key: cord-0836802-uznifixz
authors: Mathieu, Regine J.; Cobb, Caryn B.C.; Telang, Gladys H.; Firoz, Elnaz F.
title: New-onset pustular psoriasis in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causing Coronavirus Disease 2019 (COVID-19)
date: 2020-10-16
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2020.10.013
sha: fc1cb0dc1885b709a1f9c8f7fc5fed8ed8a18c48
doc_id: 836802
cord_uid: uznifixz

nan

Psoriasis is a chronic, immune-mediated disorder mainly affecting the skin and joints. Pathogenesis involves keratinocyte hyperproliferation, complex cytokine and interleukin interactions, polygenic predisposition, and known association with environmental triggers including infections, medications, trauma, and stress. 1 Severe acute respiratory syndrome coronavirus 2 (SARS- , the virus that causes Coronavirus Disease 2019 (COVID-19), is associated not only with flares of psoriasis in patients with well-documented disease, 2-4 but also with other cutaneous diseases. [5] [6] [7] However, there have yet to be any reports showing new-onset psoriasis in patients with SARS-CoV-2 / COVID-19. We report such a case in a 62-year-old woman.

J o u r n a l P r e -p r o o f

A 62-year-old female with obesity, asthma, diabetes mellitus type 2, hypertension, and atrial fibrillation presented to her primary care provider with a three-day history of fatigue, cough, shortness of breath, night sweats, chills, and myalgias. SARS-CoV-2 testing via nasopharyngeal swab was positive and the patient remained symptomatic for the next two weeks. Two weeks after resolution of symptoms, she developed blisters on her palms, which continued to progress over the ensuing two weeks prompting her to seek medical attention at a local urgent care facility, where she was prescribed triamcinolone 0.1% ointment for "dyshidrotic eczema." As the pruritic rash continued to spread to involve her forearms, trunk, and scalp, she returned to her primary care physician who referred her to the emergency department.

A well-appearing, non-tachypneic female with temperature 97.4 ºF, heart rate 110 beats per minute (irregularly irregular), blood pressure 138/90, and oxygenation 99% on room air presented to the emergency room. Medications of three years included metoprolol, apixaban, beclomethasone and albuterol inhalers, vitamin B12, and folate. She denied medication allergies. Social history was notable for 23-pack-year history of cigarette smoking (quit 1994) and alcohol consumption of four drinks weekly. Family history was notable for an aunt and cousin with psoriasis. She denied joint pain or stiffness; review of systems was otherwise non-contributory. Skin examination revealed palmoplantar pustules, palmar erythema with hyperkeratosis and desquamation, pink papulopustules of the extremities, and psoriasiform plaques of the trunk and scalp (Figures 1-3) . Laboratory examination was notable for AST/ALT 40/35, alkaline phosphatase 114, BUN/Cr 12/0.66, negative SARS-CoV-2 rRT-PCR, negative skin pustule culture, and bilateral trace pleural effusions on PA/lateral chest x-ray.

Three 4mm punch biopsies were obtained from the right palm, left wrist, and right forearm which revealed epidermal acanthosis with subtle to mild diffuse spongiosis, few dilated papillary dermal capillaries, large subcorneal neutrophilic pustules, and overlying parakeratosis with neutrophils (Munro microabscesses), consistent with psoriasis ( Figure 4 ).

Numerous and varied cutaneous associations with SARS-CoV-2 infection have been described. [5] [6] [7] Only a subset of SARS-CoV-2 cases has reported associated psoriatic flares. [2] [3] [4] The first case reported a 71year-old female with known history of psoriasis who flared on day four of SARS-CoV-2 treatment with oseltamivir and hydroxychloroquine. 2 The second case reported a 73-year-old male on maintenance cyclosporine and methotrexate for psoriasis whose medications were discontinued in the setting of SARS-CoV-2 infection, prompting a psoriasis flare two weeks later followed by improvement once his medications were restarted. 3 

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