key: cord-341118-h5t87vf8
authors: Torres‐Navarro, Ignacio; Abril‐Pérez, Carlos; Roca‐Ginés, Juncal; Sánchez‐Arráez, Javier; Botella‐Estrada, Rafael
title: A case of cefditoren‐induced Acute Generalized Exanthematous Pustulosis during COVID‐19 pandemics. Severe Cutaneous Adverse Reactions (SCARs) are an issue
date: 2020-05-26
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16664
sha: 
doc_id: 341118
cord_uid: h5t87vf8

We read with interest the article by Recalcati et al. about the report of cutaneous manifestations in COVID‐19 patients. We would like to highlight that some potentially severe manifestations in these patients are not directly related to the coronavirus but to the medications administered.

This article is protected by copyright. All rights reserved Dear editor, We read with interest the article by Recalcati et al. about the report of cutaneous manifestations in COVID-19 patients. We would like to highlight that some potentially severe manifestations in these patients are not directly related to the coronavirus but to the medications administered.(1)

A 49-year-old-woman with morbid obesity, and no other relevant antecedents, was admitted in the Intensive Care Unit, due to severe respiratory failure. Chest x-ray showed bilateral lung diffuse opacities predominantly involving the upper and middle fields. SARS-CoV-2 RT-PCR rendered a positive result. The patient required invasive ventilatory support in the intensive care unit for 24 days. Throughout this period, treatment with interferon beta (250 mg/24h), hydroxychloroquine (200 mg/12h); azithromycin (500 mg/24h), ceftriaxone (2 g/12h), lopinavir-ritonavir (800-200/24h); methylprednisolone (40 mg/12h), and tocilizumab (600 mg single dose) was administered. After successful extubation, the patient was transferred to the pneumology ward remaining asymptomatic. All the drugs where interrupted except for methylprednisolone (tapered to 16 mg daily). Seven days later, respiratory worsening was observed with cough and crackles on pulmonary auscultation. Empiric treatment with cefditoren (400 mg/12h) was started. The following day, the patient suffered an episode of fever (38.4ºC). Blood tests revealed neutrophilia [7.75 x10 3 /μl; Normal Range (NR), 1.9 -7.3 x10 3 /μl; last measurement, 3.11 x10 3 /μl] and C-reactive protein level of 59 mg/l (NR, 0 -5 mg/l). At that time, a skin rash was noticed.

Upon physical examination, a confluent reddish macular rash was observed, mainly on the trunk, but also involving the neck, face, arms, and axillary and neck folds. Small widespread pustules developed over the macules. No mucosal involvement was seen. Clinical diagnosis of Acute Generalized Exanthematous Pustulosis (AGEP) was issued. Therefore, cefditoren

This article is protected by copyright. All rights reserved was interrupted and methylprednisolone was raised (0.3 mg/kg/day of prednisone). Skin lesions improved along with the general condition of the patient.

Histological analysis showed subcorneal pustules with abundant inflammatory infiltrate, papillary edema, and few eosinophils within superficial dermis. Subsequent cultures of pustular content were negative. Thus, the diagnosis of AGEP was confirmed. The Euro-SCAR score was 11 points. Cefditoren, a cephalosporin-derived beta-lactam, was the probable culprit drug (Naranjo score of 7). 

This article is protected by copyright. All rights reserved causes of skin lesions arising on the background of SARS-CoV-2 infection. Special effort has to be made to identify drugs as the source of these events, as they may lead to SCARs.

Finally, further studies should investigate cross-reactions between cephalosporins, and the role of cefditoren as causative agent of SCARs.

This article is protected by copyright. All rights reserved 

Cutaneous manifestations in COVID-19: a first perspective

Acute generalized exanthematous pustulosis (AGEP)--a clinical reaction pattern

Recent advances in the understanding of severe cutaneous adverse reactions

Acute generalized exanthematous pustulosis: a case series of 13 patients in Brazil

Drug reaction with eosinophilia and systemic symptoms during primary Epstein-Barr virus infection

Acknowledgments: The patient in this manuscript has given written informed consent to the publication of her case details.

This article is protected by copyright. All rights reserved