Erythema Multiforme: A Presentation of COVID-19 Pneumonia

Since its emergence in December 2019, coronavirus disease 2019 (COVID-19) has been detrimental worldwide. Although COVID-19 infection is primarily known for its respiratory manifestations, extrapulmonary features are increasingly being reported. Among these, cutaneous manifestations are apparent but have a high likelihood of not being attributed to COVID-19. We present the case of a 63-year-old female unvaccinated against COVID-19. She presented with fever, cough, shortness of breath, and rash. The symptoms were present for four days and appeared after contact with a confirmed symptomatic COVID-19-positive family member. The rash started first on the chest and then spread to the face and whole body including the palms and soles. It was erythematous and maculopapular and is associated with ulceration and swelling of the lips. In places, it was confluent and had a target-like appearance. On admission, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) was negative. As she was septic with initial suspicion of tick-borne infections, she was started on doxycycline. Given her symptoms on presentation, the suspicion of COVID-19 was very high, and the SARS-CoV-2 nasal swab PCR was repeated, which was negative yet again. With the index of suspicion being very high, her presentation was speculated to be atypical, especially in the setting of a target-like rash involving the palms and soles. The antibody was checked. IgG antibodies for SARS-CoV-2 were positive. All other antibodies for mycoplasma, Lyme disease, Ehrlichia, and Rocky Mountain spotted fever (RMSF) were negative. Parvovirus DNA and chikungunya IgG, antinuclear antibody (ANA), and antineutrophil cytoplasmic antibody (ANCA) screens were negative. IgG for mycoplasma, dengue, and herpes simplex virus 1 (HSV1) were positive. During all this time, the patient did not show clinical improvement in spite of being on antibiotics. In fact, her oxygen saturation dropped, and she required oxygen through the nasal cannula. A lung tissue biopsy taken on bronchoscopy showed chronic inflammation and organizing pneumonia. To note, mycoplasma DNA PCR and HSV culture from bronchoalveolar lavage (BAL) were negative. The patient was started on intravenous steroids. A confirmatory skin biopsy was done, and it showed perivascular, interstitial, and spongiotic dermatitis related to a viral infection. While on steroids, the patient improved dramatically. Her skin rash also improved, and she was discharged. On outpatient follow-up, she was doing exceptionally well with ambulatory oxygen saturation of 100%. This patient who was COVID-19 PCR-negative twice could have been easily deemed as not having COVID-19. However, the fact that she was unvaccinated, had positive sick contact with imaging concern for COVID-19 pneumonia, and COVID-19 antibody being positive and no other test being positive clearly attributes her manifestations to the virus. The presence of a rash could easily be misleading. Awareness of the fact that a rash like erythema multiforme (EM) could be a sign of underlying COVID-19 is extremely prudent and is an addition to the ever-expanding knowledge of this virus.