0 citations0 references

Oral vesicles and acral erythema: report of a cutaneous manifestation of COVID‐19

International Journal of Dermatology2020Vol. 59(9), pp. 1153–1154

Citations Over TimeTop 10% of 2020 papers

Nessa Aghazadeh, Mona Homayouni, Julio C. Sartori‐Valinotti

Abstract

Dear Editor, Dermatologic manifestations of COVID-19 are emerging, which include a wide range of presentations from exanthema, urticaria, livedo, and petechiae to vasculitis and vasculopathic skin eruptions. Acro-ischemic, pernio-like eruptions have been reported in children and adolescents. Herein, we report a 9-year-old girl presenting with fever, a vesicular oral eruption, and acral erythematous papules and plaques preceding the development of respiratory symptoms of COVID-19. The pneumonia and skin eruption favorably improved over the course of a few weeks with supportive therapy. Clinicians should consider COVID-19 within the differential of oral vesicular eruptions, especially in children. A 9-year-old previously healthy girl, from Qom, Iran, presented with profound weakness, loss of appetite, high fever (maximum temperature of 39.6 °C), abdominal pain, diarrhea, and skin eruption. Her parents denied use of medications other than acetaminophen for pain and fever relief. There was a family history of COVID-19 infection in her aunt about 1 month before presentation; our patient had multiple close contact interactions with her aunt over the preceding weeks. On skin examination, she was noted to have vesicles and erosions involving the lips, anterior tongue, and buccal mucosa (Fig. 1). She had deep red, edematous papules and plaques involving the dorsal hands and feet (Fig. 2). Three days later, she developed dry cough, shortness of breath with tachypnea (respiratory rate: 60/minute), hypoxia (O2 saturation: 88%), and somnolence. A chest x-ray showed ground glass densities involving bilateral lungs. Nasopharyngeal swab RT-PCR was positive for COVID-19 virus. She was treated conservatively with hydration, supplemental oxygen therapy as needed at home. Her symptoms gradually improved over the course of a few weeks, and mucocutaneous eruption resolved in about a week. Reports regarding the cutaneous manifestations of a novel coronavirus infection, COVID-19, are on the rise. The initial report from Italian dermatologists described skin manifestations in 20% of affected patients; 44% of these patients had skin eruption at disease onset.1 Cutaneous manifestations of COVID-19 are polymorphic and most commonly include exanthematous and urticarial eruptions, followed by livedoid, petechial, vesicular eruptions, and cutaneous vasculitis.2, 3 An acro-ischemic, pernio-like eruption has been reported in asymptomatic or mildly affected children and adolescents.4 Histopathologic evaluation of COVID-19 skin lesions may show vascular microthrombi and lymphocytic vasculitis.5 We report a child with a vesicular/herpetiform oral eruption and acral erythematous papules and plaques as initial manifestation of COVID-19. At presentation, the differential diagnosis included hand-foot-mouth disease (HFMD), atypical herpes simplex infection, mycoplasma-induced rash and mucositis, erythema multiforme, and drug eruption. The acral eruption was not consistent with HFMD, which characteristically presents with elongated grayish vesicles on the palmar and plantar surfaces. Unfortunately, PCR for herpes simplex virus or enterovirus was not available and not performed. Classic targetoid lesions of erythema multiforme were absent, and history of drug exposure was unremarkable. She did not receive any empiric antiviral or antimicrobial drugs for this eruption. The cutaneous eruption preceded rapid progression to a typical COVID-19 pneumonia. She had a history of recent contact with an affected family member, and the PCR test for COVID-19 was positive. Hence, we believe the evidence strongly supports a diagnosis of COVID-19-related dermatosis. The noted acral erythematous papules and plaques with deep red-bluish hue could be within the spectrum of acro-ischemic/perniosis-like pediatric presentation of COVID-19.4 Unfortunately, obtaining a skin biopsy was not feasible since the patient was mostly cared for at home in isolation. To the best of our knowledge, this is the first report of vesicular and erosive lesions affecting the oral mucosa, accompanied by an erythematous acral eruption in COVID-19. Varicelliform and vesicular eruptions have been previously documented in COVID-19, involving the trunk and extremities.1 Histologically, acantholysis, dyskeratosis, ballooning degeneration, and necrosis of the keratinocytes have been reported in the skin lesions of COVID-19, which can mimic herpetic infection.5 We report this case to raise awareness that, in the appropriate clinical scenario, oral vesicles, especially in children, could represent a cutaneous manifestation of evolving COVID-19 disease.

Citations Over TimeTop 10% of 2020 papers

Abstract

Related Papers