Erythema gyratum repens after COVID‐19

Editor

Erythema gyratum repens (EGR) is considered a paraneoplastic syndrome characterized by the eruption of expanding, concentric, erythematous patches and plaques. ¹ , ² The reaction primarily affects older individuals and has a strong association with internal malignancy; such an association presents in approximately 82% of cases. ¹ , ² , ³ The most commonly associated malignancy is lung cancer, followed by oesophageal and breast cancer. ³

The exact mechanism by which EGR develops is currently unknown. ⁴ , ⁵ Rongioletti et al evaluated 112 original cases of EGR from the literature. ¹ Among these, 70% were associated with an underlying neoplasm, 30% were non‐paraneoplastic, and 29 cases have been considered as different dermatoses mimicking EGR (‘EGR‐like’ eruption). ¹

In this article, we report the first case of a patient with EGR after COVID‐19.

An 83‐year‐old White man presented with a 3‐day history of a rash affecting the abdomen and lower limbs (Fig. 1). The rash was described as red, burning, itchy and painful. On examination, distinctive serpiginous scaling patches with wood‐grained appearance were noted on the thighs and trunk. Dermoscopy of the plaques revealed erythematous background with purplish tinge in a linear pattern (Fig. 2). He reported no known allergies and denied recent irritation or substance exposure to the affected area. Treatment included daily over‐the‐counter hydrocortisone cream but failed to provide symptomatic relief.

Figure 1.

Erythema gyratum repens with extensive concentric erythematous coils arranged in parallel across the abdomen and thighs. Complete resolution of the EGR lesions after 2 weeks (right lower image).

Figure 2.

Erythema gyratum repens – (a, b) Histological examination with mild hyperkeratosis, focal spongiosis and mixed perivascular inflammatory infiltrate in the upper dermis (H&E). (c) Dermoscopy revealed erythematous background with purplish tinge in a linear pattern. Image taken with polarized light. (Original magnification: ×10).

Two weeks before, he had experienced persistent dry cough, overall fatigue, myalgia, muscle weakness, headache and fever with accompanying dysgeusia and anosmia lasting several days. At that time, reverse transcription–polymerase chain reaction (RT‐PCR) by nasopharyngeal swab testing was performed yielding positive result for SARS‐CoV‐2 and confirming COVID‐19.

There was no significant lymphadenopathy. Systemic examination was within normal limits. Routine investigations including complete blood picture, chest and skull skiagram were unremarkable. All other blood parameters including blood culture, serology for antinuclear antibody, syphilis and infections due to hepatitis B, C and A viruses and HIV detected no abnormality. Chest radiography and computerized tomogram of the thorax were normal. The lactic dehydrogenase level was normal. Histological examination of a skin biopsy showed a mild superficial perivascular dermatitis with focal spongiosis (Fig 2).

The patient totally recovered from dry cough, fatigue, myalgia and muscle weakness after 10 days with complete resolution of the EGR manifestations (Fig. 1).

The clinical appearance of EGR is quite unique, often described as an extensive eruption of concentric erythematous coils arranged in parallel across the body. ³ , ⁴ It should also be noted that the associated lesions are not static in appearance. ² As observed in our patient, the eruption can migrate through the affected area but tends to spare the hands, feet and face and is invariably pruritic.

Due to our knowledge, this is the first case of EGR related to COVID‐19. The compelling clinical manifestation of EGR in our patient was directly related to the SARS‐CoV‐2 infection and totally disappeared just after the resolution of the case. No signs of any underlying malignancies were detected.

In our opinion, EGR should no longer be considered as an obligate paraneoplastic syndrome as the cases not associated with neoplasm are clearly not so uncommon. ¹ In addition to searching an underlying neoplasm, clinicians should be aware of the possibility of other associations. ¹ COVID‐19 should be considered in patients with EGR as an underlying cause of the disease.

Conflicts of interest

Rafaela Castro e Silva, Gabriela Castro e Silva, Maria Celeste de Castro Silva and Omar Lupi do not have any conflict of interests regarding this submission.

Funding sources

We did not receive any funding regarding this paper.