A case report of toxic epidermal necrolysis (TEN) in a patient with COVID-19 treated with hydroxychloroquine: are these two partners in crime?

Abstract

Background Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is the most Serious Cutaneous Adverse Reaction (SCAR) often with a fatal outcome. Coronavirus Disease (COVID-19) is caused by Severe Acute Respiratory Syndrome–Coronavirus—2 (SARS-COV2) and is an emergent pandemic for which no cure exist at the moment. Several drugs have been tried often with scant clinical evidence and safety. Case presentation Here we report the case of 78-years-old woman with cardiometabolic syndrome and COVID-19. A multidrug regimen including others hydroxychloroquine, antibiotics, dexamethasone and paracetamol, low-molecular-weight-heparin and potassium canrenoate was started. After almost 3 weeks, the patient started to display a violaceous rash initially involving the flexural folds atypical targetoid lesions and showing a very fast extension, blister formation and skin detachments of approximately 70% of the total body surface area and mucous membranes involvement consistent with toxic epidermal necrolysis (TEN). The ALDEN algorithm was calculated inserting all drugs given to the patient in the 28 days preceding the onset of the skin manifestations. The highest score retrieved was for hydroxychloroquine. Other less suspicious drugs were piperacillin/tazobactam, ceftriaxone and levofloxacin. Conclusions To our knowledge, this is the first case of TEN in a patient suffering from COVID-19 probably associated with hydroxychloroquine. Given the activation of the immune system syndrome induced by the virus and the widespread off-label use of this drug, we suggest a careful monitoring of skin and mucous membranes in all COVID-19 positive patients treated with hydroxychloroquine in order to early detect early signs of toxicities.

Corona virus disease 2019-associated Stevens-Johnson syndrome: a case report

“…Finally, it should be considered that the coincidence of a rare disease, such as SJS, with a rarely associated drug, such as naproxen and azithromycin, could have been facilitated by the immune stimulation induced by the virus SARS CoV-2. This hypothesis has been reported previously to be the cause of hydroxychloroquineassociated SJS in COVID-19 patients [6].…”

COVID‐19‐induced toxic epidermal necrolysis

“…There have been many cutaneous manifestations of COVID‐19 reported in the literature. A recent case report suggested possible hydroxychloroquine‐induced TEN in a patient with COVID‐19, but this was not proven by histology 3 . To our knowledge, this is the first report of TEN secondary to COVID‐19.…”

Toxic epidermal necrolysis and coronavirus disease 2019: A rare association

“…Rossi et al reported a case of TEN in a 78-year-old COVID-19 patient. [11] Although the patient received multiple drugs, the authors suggested the possibility of hydroxychloroquine-induced TEN after calculating ALDEN (algorithm of drug causality for epidermal necrolysis) causality score. [12] All the suspected drugs were withdrawn and the patient was treated with systemic corticosteroids and intravenous immunoglobulin G.…”

“…Unlike the previous patients who received systemic corticosteroids (the patient with metastatic breast carcinoma was receiving dexamethasone for her brain metastasis) with or without immunoglobulin G, our patient was treated with cyclosporine. [10,11] Guisado-Vasco et al in a retrospective, single-center, observational study in 607 patients, concluded that among the different treatments adopted for COVID-19 (tocilizumab, glucocorticoids, lopinavir/ritonavir, hydroxychloroquine, and cyclosporine), a significant decrease in mortality was associated with cyclosporine alone. [16] They reported that the hyperinflammatory phase in COVID-19 could be reduced by the inhibition of calcineurin inflammatory pathway.…”