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June 24, 2020

Clinicopathologic Aspects of a Papulovesicular Eruption in a Patient With COVID-19

Author Affiliations
  • 1Department of Dermatology and Venereology, Geneva University Hospitals, Geneva, Switzerland
  • 2Department of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
  • 3Laboratory of Virology, Geneva University Hospitals, Geneva, Switzerland
  • 4Department of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
JAMA Dermatol. 2020;156(8):922-924. doi:10.1001/jamadermatol.2020.1966

There are reports of various skin findings associated with coronavirus disease 2019 (COVID-19).1-4 We describe a patient with a papulovesicular eruption.

A man in his 60s developed asthenia, anorexia, and cough. Six days later, he was hospitalized with diffuse bilateral pneumonia and was confirmed to have COVID-19 by nasopharyngeal swab using real-time reverse transcriptase–polymerase chain reaction (RT-PCR). Piperacillin-tazobactam and lopinavir-ritonavir treatment were started. Twelve hours after treatment initiation, numerous 3- to 6-mm pseudovesicular papules with superficial crusting were noted on the trunk. The papules were asymptomatic (Figure 1). Within 48 hours the papules evolved to an extensive, but not confluent, purpuric rash. The clinical differential diagnosis was a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)–associated eruption, transient acantholytic dermatosis (Grover disease), herpes simplex virus infection, or a drug reaction. Diagnostic testing was performed on a superficial skin sample for the herpes simplex, varicella zoster, and SARS-CoV-2 viruses, and the results were negative. Histologic analysis showed extensive epidermal necrosis with acantholysis and large multinucleated keratinocytes with ballooning degeneration. A dense perivascular lymphohistiocytic infiltrate with some extravasated erythrocytes and eosinophils was observed in the superficial dermis. There were also early-stage vasculitic alterations in the form of endotheliitis, with slight endothelial swelling of the dermal vessels without fibrinoid necrosis or thrombosis (Figure 2). Immunohistochemical findings were negative for the herpes simplex and varicella zoster viruses, and testing of the fixed skin tissue using RT-PCR was negative for SARS-CoV-2. Clinicopathologic correlation suggested a viral-induced skin eruption associated with COVID-19. The patient’s respiratory condition improved, and he was discharged from the hospital after 10 days.

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