Complete Remission in a Child With Multisystem Inflammatory Syndrome and Stevens-Johnson Syndrome Treated With Infliximab

Abstract

COVID-19, caused by SARS-CoV-2, can present with various dermatological manifestations, including (albeit rarely) severe mucocutaneous manifestations such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis. In contrast, multisystem inflammatory syndrome in children (MIS-C) commonly presents with mucocutaneous manifestations. The presentation of SJS in a child with MIS-C deserves increased attention from clinicians because of its potential fatality. Here we describe a 10-year-old boy with a history of exposure to confirmed COVID-19 who presented with fever, bilateral subconjunctival hemorrhage, cracked and red lips, oral ulcers, and generalized hemorrhagic skin lesions with targetoid lesions. Laboratory tests revealed leukocytosis, neutrophilia, lymphopenia, elevated C-reactive protein, sedimentation rate, ferritin, and B-type natriuretic peptide. A skin biopsy revealed patchy vacuolar interface dermatitis with subepidermal edema and superficial and deep perivascular predominantly histiocytic infiltrates with scattered eosinophils, lymphocytes, and neutrophils suggestive of SJS. In addition to supportive treatment, he was treated with IV methylprednisolone, immunoglobulins, and infliximab, after which his symptoms improved and gradually resolved.

Value of the Lymphocyte Transformation Test for the Diagnosis of Drug-Induced Hypersensitivity Reactions in Hospitalized Patients with Severe COVID-19

“…These lesions were considered secondary to the infection, but hypersensitivity to the treatments received could not be ruled out with absolute certainty [5]. The lesions described in patients with SARS-CoV-2 infection were very heterogeneous and had a similar pattern to those observed in delayed drug hypersensitivity reactions (e.g., maculopapular exanthema (MPE) and fixed drug eruption (FDE)), drug-induced liver injury (DILI), and severe cutaneous adverse reactions (SCARs) (e.g., Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reactions with eosinophilia and systemic symptoms (DRESSs), and acute generalized exanthematous pustulosis (AGEP)) [6][7][8][9]. The most common drugs prescribed for COVID-19 treatment were hydroxychloroquine (18.5%), azithromycin (11.1%), lopinavir (7.4%), ritonavir (7.4%), and paracetamol (9.2%) [3].…”

Inflammatory and Autoimmune Aspects of Multisystem Inflammatory Syndrome in Children (MIS-C): A Prospective Cohort Study

“…Like NLR, our MIS-C patients had a significantly higher median ELR of 0.132 compared to 0.004 for the COVID + cohort. The type-2 cytokines eliciting eosinophils [ 60 ] and the skin rashes with MIS-C may be like Stevens–Johnson Syndrome or an atopic response with the presence of eosinophils [ 61 , 62 , 63 ].…”