Drug‐induced vasculitis in a patient with COVID‐19

Editor,

A 57‐year‐old German woman with a history of skin reactions to unknown antibiotics, depression and high blood pressure presented with a 2‐day history of symmetrically distributed pruritic pink‐to‐red maculopapular exanthema on the trunk and extremities.

Due to a 3‐week history of a non‐productive cough and intermittent fever, she has taken amoxicillin, ibuprofen and metamizole 3 days before. She did not take aspirin or other anticoagulants.

This prescription was discontinued and an intravenous bolus of prednisolone as well as anthistamines and topical glucocorticoids were administered.

After 2 days, her rash progressed in purpuric, non‐blanching, pruritic and painful maculas and plaques on her trunk and extremities (Figs 1 and 2). Mucous membranes were spared. The patient was afebrile, and her oxygen saturation was 98% while she was breathing ambient air.

Figure 1.

Symmetric, purpuric, non‐blanching and palpable maculas and plaques on lower extremities of the patient.

Figure 2.

Purpuric, non‐blanching and palpable maculas and plaques on the trunk and upper extremities of the patient.

The blood count, prothrombin time and partial thromboplastin time were normal. An elevated D‐dimer level by 2.051 µg/L was observed. A chest radiograph showed a right lower lobe consolidation suggestive of pneumonia. A test to detect SARS‐CoV‐2 by real‐time reverse‐transcription‐polymerase‐chain‐reaction (RT‐PCR) assay of a throat swab was positive. A biopsy specimen of the skin lesion revealed a vasculitis. Blood tests for HIV, antinuclear antibodies and antineutrophyle cytoplasmic antibodies were negative.

The patient was treated with 120 mg of prednisolone per day (1.5 mg per kilogram of body weight). After 9 days, the patient's skin lesions and her respiratory symptoms improved. Two negative SARS‐CoV‐2 by RT‐PCR tests of throat swabs with sampling interval of 24 h were confirmed and the patient was discharged home.

Despite an antibiotic allergy could developed the rash and vasculitis in our patient, it is known that severe COVID‐19 induces endothelial damage and thrombosis. ¹ , ² Some reports have showed urticaria, rash, vesicles, purpura, chilblain‐like and erythema multiforme‐like patterns as cutaneous manifestations in patients with COVID‐19. ² , ³ , ⁴ , ⁵ , ⁶ This case report illustrates the potential of COVID‐19 infections to trigger severe drug‐related skin reactions such as vasculitis. More evidence is needed to understand the association of COVID‐19 and cutaneous manifestations.

Acknowledgement

We would like to thank the patient cited in this manuscript that has given a written informed consent to the publication of her case details and photographs.

Funding source

The authors received no specific funding for this work.