Toxic epidermal necrolysis and coronavirus disease 2019: A rare association

Abstract

Cutaneous manifestations of Coronavirus disease 2019 (COVID-19) are variable. We report a 57-year-old woman who developed toxic epidermal necrolysis (TEN) in association with COVID-19. The patient had not received any drugs prior to the onset of TEN. She responded to treatment with cylosporine. Previous authors have suggested a better prognosis for TEN associated with COVID-19 in comparison to drug-induced TEN.

Increased Predisposition of SJS TEN in COVID-19 Patients, Presenting as Post COVID Complication

“…Pudukadan et al . [ 7 ] also reported similar association in a 57-year-old woman who developed TEN, but had not received any drugs prior to the onset of TEN, but was COVID-19 positive.…”

Toxic epidermal necrolysis and Stevens‐Johnson syndrome after COVID‐19 infection and vaccination

“…17,21,23 Cyclosporine was also associated with significantly reduced mortality rates in both COVID-19 and TEN patients in retrospective studies and has rarely been associated with infection as an adverse effect. 17,23 Etanercept, a TNF-ɑ inhibitor, is another option that demonstrated significant oedema reduction, rapid cessation of disease progression and greater reduction of TNF-ɑ and granulysin expression levels relative to systemic corticosteroids. 2,22 Etanercept also demonstrated lower rates of gastrointestinal haemorrhage and higher efficacy in promoting re-epithelialization compared to corticosteroids.…”

“…16 Regarding TEN/SJS after COVID-19 infection, it is hypothesized that the generalized immune activation and the associated increase in cytokines induced by COVID-19 infection can directly trigger or make individuals more susceptible to TEN/SJS-inducing type IV hypersensitivity reactions. [17][18][19] This phenomenon was previously observed in HIV patients and other immunocompromised populations, and some hypothesize that post-COVID-19 infection TEN/SJS is a novel example of immune reconstitution inflammatory syndrome (IRIS). 19 In 17 of the 34 published cases (50%), there were comorbidities identified that included carcinomas, influenza and use of antibiotics, hydroxychloroquine, acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), chemotherapy and antiepileptics.…”

“… 17 , 21 , 23 By inhibiting the calcineurin inflammatory pathway, cyclosporine can treat TEN/SJS by inducing immunosuppression; furthermore, cyclosporine targets cyclophilins to inhibit viral replication. 17 , 21 , 23 Cyclosporine was also associated with significantly reduced mortality rates in both COVID‐19 and TEN patients in retrospective studies and has rarely been associated with infection as an adverse effect. 17 , 23 Etanercept, a TNF‐ɑ inhibitor, is another option that demonstrated significant oedema reduction, rapid cessation of disease progression and greater reduction of TNF‐ɑ and granulysin expression levels relative to systemic corticosteroids.…”

“…Treatments for post‐infection and post‐vaccination TEN/SJS varied significantly. Cyclosporine is a treatment option that addresses both TEN/SJS and COVID‐19 17,21,23 . By inhibiting the calcineurin inflammatory pathway, cyclosporine can treat TEN/SJS by inducing immunosuppression; furthermore, cyclosporine targets cyclophilins to inhibit viral replication 17,21,23 .…”