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COVID-19 Vaccine-Related eConsults: Case 7

eConsult Clinical Question

Please advise on whether a 32-year-old female patient needs to take any specific precautions prior to and during COVID vaccination. She has history of anaphylaxis to penicillin and her prior neurologist who she was seeing for postural orthostatic tachycardia syndrome (POTS) was concerned about possibility of mast cell activation syndrome. She was previously referred to an allergist for further testing to rule out mast cell activation syndrome but did not follow-up due to concerns about in-person care during COVID. She's currently taking propranolol for POTS - should she hold it prior to COVID shot? If there is concern for possible mast cell activation, should she premedicate with an antihistamine? Would it be appropriate to vaccinate her in a primary care setting?

eConsult Response

  1. Restatement of the question: This is a 32-year woman with reported history of anaphylaxis to penicillin and history of POTS followed by neurology and a concern raised for possible mast cell activation syndrome (MCAS). Question of safety of the COVID vaccine.
  2. Recommendation(s): She should receive the COVID vaccine. History of anaphylaxis to penicillin does not elevate risk of anaphylaxis or any type of adverse immune reaction to any form of COVID vaccine. MCAS, if she has it, also would not raise and risk of anaphylaxis or severe immune reaction to the vaccine. Moreover, MCAS does not result in anaphylactic reactions - it is a somewhat ill-defined syndrome that can result in histaminergic reactions involving skin, gastrointestinal (GI) tract, etc., but does not result to cardiovascular collapse. Individuals with MCAS can get symptoms from multiple non-specific triggers, and while a vaccine or any drug could in theory provoke symptoms, we do not withhold critical therapies from people with MCAS. Given the obvious benefits for COVID vaccine and minimal risk, she should be vaccinated. Pretreatment with antihistamine is a reasonable consideration. Vaccination in clinic is also a reasonable consideration.
  3. Rationale and/or evidence for recommendation: Understanding of safety and efficacy of SARS-CoV2 vaccines.
  4. Contingency plan: Refer to Allergy clinic.

These real-life examples have some limitations. Given the evolving recommendations and guidance on COVID-19 care, these cases should not be considered complete or definitive and may not reflect the most up-to-date guidance.