Cutaneous manifestations of COVID-19: A case report and a new finding from Egypt.

Dear Editor,

Due to its rapidly spreading nature, coronavirus disease 2019 (COVID‐19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has been announced as a pandemic by the World Health Organization in March 2020. Although it is mainly a respiratory condition, it has other manifestations including anosmia and ageusia. Skin manifestations are among the rare conditions associated with the COVID‐19, these may include chilblain‐like lesions, vascular lesions, varicella‐like eruptions, and rash.

Here, we present a case of COVID‐19 with multiple skin lesions associated with exacerbation of previous skin condition.

CASE REPORT

A 33‐year‐old female health care professional, with no previous medical condition, presented with fever (39.4°C), myalgia, abdominal pain, and severe watery diarrhea 12 hours after exposure to a highly suspected case of COVID‐19. She was tachycardic, tachypneic with hypertension, and her laboratory tests showed leukocytosis with absolute lymphopenia (white blood cells = 13.6 × 103, lymphocytes = 1 × 103 [7%], serum ferritin [315 ng/mL], and d‐dimer was high normal [0.4 μg fibrinogen equivalent units/mL]). Computed tomography (CT) of the chest was normal.

One day later, she developed sore throat, anosmia and ageusia, headache, generalized bone pain, and dry cough. Skin lesions started to appear in the form of sudden onset of morbilliform skin rash, erythematous patches, and urticarial lesions fading on pressure with itching mainly on the trunk; the skin lesions were extending to the upper and lower limbs including the palms; there were oral lesions in the form of oral congestion and petechiae; and sore throat and pain were referred to the ear (Figures 1, 2, 3 and 4).

FIGURE 1

Oral lesions in the form of petechiae and vascular congestion on the posterior wall of the oropharynx and the uvula

FIGURE 2

Itchy erythematous eruption on the palm of the hand (A), forearm (B), and antecubital fossa (C)

FIGURE 3

Erythematous itchy eruptions on the foot

FIGURE 4

Acute exanthematous erythematous lesions on the abdomen fading on pressure

She was home isolated and started symptomatic treatment. Three days later, she started to take azithromycin 500 mg/d for 5 days and oseltamivir 75 mg/12 h for 5 days, but unfortunately her condition worsened and CT chest showed ground‐glass opacities (Figure 5) and she started hydroxychloroquine per oral (PO) (400 mg /12 h for 1 day and then 200 mg/12 h for 9 days); the skin lesions started to fade out while itching continued for several days. A unique finding was seen in the form of sudden eruption of 12 wart‐like lesions on the lower extremities, of different clinical types (planter and plane) and sizes (0.2‐2 cm in diameter) (Figure 6), which, to our knowledge, was not described before.

FIGURE 5

Axial (A) and coronal (B) cuts of non‐enhanced computed tomography of the chest showing bilateral subpleural patchy ground‐glass opacities of inflammatory nature

FIGURE 6

Wart‐like eruptions on the back of the heel (A, B) and the sole (C), notice the different sizes and types of the eruptions

Her general condition worsened over the next few days, she got hospitalized, rapid test for COVID‐19 was positive for immunoglobulin M (IgM), and she was prescribed intravenous methylprednisolone (1.5 mg/kg/d for 5 days), anticoagulation therapy (enoxaparine [1 mg/kg twice daily for 5 days]), and levofloxacin (500 mg/d for 5 days).

After few days, she got better, nasopharyngeal swabs for COVID‐19 were negative, and discharged from hospital on pulse prednisone 80 mg PO 2 days a week for 2 weeks with gradual tapering and rivaroxaban (10 mg/d for 4 weeks) after which her condition resolved with deterioration of her warts in a slowly progressive fashion.

We believe that these skin lesions were part of the COVID‐19 syndrome, as she had most of the clinical, laboratory, and imaging features associated with the disease, with positive rapid IgM test.

In an early study in China, researchers found two cases with skin eruptions among the 1099 cases of COVID‐19 (0.02%); others described acral eruptions as one of the early manifestations of cutaneous COVID‐19. Vesicular lesions, hemorrhagic eruptions, or varicella‐like eruptions , are the other skin manifestations.

To our knowledge, this is the first case to report wart‐like lesions in association with COVID‐19. This may be due to the presence of subclinical infection with human papilloma virus that was dormant in skin, as a sequelae to her profession, and exacerbated by lowered immunity due to SARS‐CoV‐2 viral infection, or suggestively, the SARS‐CoV‐2 may make the host more susceptible for other viral infections.