SARS‐CoV‐2 infection associated with severe oral, conjunctival and genital lesions (Fuchs syndrome)

Abstract

Dear Editor, With the onset of the COVID-19 pandemic and the emergence of COVID-19 vaccinations, numerous cases of skin reactions related to SARS-CoV-2 infection and to vaccination have been reported, including urticaria, chilblain lesions and morbilliform rashes. 1,2 Furthermore, the induction or worsening of inflammatory skin diseases was observed. 3 However, reports on severe skin reactions like erythema exsudativum multiforme (EEM), Stevens-Johnson syndrome (SJS) and Fuchs syndrome (FS) related to SARS-CoV-2 infection are scarce. We here present a case of FS after SARS-CoV-2 infection.A 34-year-old Caucasian woman presented to our dermatological outpatient clinic with severe acute fatigue, fever, malaise, swelling of cervical lymph nodes and sudden development of infiltrating lesions on mucous membranes. Four days before, blisters and ulcers developed in the oral mucosa, the lips and the genital mucosae with concomitant conjunctivitis. No other skin lesions were observed. Initial treatment with acyclovir 5 × 800 mg by her general practitioner showed no improvement. The patient reported no other medical history, but an asymptomatic SARS-CoV-2 infection verified by an antigen test 2 weeks before first symptoms. Clinical examination revealed haemorrhagic erosions with crusting on the lips and eroded lingual lesions (Figure 1). Marked conjunctival infiltration was observed in both eyes (Figure 2). This symptom complex was clinically diagnosed as FS. To rule out differential diagnoses, extensive blood analyses were performed, and mucosal swabs taken, excluding herpes simplex virus (HSV) infection by polymerase chain reactions. Elevated C-reactive protein to 84 mg/L (reference: <5 mg/L) and thrombocytosis were observed (493 bn/L [150-370 bn/L]); liver and renal function test, white and red blood count, electrolytes and anti-streptolysin titre revealed normal results.The patient had been vaccinated against COVID three times, the last being applied 18 weeks before the onset of acute mucosal lesions. We thus concluded that this episode of FS was most likely triggered by SARS-CoV-2 infection. Due to malaise, fever, fatigue and severely worsening general condition, the patient was admitted to a dermatology hospital. Treatment included systemic prednisolone (100 mg/daily for 3 days), topical antiseptics and anaesthetic mouthwash. After ophthalmological review, prednisolone eye drops were applied for conjunctival involvement. The patient fully recovered within a week without any clinical sequelae.Clinical diagnosis of acute severe SJS-like mucosal lesions in the absence of extramucosal lesions has been described as FS. Currently, there is no published consensus on the specific criteria of FS. It is considered a rare clinical variant of erythema multiforme majus (EEM). 4 Although