key: cord-0728217-xql6cxfd
authors: Shahidi‐Dadras, Mohammad; Araghi, Farnaz; Ahmadzadeh, Arman; Rakhshan, Azadeh; Tabary, Mohammadreza; Dadkhahfar, Sahar
title: TEN/SJS‐like lupus erythematosus presentation complicated by COVID‐19
date: 2020-12-10
journal: Dermatol Ther
DOI: 10.1111/dth.14612
sha: 0442aa26040cf63e69e8ad27589785a066111273
doc_id: 728217
cord_uid: xql6cxfd

nan

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) present with extensive epidermal detachment of the skin and mucous membranes as well as systemic involvement. 1 Drug hypersensitivity is the major culprit for TEN, while mycoplasma pneumonia infection, vaccinations, acute graft-vs-host disease, and systemic lupus erythematosus (SLE) are among other causes. 2 Prior studies have reported a rare primary presentation of LE as SJS/TEN, which is defined as a new clinical entity (SJS/TEN-like lupus erythematosus). 3 Herein, we report a challenging case of SJS/TEN-like LE that highlights the importance of considering LE as a rare cause of SJS/TEN like syndrome. The current case describes a patient with acute cutaneous lupus erythematosus (ACLE) with SJS/TEN-like primary presentation. There are few points that may help to differentiate between the classic SJS/TEN and SJS/TEN-like LE. For instance, the absence of exposure to etiologic factors for SJS/TEN and photo distributed patterns of skin lesions are in favor of SJS/TEN-like LE. Further, the interval between the first rash to epidermal detachment in SJS/TEN-like LE seems to be longer (weeks to months) than the classic SJS/TEN (hours to days). 4 SJS/TEN-like LE skin lesions may appear on palms and soles more frequently than SJS/TEN 5 .

Moreover, lupus specific lesions, which is characterized by interface dermatitis response, could turn the diagnosis toward SJS/TEN-like LE. 6 Presence of continuous IgM, IgG, and C3 deposition at basement membrane zone may be observed in DIF and is of great value in distinguishing these two entities as well. 5 Previous reports indicated that the high level of lupus antibody profile (anti-nuclear antibody, anti-ds-DNA, anti-RO, and anti-LA) are detected in SJS/TEN-like LE. 7 Involvement of internal organs in the setting of SLE that often need immunosuppressive treatment increases susceptibility to severe forms of COVID-19; this should be taken into account before initiation of treatment in these patients. 8 Although there is no meticulous guidelines for treating SJS/TENlike LE, IVIg has been reported as an efficient treatment in the literature.

The possible explanation for such efficiency could be explained by the fact that IVIg blocks Fas-Fas ligands which has a crucial role in apoptosis in both LE and SJS/TEN. 3 On the other hand, IVIg may be considered as a safe option for those who are suffering from comorbidities and have higher risk of developing severe infection in the current pandemic. 9,10 It is noteworthy that many unusual skin presentations can occur in the setting of COVID-19 11 ; however, we ruled out this condition by conducting repeated screening test for COVID-19 during her admission period.

The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. F I G U R E 2 A, Histopathologic examination showed a subepidermal blister with full thickness epidermal necrosis and mild perivascular dermatitis (H&E, ×40) ; B, Higher magnification shows mild superficial perivascular dermatitis and focal lichenoid tissue reaction (H&E, ×100)

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