Erythema multiforme major requiring intensive care admission in conjunction with COVID-19 infection

ABSTRACT

A 13-year-old boy presented with oral pain and mucositis on a background of preceding sore throat, fever and malaise. His lips were swollen and ulcerated with tonsillar exudate visible. Reverse transcriptase polymerase chain reaction testing for SARS-CoV-2 was positive, and inflammatory markers were raised (C-reactive protein 77 mg L-1, erythrocyte sedimentation rate 31 mm h-1);additional virology (herpes simplex virus, cytomegalovirus, Epstein-Barr virus and HIV) was negative. Intravenous fluids, ceftriaxone, acyclovir and analgesia including morphine were commenced. He was unable to tolerate soluble oral steroid rinses. Over 24 h, his oral mucositis progressed with the additional development of conjunctival injection and nontargetoid, erythematous papules. A diagnosis of erythema multiforme (EM) major in conjunction with COVID-19 infection was made. His condition deteriorated with oral intubation required to maintain airway patency and deep sedation for pain control. During a 13-day paediatric intensive care admission he developed an extensive rash including ulceration of the external genitalia. There was marked ulceration of the trachea but fortunately tracheostomy was avoided. The patient has subsequently recovered well. A variety of cutaneous features, including EM, have been described in conjunction with COVID-19 infection. The incidence of distinct rashes varies between adults and children with EM uncommon in both groups but seemingly more frequent in paediatric patients (Bennardo L, Nistoc®o SP, Dastoli S et al. Erythema multiforme and COVID-19 what do we know? Medicina (Kaunas) 2021;57 828). The relationship of EM to outcome from COVID-19 infection itself is yet to be fully established. As with other infections, EM in children with COVID-19 exhibits a range of clinical presentations. This case highlights the severe end of the disease spectrum and underlines the role of the multidisciplinary team in management.