Two False Negative Test Results in a Symptomatic Patient with a Confirmed Case of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and Suspected Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN)

Abstract

The recent outbreak of COVID-19 has put significant strain on the current health system and has exposed dangers previously overlooked. The pathogen known as severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), is notable for attacking the pulmonary system causing acute respiratory distress, but it can also severely affect other systems in at-risk individuals including cardiovascular compromise, gastrointestinal distress, acute kidney injury, coagulopathies, cutaneous manifestations, and ultimately death from multi-organ failure. Unfortunately, the reliability of negative test results is questionable and the high infectious burden of the virus calls for extended safety precautions, especially in symptomatic patients. We present a confirmed COVID-19 case that was transferred to our burn center for concern of Steven Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) overlap syndrome after having two negative confirmatory COVID-19 tests at an outside hospital. A 58-year-old female with a history of morbid obesity, HTN, gout, CML managed with imatinib, and chronic kidney disease presented as a transfer from a community hospital to our burn center. The patient was admitted to her community hospital with febrile, acute respiratory distress. Imaging and clinical presentation was consistent with COVID-19 and lab tests for the pathogen were ordered. During observation, while waiting for results, she was placed under patient under investigation (PUI) protocol. Once negative results were obtained, the PUI protocol was abandoned despite ongoing symptoms. Subsequently, dermatological symptoms developed and transfer to our burn center was initiated. After a second negative test result, the symptomatic patient was transferred to our burn center for expert wound management. Given the lack of resolve of respiratory symptoms and concern for the burn patient population, the patient was placed in PUI protocol and an internal COVID-19 was ordered. The patient's initial exam under standard COVID-19 airborne precautions revealed 5% total body surface area of loss of epidermis affecting bilateral thighs, bilateral arms, and face. A dermatopathological biopsy suggested a bullous drug reaction with an erythema multiform-like reaction pattern versus SJS/TEN. Moreover, the internal COVID-19 test returned positive.

Dermatologic manifestations of COVID‐19: a comprehensive systematic review

“…There were single reports with detailed dermatologic information available of petechiae, 78 cherry hemangioma, 19 Raynaud’s, 19 psoriasis flare, 79 nonspecific vesicular rash, 14 acneiform rash, 6 transient acantholytic dermatosis, 40 erythema nodosum, 80 bullous interface dermatitis, 81 pityriasis rosea, 82 Grover’s, 38 digitate papulosquamous eruption, 83 cutaneous small‐vessel vasculitis, 84 oral lesions, 85 and Kawasaki 86 . Of note, for Kawasaki, though the body of literature is growing, cases with detailed dermatologic information are at this time lacking.…”

“…The average age for pediatric patients with a dermatologic manifestation was 12.9 years of age (SD 3.6, or median 14 years with IQR [14, 14]) 11,12,16–18,32,33,52,53,65,66,72,86 and for adults was 34.2 years (SD 21.8, or median 56.8 years with IQR [26, 78]) 5,6,8–15,19,21–26,28–31,34–41,43,45–51,54–61,63,64,67–71,73–77,79–85,88,89 . There was a slight preponderance of females in the pediatric population (57.1%) 12,16–18,32,33,52,53,65,66,72,86 and adult population (52.3%) 5,6,8–15,19,21–26,28–31,34–41,43,45–51,54–61,63,64,67–71,73–77,79–82,84,85,88,89 . Average latency from COVID‐19 symptoms to cutaneous findings for pediatric patients was 1.5 days (SD 2.9, ranging from −3 to 7 days) and for adult patients was 7.9 days (SD 10.7, or median 7 days with IQR [3, 20]), with a range of −2 days (i.e.…”

COVID-19 Induced Pancytopenia in a Major Molecular Response CML patient on Dasatinib: A Case Report and Review of Literature

“…It was not reported whether this patient was continued on imatinib or not. Lagziel et al described a 58-year-old woman with a history of CML managed for 4 years with imatinib, morbid obesity, hypertension, gout and chronic kidney disease who was admitted initially for fever and respiratory distress, later complicated by a disseminated erythematous and papular skin rash; biopsy was consistent with bullous interface dermatitis [6] . Using a questionnaire, Li et al studied 530 subjects with CML in Hubei province during the COVID-19 pandemic.…”

Evaluation of cutaneous symptoms in children infected with COVID‐19

“…In genetically predisposed individuals, SARS‐CoV‐2 can trigger the development of a rapid autoimmune and/or autoinflammatory dysregulation and lead to severe interstitial pneumonia 11 . A case report reported that a 58‐year‐old female patient developed SJS and TEN overlap syndrome with COVID‐19 positivity 12 . The pathogenesis of cutaneous symptoms is not understood yet.…”