Accepted Article

DR. ANDREA VANEGAS RAMIREZ (Orcid ID : 0000-0003-1303-2960)

Article type : Letter to Editor

Drug-induced vasculitis in a patient with COVID-19

A. Vanegas Ramirez, D. Efe, M. Fischer
Department of Dermatology, Venereology and Allergology
Bundeswehrkrankenhaus Hamburg

Corresponding Autor: Andrea Vanegas Ramirez

Department of Dermatology, Venereology and Allergology
Bundeswehrkrankenhaus Hamburg
Lesserstrasse 180
22049 Hamburg, Germany
Tel. +4940694713231
andreavanegas@web.de

Keywords: drug related skin reaction, vasculitis, COVID-19

Case report
A 57-year-old German woman with a history of skin reactions to unknown antibiotics, depression
and high blood pressure presented with a 2-day history of symmetrically distributed pruritic pink-
to-red maculopapular exanthema on the trunk and extremities.

Due to a 3-week history of a nonproductive cough and intermittent fever she has taken
amoxicillin, ibuprofen and metamizole three days before. She did not take aspirin or other
anticoagulants.
This prescription was discontinued and an intravenous bolus of prednisolone as well as
anthistamines and topical glucocorticoids were administered.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JDV.16588
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 After two days her rash progressed in purpuric, nonblanching, pruritic and painful maculas and
Accepted Article
plaques on her trunk and extremities (Fig.1 and 2). Mucous membranes were spared. The patient
was afebrile and her oxygen saturation was 98% while she was breathing ambient air.

The blood count, prothrombin time and partial thromboplastin time were normal. An elevated D-
dimer level by 2.051 µg/l was observed. A chest radiograph showed a right lower lobe
consolidation suggestive of pneumonia. A test to detect SARS-CoV-2 by real-time reverse-
transcription-polymerase-chain-reaction (RT-PCR) assay of a throat swab was positive. A biopsy
specimen of the skin lesion revealed a vasculitis. Blood tests for HIV, antinuclear antibodies and
antineutrophyle cytoplasmic antibodies were negative.

The patient was treated with 120mg of prednisolone per day (1,5 mg per kilogram of body
weight). After nine days the patient´s skin lesions and her respiratory symptoms improved. Two
negative SARS-CoV-2 by RT-PCR tests of throat swabs with sampling interval of 24 hours were
confirmed and the patient was discharged home.

Despite an antibiotic allergy could developed the rash and vasculitis in our patient, it is known
that severe COVID-19 induces endotelial damage and thrombosis (1,2). Some reports have
showed urticaria, rash, vesicles, purpura, chilblain-like and erythema multiforme-like patterns as
cutaneous manifestations in patients with COVID-19 (2,3,4,5,6). This case report illustrates the
potential of COVID-19 infections to trigger severe drug related skin reactions such as vasculitis.
More evidence is needed to understand the association of COVID-19 and cutaneous
manifestations.

Acknowledgment
We would like to thank the patient cited in this manuscript that has given a written informed
consent to the publication of her case details and photographs.

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Accepted Article

Fig. 1. Purpuric, nonblanching, pruritic and painful maculas and plaques on the extremities of the patient

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Accepted Article

Fig. 2. Purpuric, nonblanching, pruritic and painful maculas and plaques on the extremities of the patient

Funding
The authors received no specific funding for this work.

Conflict of interest statement

Andrea Vanegas Ramirez, Demet Efe, and Marcellus Fischer declare that they have no conflict of
interest.

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Accepted Article
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