Pseudo-Pemphigoid Gestationis Eruption Following SARS-CoV-2 Vaccination with mRNA Vaccine
Round 1
Reviewer 1 Report
Thank you I found this case interesting to read. The case report is succinct, well written with good images but I do feel there are important missed opportunities with this interesting case which would significantly improve it for your readers. I am struggling with the proposed concept of a pemphigoid gestationis-like eruption. The bullae appeared 3 days after a second dose of SARS-CoV-2 Pfizer vaccination and may have nothing to do with her pregnancy except altered vulnerable immunity. The target ag is unknown.
It is recognised that PG factor, a specific immunoglobulin type G (IgG) in the blood, binds to the BP-180 protein located in the basement membrane of the skin and placenta leading to tissue damage and blistering. In this case no such binding was found. Moreover, the authors should include findings on IMF on salt-split skin(+epidermal side in normal PG) as well as blood tests for all circulating autoantibodies including (indirect IMF) which can be used to distinguish pemphigoid gestationis from other autoimmune blistering disorders. Lastly, the baby was normal at birth but the authors do not include any findings of transferred auto antibodies. Indeed, it’s a pity no target antigen has been identified. So I suggest this is more pseudo-PG ie a mimic of PG and not PG-like surely?
Author Response
Thank you for your contributing comments!
The title (pseudo-PG and not PG-like) has been modified according to the remark.
Indirect immunofluorescence has been added.
Unfortunately, there was no blood test done for the baby.
The manuscript has been changed according to your comments
Author Response File: 
Author Response.docx
Reviewer 2 Report
Well presented case.
the DIF did not show basal membrane deposits but the diagnosis is still the Most likely one
Author Response
Due to the ELISA and IFD non-specific we change the title as a pseudo-PG (title has been modified to be more meaningful)
Author Response File: Author Response.docx
Reviewer 3 Report
The reviewer wishes to thank the editor and the authors for the opportunity to review this concise, well written and well-illustrated manuscript. This article is that of a case report of a primigravida female patient in her third trimester of pregnancy who developed a maculopapular/vesiculobullous eruption three days after receipt of the Pfizer SARS-CoV-2 vaccination. Given the clinical presentation a pemphigoid gestationis-like reaction following the Pfizer vaccination was favored with the eventual implication (considering that the discussion is focused on pemphigoid gestationis) that this is a case of pemphigoid Gestationis (PG) following SARS-COV-2 vaccination. Overall this was an interesting case and the concluding sentence encouraging patients with AIBD (albeit with caution) to be vaccinated against SARS-CoV-2 is to be applauded.
However, while this case demonstrates an eruption clinically similar to PG at time of presentation, the start of the eruption on the palms and soles with spread to the trunk is unusual. Additionally, at best this could only be considered a “PG-like” eruption given that the ELISA studies for anti-BP180 and BP 230 were negative and the DIF appears to exhibit non-specific granular staining of C3 in “few vessels.” It would be of interest to know the location (and if it was of lesional or non-lesional skin) of the DIF specimen as non-specific granular C3 staining in papillary dermal blood vessels has been reported in a variety of settings including individuals with “normal” skin, stasis dermatitis, and particularly on the skin of the lower extremities.
Perhaps this article would be more attractive with an increased emphasis on the clinical findings possibly with clinical differentials for PG-like eruptions, as the case currently cannot be histopathologically (or by DIF and serologies) confirmed.
Author Response
Thank you for your contributing comments.
Due to the ELISA and IFD non-specific we consider it as a pseudo-PG (title has been modified to be more meaningful)
The location of the biopsy for IFD was lesional/peri-lesional i.e. a small part of the lesion was included. It has been added in the manuscript.
A discussion concerning differential diagnosis has also been included in the manuscript with an approach more focused on the auto-immune bullous reactions after vaccination.
Author Response File: Author Response.docx
Round 2
Reviewer 3 Report
The reviewer would like to thank the editor and authors for the opportunity to review this revised manuscript. The change of the manuscript's title identifying this as a "pseudo-PG " eruption and the more clinically oriented spin on the augmented discussion has significantly improved the manuscript.
