Acute generalized exanthematous pustulosis induced by empiric hydroxychloroquine for presumed COVID ‐19

Abstract

stable. She was transitioned to an oral prednisone taper to further treat her active but improving rash. A skin biopsy, collected prior to treatment, showed a subcorneal pustule with neutrophils and eosinophils consistent with a diagnosis of acute generalized exanthematous pustulosis (Figure 2). The rash resolved with the prednisone taper after 38 days. The rapid spread of COVID-19 has left health care providers across the world in search of treatment options to combat the virus. This case highlights a severe cutaneous adverse reaction to HCQ, which is currently being used empirically, despite a lack of evidence to support its use. 9 In classic AGEP, onset occurs within 48 hours of drug initiation, and most cases resolve within 2 weeks after the offending medication is stopped. 1,4,5 In reported cases of HCQ-induced AGEP, there is a longer latency period, ranging from four to 30 days. Additionally, the duration of the eruption may be lengthy, up to 81 days, and prolonged treatment with systemic steroids or cyclosporine may be necessary to treat the reaction. 4-8 It is possible that the protracted course is secondary to HCQ's long half-life. 4,5 Our patient's presentation was likely somewhat attenuated, with fewer pustules, due to the systemic steroids she received prior to presentation. The absence of reliable, rapid COVID-19 testing contributed in this case. While HCQ is generally well-tolerated, dermatologic adverse effects can occur and may be severe.

A systematic review on treatment‐related mucocutaneous reactions in COVID ‐19 patients

“…We have evaluated 20 case reports including 25 cases of COVID‐19 who were treated with multiple drugs in Table 1 4‐23 . In Tables 2, 4 cohort studies are shown.…”

Acute generalized exanthematous pustulosis due to hydroxichloroquine

“…In case of HCQ‐induced AGEP, the latency period appears to be longer (ranging from 4 to 30 days 6 ) than in antibiotics‐related cases, and the eruption tends to be more serious and resistant to treatments. 7 , 8 A differential diagnosis could have been HCQ‐induced generalized pustular figurate erythema (GPFE), which has been recently described in two patients with COVID‐19; 9 however, our patient was febrile and the cutaneous presentation was more consistent with AGEP than GPFE.…”

Manifestaciones misceláneas de COVID-19

“…Además de la activación de estos virus, las repuestas inmunológicas antivirales y las respuestas inmunológicas contra los medicamentos pueden ser los mecanismos productores de las reacciones que estamos observando en los enfermos con COVID-19. 20,21 AGEP: PUSTULOSIS SUBCÓRNEA AGUDA EXANTEMÁTICA La pustulosis aguda subcórnea es una reacción medicamentosa que corresponde al grupo de las severas. Múltiples medicamentos han sido implicados en su génesis incluyendo los antipalúdicos de síntesis.…”

“…Múltiples medicamentos han sido implicados en su génesis incluyendo los antipalúdicos de síntesis. Enos T y colaboradores 21 describieron el caso de una mujer de 29 años de edad, con antecedente de deficiencia en la proteína S y un supuesto síndrome de Stevens-Johnson debido al cefaclor. Tuvo un contacto cercano con portador de SARS-CoV-2, se presentó refiriendo hipertermia, tos y dolor de garganta.…”

“…22,23 Los mecanismos productores del daño son similares a los inducidos por SARS-CoV-2, es posible que la tormenta inmunológica se manifieste en forma tardía y puede explicar estas manifestaciones como reacciones atípicas a medicamentos. [20][21][22][23]…”