Gianotti-Crosti syndrome associated with measles, mumps and rubella vaccination in an infant – A case report

INTRODUCTION

Gianotti-Crosti syndrome (GCS) is a benign skin condition, first identified by Gianotti and Crosti in 1955, that presents with a distinctive papulovesicular rash. It is most often associated with viral infections, including hepatitis B, Epstein–Barr virus (EBV), human immunodeficiency virus, human herpesvirus 6, echovirus, parvovirus, mumps, molluscum contagiosum, cytomegalovirus (CMV), coxsackievirus, adenovirus, enterovirus, rotavirus, rubella, parainfluenza, hepatitis A and respiratory syncytial virus. Certain bacterial pathogens, such as Borrelia burgdorferi, Bartonella henselae, b-hemolytic streptococci and Mycoplasma pneumoniae, have also been linked to GCS.^[1] Although uncommon, GCS has occasionally been reported after vaccinations, particularly those for hepatitis B and measles, mumps and rubella (MMR). This case report describes a child who developed GCS following MMR vaccination.

CASE REPORT

An 11-month-old developmentally normal male infant presented to the paediatric outpatient clinic with a 15-days history of a rash and a 1-day history of loose stools. The child had received the first dose MMR vaccine 7 days before the onset of the rash. On examination, the infant was alert, active and playful, with normal vital signs and systemic findings. Dermatological examination revealed multiple, discrete, symmetrical, flesh coloured papular lesions predominantly distributed over the face, buttocks and extensor surfaces of the upper and lower limbs [Figures 1a and b, 2a and b]. The lesions were pruritic and non-tender, and the mucous membranes, trunk or palms and soles were not involved. The rash had initially appeared on the back and subsequently progressed to involve the limbs and other areas, maintaining a characteristic acral and facial distribution. There was no history of recent upper respiratory symptoms, fever or new medication use. The child had no known allergies or recent exposure to sick contacts.

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Figure 1:

(a) Papules on the forehead and cheeks. (b) Papules on the extensor aspect of the upper limb.

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Figure 2:

(a) Symmetrically distributed papules on the extensor aspect of the lower limbs. (b) Papules on the extensor aspect of the lower limb.

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A clinical diagnosis of GCS was made based on the presence of a symmetrical papular rash with acral and facial distribution in a well-appearing child. The recent MMR vaccination and its temporal proximity to symptom onset suggested a possible post-vaccination trigger.

The child was managed conservatively with symptomatic treatment. Topical emollients were prescribed to maintain skin hydration, and oral antihistamines were administered to relieve pruritus. Parents were reassured about the benign and self-limiting nature of the condition. No antiviral or corticosteroid therapy was deemed necessary. Follow-up visits confirmed complete resolution of the rash within 3 weeks without complications or recurrence. Follow-up at 4 weeks showed complete resolution of the rash and no further symptoms.

DISCUSSION

GCS, also known as papular acrodermatitis of childhood, is a benign and self-limiting dermatological condition most commonly seen in children between 6 months and 14 years of age. It is characterised by symmetric, erythematous or flesh-coloured papular eruptions predominantly affecting the face, extensor limbs and buttocks, while sparing the trunk, palms, soles and mucosae.^[2]

Although the aetiology of GCS is often linked to viral infections such as EBV, hepatitis B virus, CMV and others, vaccine-related cases have also been increasingly reported.^[3,4] Table 1 presents the distinguishing clinical features of GCS in comparison with other papular rashes of similar presentation. Among vaccines, diphtheria, pertussis, tetanus, oral polio vaccine, hepatitis B and MMR have been most frequently implicated.^[1] In this case, the child developed a characteristic rash 7 days after receiving the first dose of the MMR vaccine, with no systemic symptoms, medication exposure or recent illness.

Vaccine-induced GCS is believed to result from a type IV hypersensitivity reaction to viral antigens or other vaccine components. This immune-mediated response may mimic the immune activation seen during viral infections, triggering the characteristic papular eruption.^[5]

The temporal relationship between vaccination and rash onset in this case aligns with previous literature. Babu and Arivazhahan reported a similar instance of GCS occurring in an 18-month-old child following immunisation, emphasising that clinicians should consider GCS in the differential diagnosis of rashes occurring after vaccination.^[1] Likewise, more recent reports have documented cases following measles-rubella vaccines and combined rabies and diphtheria-tetanus vaccinations, supporting the theory of post-immunisation immune modulation.^[1,6]

Diagnosis of GCS is clinical, based on morphology and distribution of the rash, and exclusion of other dermatoses. Investigations are typically unnecessary in well-appearing children unless atypical features or systemic signs are present. Treatment is supportive, including topical emollients and antihistamines for pruritus. Prognosis is excellent, with spontaneous resolution typically occurring within 2–8 weeks without residual scarring.^[2]

CONCLUSION

GCS is an important differential diagnosis in children presenting with symmetrical acral papular eruptions. Proper identification of GCS helps avoid unnecessary investigations and provides reassurance to parents. This case reinforces the importance of recognising GCS as a benign, self-limiting cutaneous reaction that may rarely follow vaccination. Paediatricians and dermatologists caring for children should be aware of this uncommon, self-limiting skin condition associated with vaccination to ensure early diagnosis and avoid unnecessary investigations.