Background
Several recent studies suggest the possibility of a skin rash being a clinical presentation of coronavirus disease 2019 (COVID-19). The purpose of this case report is to bring attention to skin manifestations in the early stage of COVID-19 in order to support frontline physicians in their crucial activity of case identification.
Case presentation
The patient is an Italian 32-year-old female nurse who had several close contacts with multiple patients with COVID-19 as part of her professional workload. On March 13, 2020, the patient developed an itchy, erythematous papular rash (sparing only her face, scalp, and abdomen), which lasted for 10 days. The rash was accompanied by a feeling of general fatigue that gradually worsened over the following days and has continued for 5 months (until the end of July 2020). During the first week of remote assessment carried out by her general practitioner, the patient gradually developed a dry cough, intermittent fever, and diarrhoea and then had a positive test result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Her skin manifestations disappeared completely 48 days after the onset of the disease, followed by the disappearance of the dry cough.
Conclusions
In light of recent studies, this case report suggests that skin manifestations, when taken into account with other situational factors (such as profession and patient history) should be taken into proper consideration by frontline physicians as possibly being caused by SARS-CoV-2. Early identification of COVID-19 is a key part of the strategy of case detection and case isolation. To enhance this activity, further research is needed to establish frequency, symptoms, signs, and pathogenesis of skin manifestations in patients with COVID-19.
Here, we present a case of an itchy, erythematous papular rash as the first clinical manifestation of COVID-19 and describe the disease course in a young Italian nurse. To the best of our knowledge, this is the only published case of skin manifestations of COVID-19 authored by GPs and entirely managed in primary care. At the onset of her illness, the patient reported a severe itchy skin rash with pruritus that worsened during the night, making it difficult for her to rest. Scabies, a skin infestation caused by the mite Sarcoptes scabiei, is a frequent cause of severe pruritus, where pruritus is due to a delayed hypersensitivity response to the mite proteins. The patient had no history indicating an increased likelihood to contract scabies or the disease-specific linear skin burrows. As a result, scabies was quickly excluded as a diagnosis. Another frequent cause of pruritus is an adverse drug reaction. Almost any drug may induce pruritus by various pathogenic mechanisms. Drug-induced skin manifestations represent a challenging differential diagnosis in patients with COVID-19 with skin manifestations. In fact, different medications have been used to treat COVID-19 in both hospital and outpatient settings, and many of them are known to cause cutaneous side effects. For this reason, it can be hard to establish causation between COVID-19 infection and skin eruptions when dealing with patients who have received these medications. In this case, we can exclude an adverse drug reaction due to the fact that the patient did not receive a COVID-19–specific drug treatment. Moreover, the skin rash was the first manifestation of the disease while the patient had no history of recent or chronic drug intake.
Other common causes of itchy skin rashes could also be reasonably excluded: the patient did not have any chronic physical or mental illnesses, lived in good hygienic conditions, did not use aggressive soaps or cosmetics, was not pregnant, and had no personal or family history of autoimmune illness, atopy, or other skin problems. The occurrence of erythematous and itchy skin lesions linked to COVID-19, like those in our patient’s case, has been reported by several studies. Sachdeva et al. highlighted that cutaneous manifestations of COVID-19 can range from maculopapular exanthem (as in our patient’s case) to papulovesicular rash, urticaria, painful acral red-purple papules, livedo reticularis lesions, and petechiae. In some cases, these lesions occurred prior to the onset of respiratory symptoms.
Also, in a large study from Spain, the most common cutaneous manifestations occurring in 375 patients with confirmed or suspected COVID-19 were maculopapular eruptions (47%). Unlike the cases reported by the authors, our patient’s rash appeared before the onset of other symptoms and was not associated with a severe episode of the disease. This difference is likely due to the underrepresentation of mild cases of COVID-19 in the study’s Spanish sample.
The results of a large international registry study across 31 countries reported morbilliform rash as the most common morphology of the dermatologic conditions experienced by patients with COVID-19. Consistent with our observations, the majority of reported morbilliform rash cases were pruritic (61%), involved arms and legs (55% and 58%, respectively), and spared the face (79%). In addition, in the majority of cases, the rash was not associated with previous comorbidity nor complications in the disease course [19]. Lastly, a review authored by Wollina et al. included maculopapular rash into the proposed categorization of the cutaneous signs of COVID-19.
The occurrence of erythematous and itchy skin lesions linked to COVID-19 have been reported by several studies, supporting our hypothesis of an association between a COVID-19 infection and our patient’s skin rash. The period of communicability of an individual infected with SARS-CoV-2 is still uncertain, as is the relationship between viral load, disease severity, and transmission rate. However, some studies suggest that the viral load is highest shortly after the onset of symptoms. This means that the transmission rate of the infection could be higher in the early stages of the disease, making the early identification of possible cases even more important. Early identification of COVID-19 symptoms and possible cases is part of the evolving strategy of case detection and isolation that, in the current phases of coexistence with SARS-CoV-2, is a crucial part of the activity of primary care providers.
Strengths and limitations The present case study suggests that a skin rash could be an early clinical manifestation of COVID-19. The plausibility of the association between our patient’s skin rash and the SARS-CoV-2 infection is supported by several elements: (1) recently published reports of skin manifestations related to COVID-19 are consistent with our observations; (2) the patient had a positive test result of a SARS-CoV-2 oropharyngeal swab by RT-PCR; (3) the patient is a healthcare professional and therefore has a high-risk epidemiological profile; and (4) we could reasonably exclude other causes of her skin rash.
Nevertheless, some limitations should be mentioned. To begin with, the patient is a healthcare professional and thus part of a professional group under enormous social and mental strain due to the pandemic. Being part of a professional group that in a health emergency has the duty to care for ill people and is therefore responsible for public well-being is likely to generate stress and stress-related clinical manifestations. In light of the above-mentioned points, we cannot exclude the possibility that the patient’s psychological stress could have had an influence on the subjective perception of pruritus, worsening it. However, we believe that in the case of our patient, the role of stress in exacerbating her symptoms was limited, and an alternative diagnosis, such as psychogenic itch, is extremely unlikely. The patient did not have any personal or family history of mental illness, and the screening questionnaire performed during the follow up period for major depressive disorder showed only borderline results.
Second, the absence of a comprehensive physical examination, due to the shortage of personal protective equipment and the massive move to telemedicine for primary care services, could have limited the diagnostic accuracy of the skin rash. However, teledermatology has been shown to be as effective as in-person care, even if the studies thus far have been focused on those done in a dermatology specialist setting. Further studies are needed to compare remote dermatologic assessment with in-person care in a primary care setting performed by GPs.
Third, no further diagnostic steps (for example, referral to a specialist, skin biopsy) were performed. This was due to the fact that during the quarantine/lockdown phase of the pandemic in Italy, both physical contact and the general movement of people were heavily restricted. Every further investigation or test had to be weighed against the risk of spreading the disease, and nonessential tests were not performed during this period. The patient was managed in a general practice setting, where, even in normal times, referral to specialist services, laboratory testing, and skin biopsy are rarely indicated for the management of an uncomplicated skin rash. That said, the authors are aware that this leaves the door open to some diagnostic uncertainty.
Finally, since the patient was in close contact with multiple patients with COVID-19, it has not been possible to establish her exact incubation period. She developed the skin rash a few days after many patients she took care of during her shifts began to experience COVID-19 symptoms and then had a positive test result for SARS-CoV-2. The onset of her symptoms is therefore consistent with the mean incubation period of 5.2 days (95% confidence interval, 4.1 to 7.0).
Conclusion The present study is, to the best of our knowledge, the first primary care case report of a female patient who developed a skin rash as the first clinical manifestation of COVID-19. No cutaneous sign can be considered pathognomonic for SARS-CoV-2 infection, and further studies involving larger patient samples are needed to better understand several aspects of the cutaneous involvement of COVID-19. Areas that merit further study include the causal relationship between the infection and skin lesions, the role of pathogenic mechanisms, the absolute frequency and the frequency of skin lesions at the onset, as well as the disease course, the severity, and the transmission rate when skin involvement is the unique manifestation of the COVID-19. More in general, our knowledge regarding the diagnostic accuracy of signs and symptoms to determine if a patient is affected by SARS-CoV-2 infection is still limited at the point that a recent Cochrane review concluded that, “based on currently available data, neither absence nor presence of signs or symptoms are accurate enough to rule in or rule out disease”
Reference & Source information: https://jmedicalcasereports.biomedcentral.com/
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