key: cord-0863144-xjoucnpf
authors: Gargiulo, Luigi; Pavia, Giulia; Facheris, Paola; Valenti, Mario; Sacrini, Francesco; Narcisi, Alessandra; Borroni, Riccardo; Costanzo, Antonio; Mancini, Luca Livio
title: A fatal case of COVID‐19 infection presenting with an erythema multiforme‐like eruption and fever
date: 2020-06-07
journal: Dermatol Ther
DOI: 10.1111/dth.13779
sha: 4ace84afce8ea9f2014e48431670206c7b0c1ad1
doc_id: 863144
cord_uid: xjoucnpf

nan

Conflict of interest statement: Antonio Costanzo has received speaker honoraria or grants for research from Abbvie, Almirall, Pfizer, Novartis, Lilly, UCB, Janssen. The other authors have no conflict of interest do disclose.

To the Editor, Coronavirus Disease 2019 (COVID-19), caused by SARS-COV-2, has rapidly spread from Wuhan, China, and it has been declared a pandemic from WHO in March 2020 1 . Although COVID-19 manifestations involve predominantly the respiratory tract, recent reports described a broader clinical spectrum, including cutaneous rashes 2 . Gàlvan Casas et al. 3 A female 72-years old patient was admitted on the 3 rd of March 2020 to the Emergency Room of our Institute with fever (TC 38.5°C) and an undetermined itchy cutaneous rash. As swab testing was negative for SARS-COV-2 and a chest X-ray scan did not show any sign of pneumonia, the patient was admitted to a COVID-free ward. On physical examination, we observed erythematous and slightly edematous patches on the trunk and upper and lower limbs, along with some isolated typical target lesions on both thighs (Fig. 1 ).

The erythematous patches were markedly coalescing on the trunk and lower limbs, while lesions were more scattered on arms. The patient did not report the assumption of any drugs before the onset of the cutaneous lesions, except for paracetamol. In the clinical suspicion of drug-related rash, methylprednisolone 40 mg i.v. was administered. As the clinical picture did not show any improvement, a skin biopsy was performed on a representative lesion of the right tight. Histological examination revealed a mixed perivascular and interstitial infiltrate, including lymphocytes, granulocytes, histiocytes, plasma cells and mast cells.

Corticosteroid therapy was confirmed, with resolution of fever and partial improvement of the skin lesion.

However, after a few days a new febrile peak occurred (TC 38.5 °C). A newly performed nasopharyngeal swab returned positive for SARS-COV-2. An antiviral therapy with darunavir/cobicistat and hydroxychloroquine was administered and CPAP was started. Despite intensive medical treatment, the patient died after a few days.

New reports of COVID-19-related cutaneous manifestations are emerging every day. There are very few evidences concerning a possible association between erythema multiforme-like lesions and COVID-19.

Infections, especially herpes simplex virus and Mycoplasma pneumoniae, and medications represent most of the causes of erythema multiforme 5 

infection have been reported from Jimenez-Cauhe et al. 4 . However, those authors described one patient who developed cutaneous lesions during hospitalization and three patients who had been previously discharged after negativization of COVID-19 test. Although we cannot rule out the possible involvement of medications, we suggest that this erythema multiforme-like rash could be related to COVID-19 infection.

Since there is still diagnostic uncertainty regarding the sensitivity of reverse transcription polymerase chain reaction (RT-PCR) in detection of SARS-CoV-2 from nasopharyngeal specimens, a single negative result may be insufficient to rule-out disease 6 .

The peculiarity of our case is that in our patient skin lesions appeared as the first manifestation of the infection, ten days before the onset of any respiratory symptoms. As stated from von Damme et al. 7 , clinicians should be aware that a febrile cutaneous rash can be the first sign of COVID-19 infection. As 

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