar aphthous ulcers with no exceptional characteristics. There were multiple ulcerations with fibrinous exudate and some with necrotic islands. All resolved spontaneously by 3 weeks and no further follow-up was needed. There were no diagnoses of COVID-19 infection after the diagnosis of the aphthous ulcer.
      Comments: The COVID vaccine is safe and efficacious for protection against COVID-19. National organizations such as American College of Obstetricians and Gynecologists (ACOG), Society for Maternal-Fetal Medicine (SMFM), American Academy of Pediatrics (AAP), and North American Society for Pediatric and Adolescent Gynecology (NASPAG) have endorsed vaccination in their respective audience. Specifically, AAP and NASPAG have encouraged eligible patients 12 through 16 to receive the Pfizer COVID-19 vaccination. Although this is a series of adverse outcomes post COVID-10 vaccination, it does shed light on the multifaceted immune response one gains from a COVID-19 mRNA based vaccine. In addition, this series further supports the long-held belief that vulvar aphthous ulcers are an immunologic response rather than a sign of a genital infection themselves.