key: cord-0977224-yma9ymor
authors: Sakaida, Takashi; Isao, Tanimoto; Matsubara, Akihiro; Nakamura, Motoki; Morita, Akimichi
title: Unique skin manifestations of COVID-19: Is drug eruption specific to COVID-19?
date: 2020-05-16
journal: J Dermatol Sci
DOI: 10.1016/j.jdermsci.2020.05.002
sha: 374f34e196d7ebf117b583b87041377bff247093
doc_id: 977224
cord_uid: yma9ymor

• COVID-19 is associated with specific skin manifestations and drug eruption. • This case shows COVID-19–related drug eruption and specific clinical features. • Drug eruption preceding COVID-19 symptoms may facilitate early diagnosis.

Key words: COVID-19, Drug hypersensitivity, Lymphocytopenia COVID-19 is associated with specific skin manifestations and drug eruption in some affected patients. Here, we report a case of suspected COVID-19-related drug eruption and specific clinical features.

A 52-year-old woman visited our dermatology clinic with itchy erythematous lesions on her limbs and erosions on her lips and buccal mucosa. She had no flu symptoms or fever. She had been treated at a dental clinic 3 days prior (Day -3) and given antibiotics (cefcapene pivoxil hydrochloride hydrate) and the non-steroid anti-inflammatory drug (NSAID) loxoprofen sodium hydrate. Erythematous lesions and erosions on the lips appeared 2 days later (Day -1). Her blood counts were normal. The skin lesions were clinically diagnosed as a drug eruption (Day 0). Pathologic analysis of a skin biopsy sample obtained from an indurated erythematous lesion (Fig 1) (Fig 1) . The biopsy specimen was taken from an indurated erythematous lesion on her abdominal skin. Pathologic analysis revealed interface changes with liquefaction and perivascular mixed cell infiltrations including histiocytes and neutrophils in the papillary dermis (Fig 2 CD) . The ampicillin/sulbactam was changed to levofloxacin. On Day 10, the erythematous lesions peaked and gradually pigmented. Polymerase chain reaction (PCR) analysis for COVID-19 on Day 1 of admission was negative, but CT showed progression of the ground glass opacity.

Repeat PCR for COVID-19 was positive on Day 3 of admission and the patient was diagnosed with COVID-19 and transferred to an intensive care unit at another hospital.

In this case, COVID-19 infection was suspected 10 days before onset. Drug eruption might develop during the latency period. COVID-19 is associated with drug eruptions, but the details remain unclear [2, 3] . Drug hypersensitivity (11.4%) and urticaria (1.4%) have been self-reported by several patients. Drug eruption might not be merely incidental, but possibly related to COVID-19-induced cytokine storm with Th17 dysregulation [4] . NSAIDs may exacerbate symptoms of COVID-19, but no evidence has yet been provided [5] . Drug hypersensitivity may be due to aggravated inflammation. Drug eruption caused by NSAIDs preceding other symptoms of COVID-19 may facilitate early diagnosis based on specific features. In this case, the macular papule lesions and pathologic findings might be unique after exacerbations with COVID-19. Interface changes with liquefaction and perivascular mixed cell infiltrations in the papillary dermis are observed. There are histiocytic infiltrations around the capillary vessels and neutrophils are scattered in the upper dermis (Fig 2 CD) . The bar is indicated size as appears.

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Acknowledgements. We declare no competing interests. We acknowledge SciTechEditInternational, LLC (Highlands Ranch, CO, USA) for providing pro bono professional English-language editing of this article.