Grover-like skin eruption: another cutaneous manifestation in a COVID-19 patient.

Dear Editor,

Coronavirus disease 2019 (COVID‐19) is caused by a new virus called severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and can affect different organs and produce a wide variety of symptoms. Many cutaneous manifestations have also been described. We present a new case with dermoscopy of the skin lesions and its histopathological findings.

A previously healthy 59‐year‐old male presented with fever, severe asthenia, myalgias, and mild cough which lasted for two weeks. Paracetamol was prescribed. Since COVID‐19 was suspected, two PCR tests for COVID‐19 were performed, with negative results. One day after a peak of fever, the patient developed a pruriginous papulovesicular eruption on his trunk, with vesicles evolving into crusted papules. The mucosae were not affected. Dermoscopic evaluation of the crusted papules showed homogeneous red areas, not centered on follicles and a superficial central yellowish area (Fig. 1). A viral culture was negative for varicella zoster virus and human herpes virus. One lesion was biopsied, revealing exoserosis and focal acantholysis and dyskeratotic keratinocytes in the epidermis and a mild dermal perivascular lymphocytic infiltration with some eosinophils. A direct immunofluorescence study on pronase‐digested paraffin section resulted negative for IgG, IgA, and IgM. Immunohistochemistry with a commercially available antibody to SARS‐Cov‐2 spike protein (1A9 GTX632604 by GeneTex®) was distinctly positive in endothelium and eccrine sweat gland epithelium (Fig. 2). The patient chose not to receive treatment for pruritus. Three weeks later, serum IgG antibodies against SARS‐CoV‐2 were detected. Along the following two weeks, the lesions resolved without scarring.

Figure 1

Clinical presentation at the outpatient consults. (a) Clinical image of the patient's skin lesions with multiple erythematous papules with central erosion and crusts located in the upper body. (b) “Macro” of the papules. (c) Dermatoscopic image, showing a central oval erosion with yellowish areas surrounded by a thin whitish halo

Figure 2

Histopathological findings. (a) Hematoxylin‐eosin x2: punch biopsy. Hematoxylin‐eosin x40: (b) exoserosis acantholysis and dyskeratotic cells with irregular nucleus surrounded by clear halo enclosed in eosinophilic shell; (c) perivascular lymphocytic infiltration with some eosinophils in the upper dermis. Immunohistochemical study for SARS‐CoV‐2 shows distinct granular positivity in (d) the endothelium of dermal vessels; (e) sweat gland epithelium

Different conditions have been reported during the COVID‐19 pandemic. A Spanish group collected a large number of clinical photographs in alleged COVID‐19 patients classifying the lesions in five major clinical patterns: pseudo‐chilblain, vesicular eruptions, urticarial lesions, maculopapular, and livedo or necrosis. Other cutaneous manifestations have been reported in COVID‐19 patients. In addition to these clinical findings, some series have the histopathological findings of these lesions but without the benefit of a confirmatory immunohistochemical study of the biopsy material, a technique previously reported by Malgro et al. and performed in the biopsy of our patient. Only a few dermatoscopic images are on record.

The demonstration of the viral spike protein in endothelium concurs with the detection of serum antibodies and suggests viral dissemination and its contribution into the development of the skin lesions.

Our patient presented a pruritic papulovesicular eruption in the trunk that appeared after a peak of fever and a skin biopsy showed focal acantholysis. At this point, these clinicopathological findings may point towards a diagnosis of Grover‐like disease, supporting that SARS‐CoV‐2 would have cytopathic capacity as Gianotti et al. suggest. Moreover, the dermatoscopic findings would match with those described in Grover disease. The pruritic morphology of the skin lesions and the histological findings suggested the differential diagnosis of drug eruption. However, the patient had previously taken paracetamol without any adverse reactions. Exogenous prurigo was another possible diagnosis, but there was no history of insect stings.

We provide the first dermatoscopic images and pathological description of “Grover‐like” clinical pattern in the setting of SARS‐Cov‐2 infection, with supportive immunohistochemical evidence of presence of the virus in skin endothelial cells and sweat glands. False negative PCR tests can occur, as in our case, and keeping a high level suspicion is paramount. In addition, the clinicopathological correlation of skin lesions may contribute to a better diagnosis and understanding of this worldwide disease with an uncertain evolution.