COVID-19 INFECTION AND STEVENS-JOHNSON SYNDROME/TOXIC EPIDERMAL NECROLYSIS: ONE MORE THING TO WORRY ABOUT?

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Stevens-Johnson Syndrome/Toxic epidermal necrolysis (SJS/TEN) are fatal cutaneous side effects occasionally seen in the ICU. Although HIV is a known risk factor for SJS/TEN, we yet do not know the relation of COVID-19 infection to these severe cutaneous adverse reactions (SCAR) [1]. Here we present a case of a young man with COVID-19 and HIV infection who developed SCAR. CASE PRESENTATION: 40-year-old male with past medical history of substance abuse, HCV, HIV infection (not on ART) presented with odynophagia, voice change and drooling. COVID-19 testing in ED was positive. Head and neck CT scan revealed retropharyngeal abscess. He was intubated emergently due to inability to manage secretions and increased work of breathing. Abscess was managed conservatively with Ampicillin/Sulbactam and methylprednisone. On antibiotic day #3, he developed purple rashes with dark brown vesicles on his face, neck and anterior chest (Image 1). The following day, this evolved into an extensive bullous eruption with de-epithelization and epithelial loss, with lesions including face, eye lids, eyes, neck, upper trunk, bilateral upper extremities, back, genitalia and bilateral lower extremities (Image 2,3). Dermatology was consulted with concern for SJS/TEN and Ampicillin/Sulbactam was discontinued. His skin biopsy demonstrated full thickness epidermal necrosis. He was managed with pain medication, IV fluids, wound care and intravenous immunoglobulin.Meanwhile, his CD4 count was 65 with viral load of 174,000 which he was started on Atovaquone for PJP prophylaxis. COVID-19 markers were elevated on admission (CRP 2.49, Ferritin 546, D-dimer 0.69 LDH 299), and remained elevated throughout his hospital stay. Chest X-ray showed bibasilar hypoventilatory change with bilateral pleural effusions. Prophylactic low molecular weight heparin and methylprednisone were initiated.Patient was transferred to other facility burn ICU for further management. Despite full care, his skin lesions worsened, and patient passed away on hospital day 15. DISCUSSION: It has been reported that concomitant HIV and viral infections can precipitate SCAR [2]. However, we know little about COVID-19 infection and its relation to SCAR. There are few documented cases of COVID-19 associated SCAR but like other viral infections, SARS-COV-2 may be another risk factor for SCAR [3]. CONCLUSIONS: This case may lead clinicians to include SCAR as a differential when evaluating newly developed cutaneous lesions in COVID-19 patients. It is also essential to monitor the skin when COVID-19 patients are being treated with possible culprits. REFERENCE #1: Incidence of Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome in an HIV Cohort. AM J Clin Dermatol. 2012 Feb 1;13(1):49-54. REFERENCE #2: Nonimmediate Allergic Reactions Induced by Drugs: Pathogenesis and Diagnostic Tests. J Investig Allergol Clin Immununol. 2009;19(2):80-90. REFERENCE #3: A case report of toxic epidermal necrolysis (TEN) in a patient with COVID-19 treated with hydroxychloroquine: are these two partners in crime? Clin Mol Allergy. 2020 Oct 6;18:19. DISCLOSURES: No relevant relationships by Gregory Bassmann, source=Web Response No relevant relationships by Vignesh Harish, source=Web Response No relevant relationships by Kyunghoon Rhee, source=Web Response No relevant relationships by Zainab Shafi, source=Web Response