CASE REPORT

1 56
2 Unilateral laterothoracic exanthem in 57
3 58
4 association with coronavirus disease 2019 Q1 59
5 60
6 61
Laura R. Glick, MD,a Alexander L. Fogel, MD, MBA,b Sarika Ramachandran, MD,b and Q4
7 62
Lydia Aoun Barakat, MDc
8 New Haven, Connecticut 63
9 64
10 Key words: case report; coronavirus disease 2019; COVID-19; rash; SARS-CoV-2; severe acute respiratory 65
11 syndrome coronavirus 2; unilateral laterothoracic exanthema. 66
12 67
13 68
INTRODUCTION
14 Abbreviations used: 69
Since the first reported case in December 2019,
15 COVID-19: coronavirus disease 2019 70
the novel severe acute respiratory syndrome coro-
16 SARS-CoV-2: severe acute respiratory syndrome 71
navirus 2 (SARS-CoV-2) has affected more than 10 coronavirus 2
17 72
million people and claimed over 500,000 lives UTLE: unilateral laterothoracic exanthem
18 73
worldwide. Although SARS-CoV-2 is widely recog-
19 74
nized as a respiratory pathogen, an increasing num-
20 75
ber of dermatologic manifestations of the virus exist. any new prescription medications or skin products.
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Here we report a case of a unilateral laterothoracic She reported taking acetaminophen prior to the
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exanthem in association with SARS-CoV-2. onset of her rash. Because of hospital restrictions, a
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24 biopsy was not obtained, as a panel of dermatolo- 79
25 CASE REPORT gists determined that this would be unlikely to 80
26 In March 2020, a 42-year old woman with no change the management of her rash. 81
27 significant medical history was admitted to the hos- The patient’s initial laboratory data showed a 82
28 pital 7 days after known coronavirus disease 2019 complete blood count of 3.5 103/L, an absolute 83
29 (COVID-19) exposure with nausea, relentless vom- lymphocyte count of 0.3 103/L, and an eosinophil 84
30 iting, a headache, and 3 days of a predominantly count of 0.6%. Her C-reactive protein was elevated to 85
31 right-sided rash. Her SARS-CoV-2 nasopharyngeal 91.9 mg/L, ferritin was 317 ng/mL, lactate dehydro- 86
32 swab was positive. genase was 285 U/L, alanine aminotransferase was 87
33 Upon arrival to the hospital, she was afebrile and 30 U/L, and aspartate aminotransferase was 39 U/L. 88
34 hemodynamically stable. She denied any respiratory Her chest radiograph showed bilateral multifocal 89
35 symptoms but reported ageusia and anosmia. On hazy opacities. The patient was treated with hydrox- 90
36 physical examination, she was noted to have abdom- ycholoroquine, 400 mg twice a day for one day 91
37 inal tenderness and a rash. The eruption consisted of followed by 200 mg twice a day for 4 days for 92
38 dozens of thin pink papules coalescing into thin pink COVID-19. She was started on triamcinolone 0.1% 93
39 plaques on the posterior lateral trunk near the axillae cream for her rash with clinical and symptomatic 94
40 bilaterally, with the right side more affected than the improvement after a total duration of 5 days. 95
41 left (Fig 1). The rash also extended to the upper 96
42 lateral right thigh and right lateral lower leg without DISCUSSION 97
43 any involvement of her palms, soles, or mucous Given the right-sided predominance and flexural 98
44 membranes. She did not have any involvement of distribution, this rash is most consistent with a 99
45 mucosal sites and had no evidence of bullae, unilateral laterothoracic exanthem (UTLE). UTLE is 100
46 vesicles, or purpura. She reported mild pruritus typically characterized by a unilateral, periflexural 101
47 without any pain. The patient denied the use of exanthema that often involves the axillae and 102
48 103
49 a b
Q3 From the Departments of Medicine and Dermatology and the JAAD Case Reports 2020;jj:j-j. 104
50 Section of Infectious Diseases, Department of Medicine,c Yale 2352-5126 105
51 School of Medicine. Ó 2020 by the American Academy of Dermatology, Inc. Published 106
52 Funding sources: None. by Elsevier, Inc. This is an open access article under the CC BY- 107
Conflicts of interest: None disclosed. NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
53 Correspondence to: Laura R. Glick, MD, Department of Medicine, 4.0/).
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54 Yale School of Medicine, 20 York Street, New Haven CT 06510. https://doi.org/10.1016/j.jdcr.2020.07.020 109
55 E-mail: laura.glick@yale.edu. 110

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111 cutaneous manifestations at the onset of the disease 166

112 and 10 (11.4%) patients following their hospitaliza- 167
113 tion. The most common finding was an erythema- 168
114 tous rash (14 patients, 15.9%) widespread urticaria (3 169
115 patients, 3.4%), and vesicular rash (1 patient, 1.1%). 170
116 The trunk was the main involved region with no 171
117 association between rash and disease severity. 172
118 Smaller case series report a purpuric rash often 173
119 on extremities caused by SARS-COV-2emediated 174
120 complement-associated vascular injury.4 Another 175
121 report describes a symmetric flexural exanthem 176
122 originating in the antecubital fossae, similar to sym- 177
123 Fig 1. Thin pink papules coalescing into plaques on the metric drug-induced flexural exanthem.5 More 178
124 posterior lateral trunk near her right axilla. recent reports of a Kawasaki-like disease associated 179
125 with COVID-19 have occurred in children.6,7 180
126 spreads to the contralateral side over time.1 However, the rash in our patient was different in 181
127 Individual cases of UTLE in association with morphology and spared the hands and feet. 182
128 Epstein Barr virus and parvovirus B19 have been Additionally, our patient’s rash started with the onset 183
129 reported.2 UTLE is typically preceded by nonspecific of illness and faded with the resolution of her 184
130 systemic symptoms, including low-grade fever, diar- COVID-19 symptoms, which is not consistent with 185
131 rhea, or rhinitis. Although most often seen in the timeline of this Kawasaki-like illness. 186
132 children, UTLE can affect adults. Based on our literature search using Medline and 187
133 The differential diagnosis in this patient with PubMed, this is the first case report of UTLE 188
134 known SARS-CoV-2 infection included viral exan- associated with SARS-COV-2. Given the novelty of 189
135 thema and exanthematous drug eruption. However, this virus and the lack of data about its cutaneous 190
136 UTLE has not been associated with medications. manifestations, future observational studies are 191
137 Although acetaminophen is a rare cause of exan- needed to further understand the full spectrum of 192
138 thematous drug eruptions, the time course of this skin disease associated with COVID-19. 193
139 eruption after 2 days of medication administration 194
140 and resolution while on acetaminophen would be REFERENCES 195
141 exceedingly quick. The morphology of the rash 1. Bodemer C, Prost YD. Unilateral laterothoracic exanthem in 196
142 could be consistent with symmetric drug-related
children: a new disease? J Am Acad Dermatol. 1992;27(5): 197
693-696.
143 intertriginous and flexural exanthema but the pa- 198
2. Duarte AF, Cruz MJ, Baudrier T, Mota A, Azevedo F. Unilateral
144 tient’s rash improved while she was on acetamino- laterothoracic exanthem and primary Epstein-Barr virus infec- 199
145 phen, making this diagnosis much less likely. Many tion. Pediatr Infect Dis J. 2009;28(6):549-550. 200
146 cases of UTLE are initially mistaken for contact 3. Recalcati S. Cutaneous manifestations in COVID-19: a first 201
147 dermatitis because of the unusual distribution.
perspective. J Eur Acad Dermatol Venereol. 2020;34(5): 202
e212-e213. Q2
148 Pathology of UTLE is nonspecific, similar to viral 203
4. Magro C, Mulvey JJ, Berlin D, et al. Complement associated
149 exanthem and exanthematous drug eruption, and microvascular injury and thrombosis in the pathogenesis of 204
150 typically shows mild spongiosis with variable lym- severe COVID-19 infection: a report of five cases. Translation 205
151 phocytic perivascular infiltrates. UTLE typically self- Res. 2020;220:1-13. 206
152 resolves with supportive care within 3 to 6 weeks
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distinctive skin rash associated with coronavirus disease 2019 ?
153 without recurrence. 208
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154 Since the beginning of the COVID-19 pandemic, 6. Verdoni L, Mazza A, Gervasoni A, et al. An outbreak of severe 209
155 an increasing number of cutaneous manifestations of Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 210
156 the virus have been reported. In a single-center epidemic: an observational cohort study. Lancet. 2020; 211
157 retrospective review from Italy, 88 patients with
395(10239):1771-1778. 212
7. Viner R, Whittaker E. Kawasaki-like disease: emerging compli-
158 cutaneous manifestations of the virus were identi- 213
cation during the COVID-19 Pandemic. Lancet. 2020;395(10239):
159 fied. The authors report that 18 (20.4%) patients had 1741-1743. 214
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