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.

Keywords: ALDEN Algorithm; Adverse Drug Reaction (ADR); COVID 19; Hydroxychloroquine; Pharmacovigilance; SARS-CoV- 2; SCORTEN Score; Severe Cutaneous Adverse Reactions (SCAR); Stevens–Johnson Syndrome (SJS); Toxic Epidermal Necrolysis (TEN).

Fig. 1

The X-ray shows bilateral and extensive interstitial infiltrates

Fig. 2

The violaceous rash extension with atypical targetoid elements (at day 3 from clinical onset) is depicted in a. b shows the complete resolution (after 6 weeks)

Fig. 3

The extensive skin detachment is showed in a (at day 5) and its favorable evolution at 6 weeks in (b)

Fig. 4

The figure shows the extensive disepithelialization with subcutaneous oozing and bleeding