Challenges in the management of toxic epidermal necrolysis and COVID-19: a case report

ABSTRACT

With the outbreak of the emergent coronavirus, there have been sparse reports of severe cutaneous adverse reactions in some severely ill patients (Chen XY, Yan BX, Man XY. TNFα inhibitor may be effective for severe COVID-19 learning from toxic epidermal necrolysis. Ther Adv Respir Dis 2020;14 1753466620926800). It is thought that this is due to clonal expansion of CD8+ cytotoxic T lymphocytes and natural killer cells that occurs during the cytokine storm elicited by the virus or the use of unconventional drugs to treat patients (Rossi CM, Beretta FN, Traverso G et al. A case report of toxic epidermal necrolysis (TEN) in a patient with COVID-19 treated with hydroxychloroquine are these two partners in crime? Clin Mol Allergy 2020;18 19;Saha M, D'Cruz A, Paul N et al. Toxic epidermal necrolysis and co-existent SARS-CoV-2 (COVID-19) treated with intravenous immunoglobulin'Killing 2 birds with one stone'. J Eur Acad Dermatol Venereol 2020;35 e97-8). In a minority of cases, viral or autoimmune forms of toxic epidermal necrolysis (TEN) may be implicated (Chen et al.;Rossi et al.). However, very little research, has been done to decipher the association or pathogenesis with TEN and the novel virus. We report an interesting case of a 51-year-old woman who developed a rash on her face, flanks and periumbilical area immediately after an intensive care admission with respiratory failure secondary to confirmed COVID-19 pneumonitis. The patient had a background of gout on allopurinol and type 2 diabetes. There were no changes in medications. While admitted, she was started on broad spectrum antibiotics. On examination, there were large, confluent patches of erythema with a targetoid appearance on the face, upper limbs and trunk, and tense blistering over the forearms. Biopsy showed full thickness epidermal necrosis and subepidermal bullous formation. An autoimmune and bullous screen was negative. Prognosis was poor with the critical care team considering end-of-life management. However, with the diagnosis of a reversible condition, supportive therapy was continued. With continued intensive care intervention, steroids and barrier protection, her TEN gradually resolved as she recovered from COVID-19, and she had a favourable outcome with only residual milia and signs of re-epithelialization.