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Stevens-Johnson syndrome as a primary skin manifestation of COVID-19
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  1. Alwi Muhd Besari1,
  2. Jo Anne Lim1,
  3. Pothene Thevi Vellaichamy1,
  4. Faezahtul Arbaeyah Hussain2,
  5. Zaleha Kamaludin2,
  6. Mokhtar Nor1
  1. 1Department of Internal Medicine, Hospital USM, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
  2. 2Department of Pathology, Hospital USM, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
  1. Correspondence to Dr Jo Anne Lim, Department of Internal Medicine, Hospital USM, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia; limjoanne{at}usm.my

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A 75-year-old lady presented to us with a 2-day history of fever, runny nose and cough. She was tested positive for COVID-19. The patient had mild symptoms and was admitted for observation due to her advanced age. No medication was given as she had been symptom-free after admission.

On day 9 of illness, she developed extensive oral ulcers with generalised purpuric macules which were predominantly axial in distribution (figure 1). The illness was also associated with malaise, poor appetite, conjunctivitis and genital ulcers. She had negative cultures and serology for all other infections screened. Skin biopsy showed focal subepidermal separation, epidermal necrosis, basal cell vacuolation, dyskeratosis and mild superficial perivascular lymphocytic infiltrates (figure 2). Direct immunofluorescent stain was negative. These features were in keeping with Stevens-Johnson syndrome (SJS). She was discharged well after 2 weeks of supportive care. At 1-month follow-up, the lesions had completely resolved.

Figure 1

Erosion and crust over the lips with multiple oral and tongue ulcers. Generalised purpuric macules predominantly axial in distribution.

Figure 2

Dermoscopic view under (A) polarised and (B) non-polarised light showed perilesional and background erythema with necrotic patches and scattered brown dots. Histology under H&E stain showed (C) subepidermal separation and detached necrotic epidermis (×40), (D) mild perivascular and periadnexa lymphocytic infiltration (×200).

Although COVID-19 is best known for causing respiratory symptoms, cytokine storms and thromboembolic sequalae, it has also been reported to be associated with dermatological manifestations.1 2

SJS occurrence in COVID-19 patients has so far been reported to be associated mostly with medications.3 Unlike drug causes, this patient demonstrated more mucosal than cutaneous lesions. This is similar to other SJS cases caused by infections.4

To date, this is the second reported case of SJS due primarily to COVID-19.5 The risk of developing severe cutaneous drug reaction from subsequent COVID-19 vaccinations in these patients is still unclear and remains a dilemma to date.

Ethics statements

Patient consent for publication

Acknowledgments

We thank the patient for providing a written informed consent. Special thanks to the director of Hospital USM for granting us permission to publish this case report. We also thank Lee Jong Koh and Izyan Rifhana Muhamad for assisting in manuscript preparation.

References

Footnotes

  • Contributors PTV contributed to patient management and initial drafting of manuscript. AMB, MN and JAL contributed to patient management, conception, critical revision of content and final approval of the manuscript. FAH and ZK contributed to histopathology analysis, critical revision of content and final approval of the manuscript. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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