key: cord-0938984-wv7coh0y
authors: Janah, H.; Zinebi, A.; Elbenaye, J.
title: Atypical erythema multiforme palmar plaques lesions due to Sars‐Cov‐2
date: 2020-06-04
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16623
sha: 83c248ac8f25901ae83b7aeabd2e42c66c4430ee
doc_id: 938984
cord_uid: wv7coh0y

Since CoronaVirus Disease 19 (COVID-19) was declared as a pandemic, all medical specialties were at the front, including dermatology. Daily, there are observations mentioning possible cutaneous manifestations of Sars-Cov-2. Among these manifestations, the most often was a rash which could be erythematous, morbilliform or urticarial mimicking viral exanthema, or chickenpox-like vesicles [1-3]. Anecdotally, dengue-like petechial eruption was reported [4].

Dear Editor, Since coronavirus disease 19 (COVID-19) was declared as a pandemic, all medical specialties were at the front, including dermatology. Daily, there are observations mentioning possible cutaneous manifestations of SARS-CoV-2.

Among these manifestations, the most often was a rash which could be erythematous, morbilliform or urticarial mimicking viral exanthema, or chickenpox-like vesicles. 1-3 Anecdotally, dengue-like petechial eruption was reported. 4 Some dermatology societies have alerted health professionals to the possibility of acral involvement such as ischaemia and livedo in the context of thromboembolic manifestations of COVID-19. Recently, a case of COVID-19 infection-induced chilblains was reported with histopathological findings showing lichenoid, perivascular and peri-eccrine infiltrate of lymphocytes associated with necrotic keratinocytes. 5 We report two patients with diagnosis of COVID-19 presenting erythema multiforme (EM) lesions which could be another acral cutaneous manifestation due to SARS-CoV-2.

First case is a 17-year-old adolescent with no medical history, documented to have a mild SARS-CoV-2 infection for which he took vitamin C only. On the 15th day of the onset of symptoms, he developed erythematous maculopapular atypical targetoid eruption of palms only (Fig. 1 ). Lesions were painless and mild itching. There was no mucosal involvement. No recent episode of recurrent herpes was reported.

Second case is a 29-year-old man with no past medical history had been diagnosed with COVID-19 and treated by hydroxychloroquine associated with azithromycin. He developed fixed and asymptomatic erythematous urticarial targetoid lesions on his palms (Fig. 2) . He had started taking medication 3 days before rash, and COVID-19 symptoms had started 12 days earlier. Hydroxychloroquine and azithromycin were continued, and palm eruption was progressively disappeared.

Erythema multiforme is immune-mediated reaction that involves the skin and sometimes the mucosa due to infections, especially herpes simplex virus and mycoplasma pneumonia (MP), and medications like hydroxychloroquine. It consists of a polymorphous eruption of macules, papules and characteristic 'target' lesions that are symmetrically distributed with a propensity for the distal extremities. Histological findings are apoptotic individual keratinocytes and perivascular lymphocytic infiltrate in the papillary dermis and along the dermo-epidermal junction.

Mycoplasma pneumonia-related EM has a distinctive presentation compared with non-MP EM, with more diffuse and atypical targets, more mucositis and respiratory tract sequelae. 6 EM is a rare hydroxychloroquine-induced cutaneous adverse reaction with generalized distribution involving trunk, abdomen, back and mucosa. 7 On another side, palmar plaques should suggest syphilis, especially in young people. 8 Both of our patients had localized acral targetoid lesions with no mucosal involvement and a negative syphilitic serology. This clinical presentation associated with chronology and evolution of eruption was suggestive of a SARS-CoV-2-related EM rather than other causes particularly hydroxychloroquine or MP. Pathophysiological mechanism could be a hypersensitivity reaction lymphocyte cells mediated with pro-inflammatory cytokines production targeting SARS- 

Rash as a clinical manifestation of COVID 19 photographs of a patient

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Syphilis at age 15 years