Rapidly progressing generalized bullous fixed drug eruption after the first dose of COVID-19 messenger RNA vaccination.

Generalized bullous fixed drug eruption (GBFDE) is a rare type of life-threatening severe cutaneous adverse reaction that is considered a medical emergency because of its potential lethality. Currently, only a few cases of bullous adverse reactions have been reported after coronavirus disease 2019 (COVID-19) vaccination. We describe a patient with distinct clinical, histopathological, and immunological findings that are consistent with severe GBFDE, after Pfizer messenger RNA COVID-19 vaccination. An 83-year-old man presented with a fever and well-demarcated multiple erythematous patches that occurred only 4 h after receiving the first dose of COVID-19 Pfizer vaccination. Over the next few days, the patches became generalized and turned into blisters covering approximately 30% of the body surface. The patient was started on intravenous methylprednisolone and oral cyclosporine. There were no additional blistering lesions after 10 days of treatment, prompting a gradual dose reduction. Our case suggests that a stepwise vaccination adhering to the standard dosing schedule should be warranted with close monitoring for possible significant side effects.

X-Linked Inhibitor of Apoptosis (XIAP) deficiency presenting as hemophagocytic lymphohistiocytosis triggered by drug allergy

X-linked inhibitor of apoptosis (XIAP) deficiency is a primary immunodeficiency associated with recurrent hemophagocytic lymphohistiocytosis (HLH) episodes. The clinical phenotypes of XIAP deficiency vary, ranging from splenomegaly to life-threatening inflammation. We report a case of XIAP deficiency with unusual late-onset HLH presentation likely triggered by a drug allergy. A previously healthy adolescent boy presented to the hospital with fever and rash seven days after starting antibiotics for a neck abscess. Laboratory evaluation demonstrated cytopenias, elevated liver enzymes, and increased inflammatory markers. Initially, antibiotics were discontinued due to concern for drug rash. He continued to deteriorate clinically and became hypotensive. Additional testing revealed decreased NK cell function, as well as elevated ferritin, triglycerides, and soluble IL-2 receptor. SLAM-Associated Protein (SAP) and XIAP evaluation by flow cytometry demonstrated decreased XIAP expression. Subsequently, genetic testing revealed a known pathogenic mutation in BIRC4 (c.421_422del), confirming the diagnosis of XIAP deficiency.Copyright © 2023

Case report of an antimelanoma differentiationassociated protein 5 antibody-associated amyopathic dermatomyositis

Autoantibodies against melanoma differentiation-associated protein 5 (MDA5) associated with dermatomyositis have recently been described in Asians with rapidly progressive respiratory disease. Here we report the case of a middle-aged white woman with anti-MDA5 antibody-associated amyopathic dermatomyositis with interstitial lung disease (ILD), which is stable with minimal immune suppression. A 55-year-old woman was referred to a virtual dermatology clinic during the COVID-19 pandemic suspected of having widespread eczema involving the chest, face, arm and hands on the background of atopy. On direct questioning, she admitted to having constitutional symptoms, exertional dyspnoea, joint pain and symptoms of proximal muscle weakness. On clinical suspicion of possible connective tissue disorder, she was urgently reviewed in the hospital, where she was found to have a photodistributed rash involving cutaneous ulceration and violaceous plaques. Hand examination showed mechanic's hand mimicking hand eczema, ragged nail cuticles and acute tenosynovitis in the left index finger. Her upper and lower limb muscle power was normal and respiratory examination revealed bi-basal fine end-expiratory crepitation. Her repeated biochemical, haematological and muscle enzymes remained normal. Skin biopsy taken from photosensitive rash over the wrist showed hypergranulosis, Civatte body formation, colloid bodies and dyskeratotic keratinocytes, in keeping with severe lichenoid eruption. Superficial dermis showed patchy red-cell extravasation, perivascular chronic infiltration, dermal oedema and serum on the surface, in keeping with ulceration secondary to severe inflammatory processes. There were no eosinophils and eccrine coils were free of inflammation, raising the suspicion of a drug eruption. Her antinuclear antibody and double-stranded DNA were repeatedly negative. Myositisspecific antibody panel was performed owing to a high clinical suspicion of photosensitive dermatoses, both clinically and histologically. Histology revealed positive anti-MDA5 antibodies;repeated positive testing confirmed this. Although lung function was normal, computed tomography revealed evidence of ILD. We made a diagnosis of anti-MDA5 antibodyassociated amyopathic dermatomyositis with ILD. Her malignancy screening was negative. The patient was started on lowdose prednisolone and hydroxychloroquine 200 mg twice daily, with topical steroid applications, which resulted in remarkable clinical improvement. Anti-MDA5 associated dermatomyositis has characteristic cutaneous lesions consisting of skin ulceration and tender palmar papules, mechanic's hands, inflammatory arthritis and rapidly progressive ILD, which is frequently fatal. Although our patient had ILD, she was relatively stable on minimal immunosuppression. It is important for clinicians to have an increased awareness of this disease as it could have a highly variable clinical presentation in the white population.

Clinico-Epidemiological Profile of Cutaneous Adverse Drug Reactions at Rural Tertiary Care Centre

Background: Cutaneous adverse drug reactions (CADRs), also known as toxidermia, are skin manifestations resulting from systemic drug administration and it constituted 10%-30% among all reported adverse drug reactions (ADRs). These reactions range from mild morbilliform drug rash to much more severe reactions. Material(s) and Method(s): A retrospective observational study was conducted at dermatology outpatient department of rural based tertiary care center for a duration of 03 years from August 2019 to July 2022, a total of 211 patients who had been clinically diagnosed or were suspected to have drug reactions were studied. Result(s): In this observation there was male preponderance (59.72%) and majority of patients were in their 3rd and 4th decade (40.28%) with maculopapular drug rash (33.17%) being most common clinical profile of CADRs, followed by urticaria (23.70%). Less frequently seen CADRs were acneiform eruptions (21), hair Loss (9), photodermatitis (9), generalised pruritus (7), erythroderma (2), pityriasis rosea (2), Stevens Johnson Syndrome-Toxic Epidermal Necrolysis (SJS-TEN) (4), lichenoid drug eruptions (3), Vasculitis (1) and pustular drug eruption (1). The most common group of drugs causing CADRs were antibiotics (40.28%), followed by NSAIDs (28.43%). Conclusion(s): Cutaneous Adverse Drug Reactions (CADRs) are price we pay for the benefits of modern drug therapy;knowledge of these reactions is important for treating physician as prompt recognition and treatment can prove lifesaving.Copyright © 2022 Academic Medicine and Pharmacy

Fixed Drug Eruption Secondary to Fluconazole Confirmed by Self-Challenge

Introduction: Fixed drug eruption (FDE) can have a wide array of culprits, especially in patients who use multiple medications. We present a patient with Fixed Drug Eruption (FDE) secondary to fluconazole. Case Description: A 36-year-old female was evaluated for recurrent pruritic and tender violaceous to hyperpigmented patches on her face (Figure 1A), neck, upper extremities, buttocks, flank, and genitals. Patches would blister after 2-3 days. These lesions occurred every 2-3 months for 1 year with Non-Steroidal Anti-inflammatory Drugs (NSAIDs) or fluconazole, and after her second Pfizer COVID-19 vaccine with acetaminophen as premedication. Punch biopsy showed focal dyskeratosis, papillary dermal eosinophils and neutrophils (Figure 1B). She was diagnosed with FDE and instructed to avoid NSAIDs, Polyethylene Glycol (PEG), over-the-counter medications, and fluconazole. Patch testing was performed for fluconazole (pet 5%), ibuprofen (pet 5%), celecoxib (pet 10%), povidone (pet 2% and liquid), and croscarmellose (pet 10% and liquid). All patch tests were negative at 48 hours, 72 hours, 5 days, and 7 days readings. Prior to performing a provocation test, the patient self-administered fluconazole for vaginal itching and the FDE recurred within 2 minutes on the same locations. She tolerated celecoxib and COVID19-vaccine booster without adverse reactions. The patient was instructed to avoid all azoles and use alternative agents. Discussion(s): When multiple possible agents are suspected in FDE, patch testing followed by provocation tests may be considered. In this case, the diagnosis was confirmed by self-administration of fluconazole. Copyright © 2022

Generalized fixed drug eruption following Pfizer-BioNtech COVID-19 vaccination.

Fixed drug eruption is a cutaneous drug reaction which recurs at the same site when the individual is exposed to the causative drug, characterized by single or multiple round sharply demarcated erythematous-to-violaceous patches. Here, we report a patient with generalized non-bullous fixed drug eruption following mRNA-based Pfizer-BioNTech COVID-19 vaccine.

Livedoid skin reaction to 2nd dose of mRNA Covid-19 vaccine.

Skin often represents a target organ for adverse drug reactions and this also applies to the mRNA vaccines against Sars-CoV-2. Here we present a case of extensive livedoid reaction after 2nd dose of BNT162b-2 vaccine with massive blood skin extravasation and no systemic symptoms apart from anemization. The 30-year-old woman developed progressively enlarging livedoid lesions on limbs and abdomen. Histology showed a near-normal epidermis and a very mild interstitial mixed inflammatory infiltrate with extensive blood extravasation in mid- and deep dermis. Diagnosis was adverse reaction to vaccine with skin capillary hyperpermeability and anaemization with lower than diagnostic features of cutaneous small vessel vasculitis. To date, no cases of a livedoid skin reaction associated to Covid-19 vaccine have been reported, and this case illustrates that massive livedoid reaction can be another kind of skin reaction to mRNA Covid-19 vaccine.

LUNG INVOLVEMENT in VEXAS SYNDROME

Background: Vacuoles, E1 enzyme, X-linked, autoinfammatory, somatic (VEXAS) syndrome is a recently identifed disorder caused by somatic mutations in the UBA1 gene of myeloid cells. Various manifestations of pulmonary involvement have been reported, but a detailed description of lung involvement and radiologic fndings is lacking. Objectives: To describe lung involvement in VEXAS syndrome. Methods: A retrospective cohort study was conducted of all patients iden-tifed at the Mayo Clinic with VEXAS syndrome since October 2020. Clinical records and chest high resolution computed tomography (HRCT) scans were reviewed. Results: Our cohort comprised 22 white men with a median age of 69 years (IQR 62-74, range 57-84). Hematologic disorders including multiple myeloma, myelodysplastic syndrome and pancytopenia were present in 10 patients (45%), rheumatologic diseases including granulomatosis with poly-angiitis, IgG4-related disease, polyarteritis nodosa, relapsing polychondritis, and rheumatoid arthritis were found in 10 patients (45%), and 4 patients had dermatologic presentations including Sweet syndrome, Schnitzer-like syndrome or drug rash with eosinophilia skin syndrome (DRESS). VEXAS syndrome-related features included fever (18, 82%), skin lesions (20, 91%), lung infiltrates (12, 55%), chondritis (10, 45%), venous thromboembolism (12, 55%), macrocytic anemia (21, 96%), and bone marrow vacuoles (21, 96%). Other manifestations observed were arthritis, scleritis, hoarseness and hearing loss. Median erythrocyte sedimentation rate (ESR) was 69 mm/1st hour (IQR 34.3-118.8) and median C-reactive protein (CRP) of 55.5 mg/dL (IQR 11.4-98.8). The somatic mutations affecting methionine-41 (p.Met41) in UBA1 gene were: 11 (50%) p.Met41Thr, 7 (32%) p.Met41Val, 2 (9%) p.Met41Leu, and 2 (9%) in the splice site. All patients received glu-cocorticoids (GC) (median duration of treatment was 2.6 years);21 (96%) received conventional immunosuppressive agents (methotrexate, aza-thioprine, mycophenolate, leflunomide, cyclosporin, hydroxychloroquine, tofacitinib, ruxolitinib) and 9 (41%) received biologic agents (rituximab, tocilizumab, infliximab, etanercept, adalimumab, golimumab, abatacept). Respiratory symptoms included dyspnea and cough present in 21 (95%) and 12 (55%), respectively, and were documented prior to VEXAS diagnosis. Most of the patients were non-smokers (14, 64%) and obstructive sleep apnea (OSA) was present in 11 patients (50%). Seven patients (32%) used non-invasive ventilation, 6 used C-PAP, and 1 used Bi-PAP. Bronchoalveolar lavage (BAL) was available in 4 patients, and the findings were compatible with neutrophilic alveolitis in 3. Two patients had lung biopsies (2 transbronchial and 1 surgical) that showed ATTR amyloidosis and organizing pneumonia with lymphoid interstitial pneumonia, respectively. Pulmonary function tests were available in 9 (41%) patients and showed normal results in 5;3 patients had isolated reduction in DLCO and 1 with mild restriction. On chest HRCT, 16 patients (73%) had parenchymal changes including ground-glass opacities in 9, septal thickening in 4, and nodules in 3;pleural effusions were present in 3 patients, air-trapping in 3 patients and tracheomalacia in 1 patient. Follow-up chest HRCT was available for 8 patients (36%), the ground-glass opacities resolved in 5 patients, 3 patients manifested new or increased ground-glass opacities, and 1 patient had increased interlobular septal thickening. After 1 year of follow-up, 4 patients (17%) had died;3 due to pneumonia (2 COVID-19,1 bacterial) and 1 due to heart failure. VEXAS flares occurred in 18 patients (82%), the maximum number of relapses was 7, and they were mainly managed with GC and with changes in the immuno-suppressive regimen. Conclusion: Pulmonary involvement was documented by chest HRCT in most patients with VEXAS syndrome. Respiratory symptoms occurred in over one half of patients and about 20% had PFT abnormalities. The pulmonary manifestations of VEXAS are nonspecifc and characterized predominantly by infamma-tory parenchymal involvement.

COVID-19 Vaccine Booster-Induced Dermatographism.

The urgent requirement for a preventative vaccination became more pressing due to the severe repercussions that the SARS-CoV-2 (COVID-19) virus had on society and the economy. The deployment of the COVID-19 vaccination program had to be expedited. As with all vaccinations, adverse events have been recorded with the COVID-19 vaccine. Some patients may experience cutaneous reactions such as rashes, itching, hives, and swelling after receiving the COVID-19 vaccine, but it is unclear how common these events are or how frequently they recur. This article discusses an unusual case of a young man who got chronic severe dermatographism after receiving a booster shot of the Moderna vaccine (Moderna, Inc., Cambridge, Massachusetts).

LESIONS MIMICKING KAPOSI SARCOMA IN A WOMAN LIVING WITH HIV FOLLOWING PFIZER-BIONTECH COVID- 19 VACCINATION

Introduction A spectrum of skin reactions following mRNA COVID vaccinations have been reported that can mimic dermatological manifestations of Human Immunodeficiency Virus (HIV) infection. Case Description A 47-year-old Zimbabwean female living with HIV since 2011 (nadir CD4 366 cells/mm3) was seen in our HIV clinic with a widespread rash and raised, itchy lesions over her body measuring approximately 5-7mm which appeared three weeks after her first Pfizer-BioNTech COVID-19 vaccine. There was no systemic involvement. Her CD4 count was 641 cells/mm3 (44%) with a fully suppressed viral load on antiretroviral therapy since June 2015 with no other pertinent medical history. There was no response to topical anti-fungal therapy but symptomatic relief with anti-pruritic and anti-histamine was noted. Treatment with oral erythromycin 500mg four times a day for two weeks decreased the size of the lesions and improved the rash. A punch biopsy of pale brown skin at this time was performed with appearances in keeping with those of a lichenoid pattern of inflammation. Our patient continues to improve with erythromycin.Topical or systemic corticosteroid therapy can be considered to further ameliorate her condition. Discussion Lichenoid drug eruptions are well recognized. Our case demonstrates such a reaction to the Pfizer-BioNTech COVID-19 vaccination which adds to cases described in the contemporary medical literature. It is vital to recognize this complication in our specialty as lesions may mimic lichen planus clinically and histologically and may be mistaken for dermatological manifestations associated with HIV, including Kaposi Sarcoma (KS) and bacillary angiomatosis, which can manifest regardless of immune status.

Shades of COVID-19 vaccine

SARS-CoV-2 infection is associated with a wide spectrum of skin manifestations and few may appear after immunization with vaccines expressing the SARS-CoV-2 spike protein. The COVID-19 pandemic has led to the rapid invention and approval of vaccines and, like any vaccination programme, reports of side-effects have begun to emerge. Though initial reports were about mild side-effects, reports of varied other moderate to severe side-effects have now started to emerge. Although these side-effects seem to be rare, the symptoms can be severe and data on them are scarce. We report a case of a 49-year-old woman with Fitzpatrick skin type VI developing coin-shaped well-defined, round to oval, erythematous to violaceous plaques with central dusky appearance along with vesicles and bullae on her right cheek, left cheek and left posterior thigh. This was seen a few days following each dose of AstraZeneca COVID vaccine but self-resolved in about 2 weeks with hyperpigmentation. There was no cutaneous disease elsewhere and no mucosal involvement. We considered a diagnosis of fixed drug eruption (FDE) based on history and clinical features. FDEs represent a cutaneous adverse drug reaction characterized clinically by the appearance of recurrent, quasiidentical, cutaneous eruptions in the same anatomical location on exposure and re-exposure to the offending drug.

COVID vaccine-induced bullous drug eruption and a vaccine conundrum: case report

SARS-CoV-2 vaccines have been associated with various dermatological adverse events including bullous eruptions (Tomayko M, Damsky W, Fathy R et al. Subepidermal blistering eruptions, including bullous pemphigoid, following COVID-19 vaccination. J Allergy Clin Immunol 2021;148: 750- 751;Gambichler T, Boms S, Susok L et al. Cutaneous findings following COVID-19 vaccination: review of world literature and own experience. J Eur Acad Dermatol Venereol 2021;36: 172- 80). Certainly, the association could be coincidental, or it is also possible that a subclinical bullous pemphigoid (BP) was unmasked by vaccination. We present a unique case of BP-like eruption after COVID-19 mRNA vaccine that also posed a dilemma of further suitable vaccination in a patient with platelet disorder. A 57-year-old woman had her first dose of the Pfizer COVID-19 vaccine on 2 February 2021 on her left arm and within 24 h of receiving it she developed bruising of the entire arm. The patient was hospitalized for further investigations when she developed a bullous rash on her left arm that eventually involved her face and legs. Treatment with systemic steroids was commenced. Owing to her complex medical history including platelet disorder and Ehlers-Danlos syndrome, we were posed with a dilemma of a further suitable vaccination. After a multidisciplinary team meeting, the patient has been encouraged to receive a Moderna vaccine for the second dose. Clinicians should be aware of BP-like disease that may develop after COVID-19 mRNA vaccination. However, with the underlying cause of BP being uncertain, the rarity of its occurrences and the greater risks of SARS-CoV-2 infection, it is important to encourage full vaccination including completion in those with blisters after the first dose. Further studies are required to study the natural history of BP-like disease associated with the COVID-19 vaccines.

Fixed drug eruption after the Sinopharm COVID-19 vaccine

After coronavirus disease 2019 (COVID-19) became widespread around the world, several vaccines have been developed with variable efficacy and potency and based on different platforms to control the pandemic. One of these vaccines is Sinopharm (BBIBP-CorV), which is an inactivated virus that was released by Sinopharm's Beijing institute in the summer of 2020. The most commonly reported side effects of the Sinopharm vaccine have included pain at the injection site, muscle pain, headache and fatigue. Dermatological reactions are also reported as less common and were mainly local injection site reactions. Fixed drug eruption (FDE) is a rare and unusual adverse effect and accounts for less than 1% of all severe acute respiratory syndrome coronavirus 2 vaccine-related cutaneous manifestations. FDE has not been reported following the COVID-19 inactivated vaccine. Here, we describe a rare case of FDE following the administration of the first shot of the Sinopharm vaccine.

Morbilliform Eruption After Administration of Second Dose of Oxford/AstraZeneca Vaccine.

Morbilliform eruption typically implies a maculopapular rash of acute onset. Drugs are the predominant cause of this cutaneous reaction in adults, followed by infectious exanthems and some rheumatological diseases. In this article, we report on the clinical and histopathological features of generalized pruritic morbilliform eruption in a 28-year-old female following her second dose of Oxford/AstraZeneca COVID-19 vaccine. The reaction started 12 hours after receiving the vaccine with no other identifiable cause. The patient had no improvement with IV antihistamine received in the emergency department. Afterward, she showed marked improvement after receiving a short course of oral corticosteroids along with topical corticosteroid and oral antihistamine. To the best of our knowledge, we hypothesize that the basic immunological mechanism is the cause behind COVID-19-vaccine-related morbilliform eruption. Therefore, physicians should be aware of the possible adverse reactions associated with COVID-19 vaccines, such as morbilliform eruptions and other cutaneous manifestations.

Fixed drug eruptions-this century's common and novel culprits

Aims: A fixed drug eruption (FDE) is a common cutaneous adverse drug reaction which occurs following administration of an offending drug or substance. The list of drugs incriminated in FDEs is ever changing, being influenced by the prescribing patterns of a given region. As newer drugs enter the market, and older drugs lose favour, one must refresh one's knowledge on potential culprits. The aim of this review is to provide an update on the list of drugs causing FDEs, with a focus on emerging drug culprits reported since the start of the century. Methods: A review of current FDE literature was performed, focussing on new and emerging drug culprits from the current century. Results: Across currently published literature, triggers for FDE are widely varied. The most frequently implicated drugs including analgesia (NSAIDs and paracetamol) and antibiotics. Co-trimoxazole is perhaps the most well described single agent. Since the start of the century there have been over 200 drugs named in case reports on FDE. Newer novel agents of note include cyclooxygenase 2 specific inhibitors, fluconazole, and phosphodiesterase 5 inhibitors. Other drugs, including vaccines (such as various SARS-CoV-2 vaccines), herbal medicine preparations and contrast, are of particular interest as patients may omit reporting this as part of their medication history. Conclusion: Drugs incriminated in FDE vary based on the geographical region studied and prescribing patterns at a given times. Newer drugs continue to enter the market and are playing an increasing role in the field of FDE. Awareness of rarer culprits and emerging novel agents can help identify a patient trigger, allowing for prompt withdrawal of the causative agent, preventing recurrence.

The Effects of Changing Lifestyle and Daily Behaviours in the First Months of COVID-19 Outbreak on Dermatological Diseases: Retrospective Cross-Sectional Observational Study

Objective: COVID-19 disease caused panic, fear of death, anxiety in people at the beginning of pandemic. This situation has dramatically changed people's lifestyle and daily behavior. The aim of our study was to determine the effects of changing lifestyle and daily behaviours on dermatological diseases in the first months of outbreak. Material and Methods: The diagnosis of the first patient with COVID- 19 in Turkey was established on 11 March 2020.In the same period, between 11 March and 30 April of 2020 and 2019, 454 versus 2.903 patients were admitted to the dermatology outpatient clinic and included in the study. The rates of dermatological diseases were compared. Pearson's chi-square test was used for statistical analysis. Results: Most of the patients were women (59.2 and 64.8%), and the average ages of the patients were 36.6±17.5 and 35.1±18.2 years for these time periods. Although admission to the hospital for those under 20 years of age due to curfew was decreased (16.8-10.1%), acne frequency increased (18.6- 21.1%, p=0.198). The frequency of psoriasis among papulosquamous diseases significantly increased (p=0.016). Urticaria (4.33-9.47%, p<0.001), drug eruptions (0.17-1.32%, p<0.001), and dermatitis and eczema (25.52-30.44%, p=0.025) significantly increased. The frequency of alopecia areata among hair disorders significantly increased (p=0.005). Rosacea (1.59-0.44%, p=0.05), bacterial infections (1.45- 0.44%, p=0.046), fungal infections (5.29-3.3%,p=0.042) and xerosis cutis (6.26-1.1%, p=0.025) significantly decreased. Admissions due to benign skin diseases (1.38-0%, p=0.012) significantly decreased. Conclusion: We consider that this study will contribute to providing the needed-evidence for the prevention and treatment of dermatological comorbidities by helping to identify the effects of changing lifestyles and daily behaviours on dermatological diseases because of the novel experimental environment created by the COVID-19 outbreak.

SÍNDROME DRESS – DIAGNÓSTICO DIFERENCIAL PARA A SÍNDROME INFLAMATÓRIA MULTISISTÊMICA (MIS-C) PEDIÁTRICA ASSOCIADA AO SARS -COV- 2

O termo DRESS (drug rash with eosinophilia and syste- mic symptoms – erupcao a droga com eosinofilia e sintomas sistemicos) surgiu em 1996, para caracterizar um tipo de reacao de hipersensibilidade a medicamento com caracteristicas sistemicas, que incluia erupcao cutanea grave, febre, linfadenopatia, hepatite e anormalidades hematologicas (hipereosinofilia e linfocitose atipica). Em criancas, esta sindrome e rara, muitas vezes subdiagnosticada, pois seu quadro clinico inespecifico se confunde com muitos outros diagnosticos diferenciais. Em ano de Pandemia em que muitos diagnósticos convergiam para COVID, esse relato de caso faz um diagnóstico diferencial com MIS. Por causa da raridade dessa reacao e da dificuldade e importancia de seu reconhecimento, relata-se o caso de um menino de 13 anos de idade com Síndrome de DRESS secundária a Vancomicina. Relato de caso: Menino admitido na UTI para tratamento de Osteomielite em membro inferior após trauma. Evoluiu com sepse clínica. Durante internação apresentou trombose venosa em sítio de acesso profundo. Iniciado anticoagulação. Persistia febre. Iniciado Vancomicina. Paciente apresentou melhora clínica sendo transferido para enfermaria. Na segunda semana do início da Vancomicina evoluiu com aumento de transaminases, erupção cutanêa importante principalmente em face. Hemograma apresentou eosinofilia e linfocitose atípica. Suspeita de COVID foi feita. Realizado PCR COVID que veio negativo. Suspenso Vancomicina. Trocado esquema antibiótico. Paciente recebeu Imunoglobulina 2g/kg com pouca melhora da lesão de face. ECO mostrava alterações agudas sugestivas de cardite. Paciente recebeu alta fazendo Clexane. No retorno ambulatorial como mantinha lesão em face foi iniciado terapia com corticoide 1mg/kg/dia. Após 30 dias anticoagulação foi suspensa e discutido com Cardiologia uso de AAS. Paciente com 2 meses de corticoide apresentou melhora de lesão cutânea que não retornou após a suspensão do corticoide.Apresentou melhora progressiva da eosinofilia. Realizado sorologia para COVID que demonstrou igG e IgM negativos. A hipótese de Reação a Vancomicina foi feita uma vez que preencheu os critérios para Sindrome de Dress – exposição a medicação, cardite, elevação de enzimas hepáticas, linfocitose atípica, eosinofilia além dos exames para COVID negativo.

Urticaria in COVID-19 Patient Treated with Lopinavir/ Ritonavir

The unknown pneumonia was first found in Wuhan, China in December 2019. A novel corona virus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was isolated from lower respiratory tract swab in infected patient. The disease caused by this novel virus was then named as COVID-19 (Coronavirus Disease 2019). We report a male patient with urticarial lesions, varies on size and shape on the both arms and both legs and diagnosed with COVID-19 confirmed case. He was treated with powdered oral medicine containing combination of lopinavir and ritonavir. He developed urticarial lesions in three hours after administration of the drug. The lesions then dissapeared and resolved after 4 days of treatment using cetirizine. The conclusion of this case is still needed to be proven whether the urticarial lesion is related to COVID-19 or drugs used for COVID-19 therapy. © 2021 Pakistan Association of Dermatologists. All rights reserved.