Erythema multiforme in COVID-19: a case report

Ivan A. Jones*, G. Dominic Rodriguez

Department of General Medicine, Kauvery Hospital, Trichy, Tamilnadu, India

*Correspondence: keitch.jones@gmail.com

Abstract

COVID-19 infection, declared as pandemic by WHO in 2020, may result in various patterns of dermatological manifestations. Understanding the causal relationship of skin manifestations and covid-19 infection and diagnosing them helps in managing the patients effectively.

Keywords: COVID-19, Erythema multiforme, Target lesions

Background

Different patterns of skin manifestations of COVID-19 infection have been reported by clinicians across the globe. These include maculo-papular rashes, urticaria, pseudo-chilbain, vesicles, livedo-reticularis, petechiae, and erythema multiforme like lesions [1].

We report a male diabetic patient, who got COVID-19 infection and developed erythema multiforme like lesions in his second week of illness.

Case Presentation

A 53-year-old gentleman who was a diabetic presented with history of fever for one week associated with sore throat, cough, headache, diarrhoea. He was taking oral anti-diabetic drugs for diabetes and had taken one dose of COVISHIELD Vaccine one month back. On evaluation he was hemodynamically stable with normal oxygen saturation. Clinically there was no specific localising signs and system examination was normal. RT–PCR for COVID-19 was positive and CT THORAX revealed focal ground glass density in right lower lobe. Blood investigation were done and total count was 7900. Neutropil-lymphocyte ratio was 1.73.C-reactive protein, d-dimer, LDH, ferritin was within normal limits.

He was treated with oral paracetamol, cough suppresant, vitamin C, multivitamin, prophylactic dose of low molecular weight heparin, insulin. On 14th day of illness, patient developed itchy erythematous targetoid macules over both forearms, later it involved the dorsum of both hands, both lower limbs, and subsequently he developed multiple superficial erosions in oral mucosa. Ocular and genital mucosa were not involved. There were no preceding or co-existing herpetic lesions. Images were photographed after informed written consent from patient (Figs. 1–4).

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Fig. 1. Target lesions over the dorsum of left hand.

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Fig. 2. Oral mucosal erosions.

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Fig. 3. Lesions over right forearm.

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Fig. 4. Lesions over left thigh.

A provisional diagnosis of COVID-19 related Erythema multiforme was made. Blood investigations were repeated. Total count was elevated with high neutrophil-lymphocyte ratio. He also had elevated C-reactive protein and elevated d-dimer. Renal function test was normal and urine analysis was normal (Table 1).

Table 1. Laboratory investigations

Day of illness – 8 Day of illness – 11 Day of illness – 18
Hb (g/dl) 14.3 13.4 14.8
Total count (cells/cumm) 7900 6700 13600
Neutrophil (%) 57.6 39.4 67.1
Lymphocyte (%) 32.6 49.1 21.8
Monocyte (%) 8.7 8.6 8.3
Eosinophil (%) 0.7 3.0 2.1
Basophil (%) 0.4 0.9 0.7
Neutrophil-lymphocyte ratio 1.73 0.81 3.06
CRP (mg/L) 8.4 9.0 48.4
d-dimer (ng/mL) 456.15 237.17 984.45
Urea (mg/dl) 26 21 13
Creatinine (mg/dl) 0.76 0.80 0.89

He was treated with anti-histamines, topical anaesthetic for oral lesions. He improved symptomatically over the next five days showing resolution of skin lesions and oral ulcers.

Discussion

Erythema multiforme like lesions have been reported rarely in COVID-19 patients. Erythema multiforme is an acute immune mediated condition characterised by the appearance of distinctive target like lesions on the skin, often accompanied by erosions or bullae involving oral, genital and/or ocular mucosae. Many factors such as infections-most commonly Herpes simplex virus, medications, autoimmune disease, radiation, sarcoidosis have been linked to the disease.

Diagnosis is mainly done by history and clinical findings. Skin biopsies may be done to confirm the diagnosis if necessary. Erythema multiforme may be self-limiting. In few severe cases, systemic corticosteroids may be necessary [2].

Our patient developed skin lesions suggestive of Erythema multiforme in his second week of illness suggesting a possibility of immune mediated pathogenesis for his skin lesions. He developed skin lesions after getting treatment for COVID-19, hinting a possibility of drug induced Erythema multi-forme. But after reviewing his drug details, we could not ascertain any particular drug that could have most likely caused the skin lesions. There were no preceding or co-existing herpetic lesions, hence the possibility of Herpes induced Erythema multiforme does not fit in. The fact that he developed Erythema multiforme after getting diagnosed with COVID-19 makes the causal association more likely. He improved with symptomatic treatment and he did not require either topical or systemic corticosteroids. We present this case to highlight the dermatological manifestation of COVID-19 infection and it could possibly be attributed to immune mediated mechanism.

Acknowledgements

Thankful to Dr. Niraimathi MBBS MD DNB consultant dermatologist Kauvery Hospital Tennur who helped in diagnosis and management of the patient.

Author contributions

Supervised by Dr. Dominic Rodriguez. Report written by Dr. Ivan A Jones and edited by Dr. Dominic Rodriguez.

Competing interest

The authors have no competing interest to declare.

References

  • Tan SW, Tam YC, Oh CC. Skin manifestations of COVID-19: A worldwide review. JAAD Int. 2021;2:119–33.
  • Demirbaş A, Elmas ÖF, Atasoy M, Türsen Ü, Lotti T. A case of erythema multiforme major in a patient with COVID 19: The role of corticosteroid treatment. Dermatol Ther. 2020;33(6):e13899.

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