Self-case report of oral and skin lesions associated with positivity of COVID-19.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

Dear Editor,

We would like to present, according to the CARE guidelines, a case report of a surgeon who had been repeatedly exposed to coronavirus disease (COVID‐19) patients and developed oral and skin lesions before typical respiratory symptoms of COVID‐19.

A previously healthy 26‐year‐old female maxillofacial surgeon working full‐time at F. D. Roosevelt University Hospital (Banska Bystrica, Slovakia) reported a history of occasional itching and burning sensation for 7 days before her dermatologic visit. She presented to the dermatologic clinic with a skin rash extended around the mouth, mainly on the chin's skin, which spread to the nasolabial sulcus toward the nose. The clinical examination revealed a maculopapular rash with signs of eczema (Figure 1). Based on the anamnestic information, the dermatologist concluded that this perioral contact dermatitis had resulted from the constant wearing of FFP respirators as an occupational hazard for healthcare professionals during the ongoing pandemic; therefore, the patient was prescribed topical azelaic acid (Skinoren 20% Cream) and topical ammonium bituminosulfonate (Ichthammol Powder). The dermatologist also suggested retaining fluoride‐containing toothpaste and make‐up cosmetics use.

FIGURE 1

(A) perioral dermatitis and (B) minor aphthous stomatitis of the lower lip of a COVID‐19 patient

Five days before the hospital staff's routine screening, the patient started to suffer from sore throat and ear pain, which was progressively complicated with sinus pain and rhinorrhea. During the following days, headache, myalgia, and fatigue had emerged gradually. The hospital staff's routine screening revealed her infection by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) due to the positivity of the antigen (Abbott Laboratories, 2020); therefore, she was ordered home quarantine and prescribed symptomatic treatment, including paracetamol. Three days after being tested positive, she had a total loss of smell and taste which emerged suddenly. Four days after being tested positive, the lower lip's mucosal lesion appeared with three millimeters in diameter and erythematous margin and a white halo. The lesion was painful on palpation and could not be wiped off, thus indicating minor aphthous stomatitis (Figure 1). Despite occasional pain provoked by eating, the oral lesions did not require medication due to the patient's professional experience of the lesion nature as a self‐limiting condition. The hospital epidemiologist decided to check the course of the infection by polymerase chain reaction (PCR) test, 5 days after the positive antigen test, which was positive with a cycle threshold value of 27.86, recommending continuity of quarantine due to infectivity.

Eight days after the positive antigen test, the antigen test turned negative, and the sense of smell recovered since the morning. The intraoral lesion had healed entirely within 5 days without scars. However, the patient was without protective equipment, for example, drapes or respirators, and stopped using fluoride‐containing toothpaste and make‐up cosmetics during the 10‐day quarantine; the perioral lesions had periods of remission and recurrence in the following weeks and months, and the perioral skin did not heal for 4 months. Three months after her initial presentation, the patient sought dermatologic consultation and was prescribed erytromycine and ivermectinum for local application. Ten days after local therapy, symptoms degraded, although the dermatologist recommended continuing local therapy for 1 month.

This case supports the evidence that routine screening by antigen test for hospital staff every 14 days is an effective practice against the COVID‐19 pandemic; additionally, alertness and self‐diagnosis of healthcare professionals are inevitable assets for early intervention. Since our case is similar to the COVID‐19 cases reported by Brandao et al 2020, who had mucosal lesions concurrently with ageusia and anosmia, it may confirm the hypothesis of early susceptibility of the oral cavity to SARS‐CoV‐2 because of the high expression of angiotensin‐converting enzyme 2 (ACE2). , Due to the lack of PCR swabs from the perioral lesions, COVID‐19 infection was not assumed as a direct cause during the initial dermatological examination and differential diagnosis. Skin lesions before COVID‐19 diagnosis and associated oral mucocutaneous manifestations might be inaugural symptoms that require attention, especially in suspected individuals like healthcare professionals. , This case report is an autoanamnesis of the first author, B.H.