Hydroxychloroquine-Induced Stevens-Johnson Syndrome in COVID-19: A rare Case Report

Abstract

Background: The international outbreak of respiratory illness termed coronavirus disease 2019 (COVID-19) began in December 2019 that has affected more than 0.8 million individuals. To date, there are no specific therapeutic agents for coronavirus infections. One of the drugs that have an effective role in improving the condition of patients with COVID-19 is hydroxychloroquine (HCQ). This drug is not a definitive treatment for this disease and has a supportive role. Like all medications, HCQ has side effects and may occur in COVID-19 patients. Stevens-Johnson syndrome caused by HCQ is very rare.Case presentation: A 42-year-old woman, presented with fever and dry cough in the past two days to her family physician. Lab tests revealed elevated lactate dehydrogenase (LDH, 648 units/liter (U/L)), C-reactive protein level (CRP, 52 milligrams/Liter (mg/L), normal: <10 mg/L), aspartate aminotransferase (AST, 59 U/L, normal: 10-40 U/L), thrombocytopenia, and leukopenia. Mild bilateral patchy ground-glass opacity was seen in lung CT-Scan. Due to COVID-19 pandemic and clinical findings, the nasopharyngeal swab test was done and SARS-CoV-2 nucleic acid was detected by RT-PCR. HCQ 200 mg twice daily was started. After two days, the patient presented with a pruritic erythematous maculopapular rash and flat atypical targets that started from the distal of upper extremities and rapidly, involved the entire body, and torn blisters which were only be seen as ulcers on orolabial area. The Nikolsky sign was positive. Due to the likelihood of a drug reaction, HCQ was discontinued, and COVID-19 treatment was changed to lopinavir/ritonavir (LPV/RTV) 400 mg twice daily. Finally, she was discharged after five days with nonpruritic scalded skin on the distal of upper extremities. Conclusions: It is worth noting that although HCQ appears to be safe and has mild side effects, however, the boundary between therapeutic and toxic doses is narrow and severe disorders of their use can life-threatening. One of the side effects of HCQ is SJS caused by the drug, and given the worldwide pandemic of COVID-19 and the increasing need for this drug, we need to be careful about its use in order to control and manage the side effects of this drug.

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.…”

“…It should be notified that logically the rate of dermatologic adverse effects among antivirals is related to their frequency of usage, too. Since, adverse drug reactions of skin are frequently observed in pandemic area, dermatologist and specialists of other fields really need to be more informed about drugs with more mucocutaneous adverse reactions and the type of reactions and some of these reactions may be severe or even life‐threatening also management of patients in such conditions could be really challenging regarding skin eruption and concomitant COVID infection 4,19,20 . The authors of this study have been focused on various aspects of COVID‐19 especially in the field of dermatology and now it seems that focus on this topic is of great importance.…”

COVID-19: The experience from Iran

“…On the other hand, HCQ-induced drug reactions became one of the challenges in dermatology practice. Acute generalized exanthematic pustulosis, 60 , 61 , 62 Stevens-Johnson syndrome, 63 maculopapular and urticarial rashes, 64 drug reaction with eosinophilia and systemic symptoms syndrome, 65 and itching 64 are known cutaneous reactions of HCQ. Another potential hazard is the exacerbation of psoriasis.…”

“… 66 Iranian dermatologists managed many patients with such reactions in e-visits, e-consults, in-person visits, dermatology wards, and COVID-19 services. 63 There are recent reports regarding HCQ cardiotoxicity and questionable efficacy. 67 , 68 …”

COVID-19 outbreak: Challenges in pharmacotherapy based on pharmacokinetic and pharmacodynamic aspects of drug therapy in patients with moderate to severe infection

“…), gastrointestinal adverse reactions, hepatic adverse reactions (hepatitis and increased liver enzymes), etc. Results of a recent case report emphasized that chloroquine/hydroxychloroquine administration could induce severe dermatologic side effects such as Stevens Johnson syndrome (SJS) in a patient with COVID-1950 . Also the results of a systematic review on dermatologic adverse effects of hydroxychloroquine emphasized that the most common dermatologic reactions due to hydroxychloroquine administration were rash, SJS, toxic epidermal necrolysis (TEN),…”