key: cord-0861420-b21l3prw
authors: Reguero‐Del Cura, Leandra; Gómez‐Fernández, Cristina; López Obregón, Cristina; López‐Sundh, Ana Elisabet; González‐López, Marcos Antonio
title: Onset of erythema multiforme‐like lesions in association with recurrence of symptoms of COVID‐19 infection in an elderly woman
date: 2020-08-20
journal: Dermatol Ther
DOI: 10.1111/dth.14208
sha: fb1b5c2872876eaeebc8b462df888fc05b5e24d6
doc_id: 861420
cord_uid: b21l3prw

nan

To the Editor,

We read with great interest the manuscript recently reported by Askin et al (1) .The authors describe different patterns of cutaneous manifestations in 52 patients during Coronavirus Disease 19 (COVID-19), including erythematous scaly rash, maculopapular rash, urticarial lesions, petechial purpuric rash, necrosis, enanthema and apthous stomatitis, vesicular rash, pernio and pruritus. These clinical patterns are in concordance with previous reported studies (2) (3) (4) . In addition to these cutaneous manifestations, we would like to emphasize that a few cases of erythema multiforme (EM) like rashes related to COVID-19 have recently been reported (2, (5) (6) (7) (8) (9) . These cases have mainly been observed in young patients and have been associated with milder COVID-19 disease course (4) . We present herein a new case of EM-like lesions in an elderly patient with recurrence of symptoms of COVID-19 infection.

A 95-year-old woman was admitted to the hospital with a slightly itchy cutaneous rash, fever and dyspnea during the COVID-19 outbreak in Spain. She had been discharged two days before, once recovered from COVID-19 pneumonia (CURB-65 2p) and after completing a ten-day course of hydroxychloroquine. Physical examination revealed typical target and targetoid lesions on the trunk and extremities, and confluent purpuric macules on the lower limbs ( Figure 1, A and B ). Mucous membranes were spared. A chest radiograph showed patches of increased density in both hemithorax with a peripheral predominance. The findings had minimally worsened respect to the chest Xray performed before discharge. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was isolated from a sputum culture. Blood count showed mild leukocytosis with neutrophilia and large granular lymphocytes were seen in a blood smear. Serological study on parvovirus B19 infection showed negative IgM and positive IgG. A skin biopsy was obtained from a representative lesion of the thigh. A superficial This article is protected by copyright. All rights reserved. perivascular and interstitial dermatitis with a predominantly mononuclear inflammatory infiltrate was observed. Symptomatic treatment for fever and dyspnea and topical corticosteroids were initiated with progressive improvement of the skin lesions.

EM-like eruptions related to COVID-19 infection have rarely been described. To our knowledge, less than 20 cases have been previously reported in the medical literature.

Comparing our case with those described previously, we consider it relevant to highlight the following findings: (a) this is the first case in which respiratory symptoms of COVID-19 infection and EM-like rash developed simultaneously. (b) The age of our patient is distinctive given the age range of the patients previously reported, which ranges from 11to 17 years in children (7, 9) and from 29 to 77 years in adults (5) (6) (7) (8) . In this case, we cannot completely rule out that hydroxychloroquine could be implicated in the development of EM-like rash. However, there are some clues that suggest an infectious cause rather than a toxicoderma. Thus, the coexistence of fever, respiratory symptoms and radiologic worsening are not typical findings in a drug reaction. Moreover, no eosinophils were observed in the histopathological examination of the skin lesions. Finally, and in accordance with previous reports, it should be noted that our patient had an excellent outcome, although a fatal case of COVID-19 infection with EM-like eruption has been recently described (6) . 

This article is protected by copyright. All rights reserved.

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