Acute Generalized Exanthematous Pustulosis After COVID‐19 Infection: A Case Report From Saudi Arabia

Abstract

There is a dearth of robust evidence regarding coronavirus disease 2019 (COVID-19)-related coetaneous manifestations, complications and adverse treatment events. Upon review of the literature there are only a few cases reported of acute generalized exanthematous pustulosis (AGEP) in COVID-19 patients after treatment. Therefore, we are reporting a case of a 34-year-old male not known to have any chronic illness. His severe COVID-19 infection resolved four days prior to presentation to the Emergency Department with pustular rash on erythematous base over his face, neck, upper limbs, anterior and posterior trunk including oral cavity and tounge. The rash started after he took azithromycin, oseltamivir, ribavirin, lopinavir, hydroxychloroquine, prednisolone, ceftriaxone, clindamycin, interferon (IFN) beta, and ceftazidime for COVID-19. Skin punch biopsy was done and he was diagnosed with AGEP but it was still not known if it was related to COVID-19 or a drug-induced condition. Patient was treated with betamethasone valerate 0.1% ointment and lotion, promethazine hydrochloride 25mg tablet, paracetamol 500mg tablet, calcipotriol 50mcg/g and betamethasone 0.5mg/g gel. He discharged the same day to manage at home despite not improving. In the end, we found only a few studies that describe the cutaneous manifestations of COVID-19 infection, which were mainly case reports. We can't be sure that AGEP is a late and severe complication of COVID-19 infection. However, AGEP could be a rare adverse effect of hydroxychloroquine therapy. Improving the knowledge about a wide range of different signs and symptoms of the disease and its severity in addition to all possible adverse treatment events and complications can improve patient safety, survival rate, and quality of life.

Manifestaciones orales asociadas a SARS-COV-2: Revisión de la literatura

“…Si bien se han reportado lesiones en mucosa oral en pacientes infectados con el virus SARS-COV-2, se cree que la causa no sería el virus propiamente tal, sino que las lesiones serían secundarias a los fármacos (5,7,(9)(10)(11)15,17,18,21,26,28,30,32,36,39,41,43,50) , administrados para el tratamiento, o debido compromiso y deterioro del sistema inmune (1,6,(9)(10)(11)(12)(15)(16)(17)26,27,33,34,36,38,41,45,50) , lo cual también trae consigo infecciones oportunistas (5,6,(9)(10)(11)(15)(16)(17)(18)(25)(26)(27)(28)33,<...>…”

“…Pese a estas suposiciones, algunos de los estudios revisados señalan la teoría de un efecto vascular y trombótico en la mucosa oral generado por el virus SARS-CoV-2 (6,9,12,15,17,23,27,29,34) . De igual manera, las lesiones de la mucosa oral podrían ser desencadenadas por factores como estrés (5,8,18,22,25,26,32,37) . Es fundamental recalcar la importancia del receptor de ACE2 (Enzima Convertidora de Angiotensina 2), este está distribuído en la membrana celular de diversos órganos y tejidos, tales como el tracto respiratorio, sistema nervioso, sistema digestivo y músculo esquelético (1,9,13,23,24,27) .…”

“…De los casos reportados en la literatura, se han encontrado lesiones bastante heterogéneas entre pacientes, e incluso en un mismo paciente (10)(11)(12)(13) describiendo distintas presentaciones, localizaciones y tamaños (5,10,12,29) . Las manifestaciones a nivel oral se han presentado en pacientes COVID-19 sin antecedentes médicos de relevancia, describiéndose sanos (1,5,12,13,18,(30)(31)(32)(33) y también en pacientes que presentan enfermedades de base (1,7,10,12,13,16,18,23,(27)(28)(29)(30)(33)(34)(35)(36)(37)(38)(39)(40)(41) .…”

An AGEP case due to COVİD‐19 or favipiravir or enoxaparin

“…AGEP, morbilliform drug eruptions, vasculitis, DRESS syndrome, urticarial vasculitis, and others have been reported due to these drugs. There are a few cases reported AGEP in COVID‐19 patients after treatment, but cases are using hydroxychloroquine frequently 3–6 . There are no adverse cutaneous events that have been reported to date caused by favipiravir 7 .…”

Warfarin-Induced Calciphylaxis in a COVID-19 Patient

“…Another differential diagnosis was COVID-19-related skin necrosis which was differentiated from calciphylaxis after histopathology results [ 1 , 9 ]. Other differentials were excluded such as atherosclerotic vascular disease, venous stasis ulcer, cholesterol embolization, necrotizing vasculitis, and livedoid vasculopathy [ 10 - 11 ].…”