Acute generalized exanthematous pustulosis with erythema multiforme‐like lesions induced by Hydroxychloroquine in a woman with coronavirus disease 2019 (COVID‐19)

Test, Elisa Robustelli; Vezzoli, Pamela; Carugno, Andrea; Raponi, Francesca; Gianatti, Andrea; Rongioletti, Franco; Sena, Paolo

doi:10.1111/jdv.16613

Cited by 48 publications

(41 citation statements)

References 8 publications

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“…Some reports of erythemato-violaceous papules and patches with a pseudo-vesicle in the center, resembling erythema-multiforme and an enanthem of the oral cavity in some of those patients during or after improvement of COVID-19 symptoms exist (55)(56)(57)(58). If those lesions are related to SARS-CoV-2 infection or drugs applied in this context or both remains to be elucidated in further studies.…”

Section: Virus Induced Vesicular Eruptionsmentioning

confidence: 96%

SARS-CoV-2, COVID-19, skin and vascular system - what do we know so far?

Novak

Peng

Naegeli

et al. 2020

Preprint

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The pandemic condition Coronavirus-disease (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can take asymptomatic, mild, moderate, and severe courses. COVID-19 affects primarily the respiratory airways leading to dry cough, fever, myalgia, headache, fatigue, and diarrhea and can end up in interstitial pneumonia and severe respiratory failure. Different clinical symptoms caused by involvement of organs outside the respiratory system have been also described. Interestingly, reports about the manifestation of various skin lesions and lesions of the vascular system in some subgroups of SARS-CoV-2 positive patients as such features outside the respiratory sphere, are rapidly emerging. However, knowledge about prevalence and pattern of skin involvement, time of onset, predilection, and its direct or indirect relation to SARS-CoV-2 is still limited. In order to update information gained, we provide a systematic overview of the skin lesions described in COVID-19 patients, discuss potential causative factors and describe differential diagnostic evaluations.

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Section: Virus Induced Vesicular Eruptionsmentioning

confidence: 96%

SARS-CoV-2, COVID-19, skin and vascular system - what do we know so far?

Novak

Peng

Naegeli

et al. 2020

Preprint

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“…Maculopapular lesions resembling pityriasis rosea, erythema elevatum diutinum, erythema multiforme, and Grover disease have been described among COVID-19 patients [25,32,49,83,84]. A case report also documented the appearance of confluent and pruritic erythematous-yellowish papules limited to both heels 10 days after the onset of respiratory symptoms in a female patient with confirmed SARS-CoV-2 infection [26].…”

Section: Other Manifestationsmentioning

confidence: 99%

“…The spectrum of mucocutaneous manifestations of SARS-CoV-2 infection Other cutaneous manifestations reported in COVID-19 patients include maculopapular lesions resembling pityriasis rosea, erythema elevatum diutinum, erythema multiforme, Grover disease, cutaneous vasculitis, and elbow/knee joint erythematous-edematous plaques[16,22,25,32,49,83,84] …”

mentioning

confidence: 99%

Dermatological aspects of SARS-CoV-2 infection: mechanisms and manifestations

2020

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The human infection caused by the novel SARS-CoV-2 is a public health emergency of international concern. Although the disease associated to this virus, named COVID-19, mainly affects the lungs, the infection can spread to extrapulmonary tissues, causing multiorgan involvement in severely ill patients. The broad infective capacity of SARS-CoV-2 is related to the pattern of expression of the viral entry factors ACE2 and TMPRSS2 in human tissues. As such, the respiratory and gastrointestinal tracts are at high risk for SARS-CoV-2 infection due to their high expression of ACE2 and TMPRSS2, which explains the clinical phenotype described in the vast majority of infected patients that includes pneumonia and diarrhea. Recently, preoccupation about the potential of the virus to infect the skin has been raised by dermatologists due to the increasing observations of cutaneous manifestations in patients with SARS-CoV-2 infection. Although there is little evidence of the expression of ACE2 and TMPRSS2 in the normal skin, the dermatological findings observed among COVID-19 patients warrants further investigation to delineate the mechanisms of skin affection after SARS-CoV-2 infection. Here, we provide a summary of the dermatological findings observed among patients with laboratory-confirmed SARS-CoV-2 infection based on recent reports. In addition, we analyze possible mechanisms of skin injury in COVID-19 patients and discuss about the risk of individuals with chronic skin conditions for SARS-CoV-2 infection. The present review constitutes a useful informative tool to improve our understanding of the pathophysiological mechanisms of COVID-19 and the possible implications of the current pandemic in dermatology.

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“…Regarding integumentary manifestations, clinical images or histopathological registers cannot be assessed for all cases reported so far. Authors have described these cutaneous lesions under distinct dermatological terms: (i) erythematous rash , [ 10,16] widespread urticaria [ 10,16,18,19] and chickenpox‐vesicles ; [ 10] (ii) “ mottling ”; [ 11] (iii) Dengue‐like purpuric exanthema ; [ 12] (iv) pneumonia with urticaria and pneumonia with atopic dermatitis ; [ 13] (v) urticarial eruption ; [ 8] (vi) acroischaemia of the finger/toe with cyanosis (blue toe syndrome) , dry gangrene with or without disseminated intravascular coagulation (DIC), [ 9] DIC‐like acral manifestations and severe perniosis ; [ 9,10] (vii) retiform purpura and livedo racemose ; [ 8,32,35] (viii) varicella‐like exanthema ; [ 8] (ix) chilblains‐like disease ; [ 8] (x) transitory unilateral livedo after sun exposure; [ 14] (xi) confluent erythematous‐yellowish papules in the heels; (xiii) acute flexural rash similar to Symmetrical Drug‐Related Intertriginous and Flexural Exanthema (SDRIFE); (xiv) purpuric skin rash with coalescing macules in the axillae ; [ 15] (xv) erythema multiforme‐like eruption; [ 8] (xvi) acute generalized exanthematous pustulosis (AGEP) with erythema multiforme‐like lesions ; [ 3,21,46] (xvii) drug‐induced vasculitis , [ 4] (xviii) oral and cutaneous vesiculobullous lesions ; [ 8,41] (xix) vascular acrosyndromes with indurated erythematous or violaceous plaques on heels and toes; [ 8] (xx) viral‐like morbilliform exanthema ; [ 7,8,27,28] (xxi) maculopapular eruptions , [ 8,22,29] (xxii) diffuse maculopapular eruption involving the trunk, similar to Grover disease ; [ 5] (xxiii) petechial skin eruption [ 6,16] and (xxiv) pruritic papular‐vesicular eruption surrounded by erythematous halos affecting trunk and limbs, suggestive of Herpes infection; [ 7,40] (xxv) necrosis ; [ 16,33] (xxvi) mucosal lesions ; [ 16,36‐39,43] (xxvii) perifollicular eruption ; [ 20,45] (xxviii) pruritic rash ; [ 23‐26,47] (xxix) lichenoid eruption ; […”

Section: What Has Been Reported About Cutaneous Lesions In Covid‐19 Pmentioning

confidence: 99%

“…Analysis of skin samples from patients with distinct COVID‐19 skin lesions may help establish the pathophysiology of cutaneous involvement, which appears to be less frequent than manifestations of the virus in other organs and tissues. A literature search in PubMed using the key terms “skin and COVID‐19” or “cutaneous and COVID‐19” identified descriptions of cutaneous manifestations in 89 articles, [ 3‐47] and almost 1150 patients registered with a variety of cutaneous lesions.…”

Section: Introductionmentioning

confidence: 99%

Potential interactions of SARS‐CoV‐2 with human cell receptors in the skin: Understanding the enigma for a lower frequency of skin lesions compared to other tissues

Criado

Pincelli

Criado

et al. 2020

Experimental Dermatology

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The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) represents a new public health problem, with a total of 10.577.263 documented COVID‐19 cases worldwide and 513.441 deaths up to the present date. Few cases of disease‐related cutaneous manifestations have been reported in the literature, and such manifestations are scarce. Integumentary manifestations from COVID‐19 include exanthemas and papular dermatoses, urticarial eruptions, atopic dermatitis, vesiculobullous lesions and skin signs of hypercoagulable states, such as acral ischaemia, livedo and retiform purpura. Most common extracutaneous manifestations from the disease include headache, cough, anosmia, ageusia, fever, dyspnoea, nausea, diarrhoea and cardiovascular events. The objectives of this review were to discuss the role of human cell receptors described as interaction targets of SARS‐CoV‐2, as well to understand the current state of knowledge on skin expression of these receptors, in order to substantiate future research. The authors present a thorough literature review on SARS‐CoV‐2 and its possible interaction with cell receptors and human tissues including the skin. They discuss a molecular hypothesis to explain the lower prevalence of dermatological manifestations from direct SARS‐CoV‐2 infection. Distinct human cell receptors binding the virus appear to be less expressed in the skin compared to other organs. Additionally, the presence of resolvins and the disintegrin metalloprotease ADAM17 provide a putative protection to the skin, explaining the majority of COVID‐19 manifestations to be extracutaneous. This review represents an excellent opportunity for future studies using skin biopsies from COVID‐19 patients to investigate molecular expression in the pathophysiology of cutaneous manifestations of the disease.

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Acute generalized exanthematous pustulosis with erythema multiforme‐like lesions induced by Hydroxychloroquine in a woman with coronavirus disease 2019 (COVID‐19)

Cited by 48 publications

References 8 publications

SARS-CoV-2, COVID-19, skin and vascular system - what do we know so far?

SARS-CoV-2, COVID-19, skin and vascular system - what do we know so far?

Dermatological aspects of SARS-CoV-2 infection: mechanisms and manifestations

Potential interactions of SARS‐CoV‐2 with human cell receptors in the skin: Understanding the enigma for a lower frequency of skin lesions compared to other tissues

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