key: cord-0845063-0owy69as authors: Putra, Bayushi Eka; Adiarto, Suko; Dewayanti, Santi Rahayu; Juzar, Dafsah Arifa title: Viral Exanthem with “Pin and Needles Sensation” on Extremities of COVID-19 Patient date: 2020-05-08 journal: International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases DOI: 10.1016/j.ijid.2020.05.020 sha: f07c15610e6a23c52c2afd20639fe9a6115f849c doc_id: 845063 cord_uid: 0owy69as Abstract Cutaneous manifestation is a newly reported clinical manifestation of COVID-19 infection. The clinical description of cutaneous manifestation is still not fully described. Our patient, a medical personnel, had viral exanthem distributed in the extremities along with “pin and needles sensation” which differ from the previously published paper on cutaneous manifestation. The differential diagnosis of drug-induced skin rash and hand-foot-mouth disease have already been ruled out based on the patient's previous history and course of disease. As of the 4th of May 2020, the number of coronavirus diseases 2019 patients keeps increasing worldwide reaching a total of 3.515.177 number of confirmed cases. [1] From that number, 1.133.932 patients recovered and 245.607 patients died. 1 In Indonesia, confirmed cases were 11.192 patients with 1.876 already recovered and 845 died. 2 Thus, the number keeps increasing as the spreading is rapid from person to person. 3 The widely known manifestations of COVID-19 patients are fever (99% of patients), fatigue (70% of patients), dry cough (59 percents of patients), anorexia (40% of patients, along with myalgias, dyspnea, and sputum production each under the prevalence of 40% as reported in the clinical characteristic of patients in Wuhan, China. 4 These clinical manifestations are paramount for initial screening of COVID-19 patients. Recently, it was mentioned that 20.4% of COVID-19 patients in Italy develop cutaneous manifestation of erythematous rash, widespread urticaria, and chickenpoxlike vesicles with the trunk as the main involved region. 5 Cardiovascular disease is among the most common comorbidity found in COVID-19 patients. This study will highlight a self-reported case of exanthema manifestation which manifested in the extremities of a medical personnel serving at the isolation room of a National Cardiovascular Center, who suffered from COVID-19. The goal is to describe in detail the clinical manifestation of COVID-19 patients, especially the cutaneous manifestation that was just recently known to present in COVID-19 infection along with its appearance after the treatment. A 29-year-old Asian Male experienced a fever of 38.4-38.7 degrees Celsius in the first to the third days. The patient was a medical personnel in National Cardiovascular Centre Harapan Kita, Indonesia. History of contact was with a patient who confirmed positive of COVID-19. The fever tended to increase in the afternoon and peaked in the evening and lasted for the first three days. Back pain was present during every feverish period. Myalgia, sore throat, and dry cough are also prominent for the first three days of symptoms [2] (Figure 1 ). Oral paracetamol 500 mg was only given if the body temperature was above 38 o C to monitor the pattern of the fever. Azithromycin 1x500 mg was started at day two of symptoms. Patient's blood pressure was 120/80 mmHg with a pulse rate of 80 bpm. No murmur or irregularity from the heart auscultation. No crackles or wheezing was heard from the lung auscultation. Other physical examinations were normal. Laboratory examination on day two of symptoms showed: Hemoglobin 13.6 g/dL, Hematocrit 42.7 %, Thrombocyte 232.000/µL, Leukocyte 8800/µL with basophil 0.2%, Eosinophil 0.1%, Neutrophil 88.7%, Lymphocyte 6.6% ([3]Lymphocyte absolute 528/µL), and Monocyte 4.4%. The high sensitive c-reactive protein (CRP) was elevated to 46.1 mg/L (normal level ≤ 10 mg/L). Neutrophil to lymphocyte ratio was 13.44; meanwhile, the lymphocyte to CRP ratio was 11.47. Chest X-ray on day three of symptoms and follow-up lung computed tomography on day seven of symptoms showed normal cardiac silhouette with no infiltrate nor cranialization of lung vascularization. symptoms for polymerase chain reaction (PCR) examination for COVID-19 DNA strain. Treatment for COVID-19 was planned to wait for the PCR result. Fever resolved on day three of symptoms; however, there was pin and needles sensation at the fingertips and the toe tips along with the appearance of discrete multiple lenticular redness papules with maximum diameter of 3 mm which appeared at the extremities [4] (Figure 2 ; Upper and Middle Row). The lesion did not spread to the trunk and became more apparent on day four and five of symptoms. Considering the newly reported case of cutaneous manifestation of COVID-19, treatment for COVID-19 by local protocol treatment was administered at the day four of symptoms without waiting for the PCR result: azithromycin 1x500 mg was given for ten days, hydroxychloroquine 1x400 mg was given for ten days, oseltamivir 2x75 mg was given for ten days, vitamin C 3x1000 mg was given for 14 days, and vitamin D 1x5000 IU was given for 14 days. On day six, the lesion lessened in number and on day seven of symptoms the lesion darkened in color. The pin and needles sensation persisted to day seven (visual analog score 3-4) and disappeared on day eight of symptoms. The toe tips and fingertips skin was thickened and exfoliated on [5] day fourteen of symptoms [6] (Figure 2 ; Bottom Row). Stomatitis aphthous was noticed on day seven and resolved on day ten after treatment with usual hygiene oral care. On day 10 and 11, no other symptoms aside from dry cough. However, on day 12, rhinorrhea and anosmia were apparent and persist until day 14. Association stating the use of azithromycin 1x500 mg should be given only for three days, hydroxychloroquine 1x400 mg should be given only for five days, and oseltamivir 2x75 mg should be given only for five days [7] for mild presentation of COVID-19 infection. Oseltamivir, hydroxychloroquine, and azithromycin were stopped on day eight of treatment in accordance with the treatment protocol. [8] 5 In our case, the onset started after the fever has subsided, notably on day four and five of symptoms. Based on the aforementioned paper in Italy, the onset of cutaneous manifestation was variable among the subjects, either before or after hospitalization; however, the onset was not clearly mentioned. Trunk area was also mentioned as the main involved region in the previous paper, 5 however, we found it to be distributed only in the extremities area along with the pin and needles sensation which hadn't been mentioned before. Skin eruptions were known to be a great imitator and might be caused by any kind of etiologies including drug eruptions. Systemic antibiotics and antiviral medications used in COVID-19 treatment such as chloroquine, cyclosporine, and azithromycin were thought to cause skin eruptions. 6 But this might not be the case in our patient. Patient was known for not taking any new drugs during the previous 15 days aside from azithromycin which was started two days before the skin lesion erupted. Azithromycin was known to cause fixed drug eruption and erythema multiforme. However, target lesions that were pathognomonic for erythema multiforme were not present and despite continued use of azithromycin from day two to day 11 of symptoms, the skin lesion Page 8 of 13 J o u r n a l P r e -p r o o f 8 toned down and resolved by itself from day seven of symptom, proving the skin eruptions to be caused by viral exanthema. 7, 8 Aside from due to drug eruption, viral exanthem distributed in the extremities area was at first thought to be the manifestation of hand, foot, and mouth disease (HFMD). The manifestation of stomatitis aphthous also supported the diagnosis of HFMD. 9 However, there are several characteristics of HFMD which did not fit to our patient: first, the most prevalent age-group of HFMD was among the patients below five years of age; second, the mucosal lesions usually erupt in the first two days; third, lesions in buttocks and genitalia are usually notifiable. 10, 11 Moreover, the PCR nasooropharyngeal swab examination also clearly stated the presence of COVID-19 infection in our patient and no previous contact to HFMD patient was noted. Although exfoliation from the skin eruption might be normal. Thickening of skin along with exfoliation at the fingertips should raise questions regarding the possibility of finding the COVID-19 DNA in the exfoliating area and the probability of viral transmission through the skin break from the exfoliating area. Research on this area should still be thoroughly studied. There are no conflicts of interest. Funding Source: Publication is supported by National Cardiovascular Centre Harapan Kita Ethical Approval: The first author, which is also the patient in this case report, has given permission for the publication of this case report and the accompanying images. Coronavirus Update (Live): 1,521,030 Cases and 88 Peta Sebaran | Gugus Tugas Percepatan Penanganan COVID-19 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China Cutaneous manifestations in COVID-19: a first perspective Role of dermatologists in the uprising of the novel corona virus (COVID-19): Perspectives and opportunities. Dermatologica Sinica Drug induced erythema multiforme: two case series with review of literature Fixed drug eruption probably induced by azithromycin Viral exanthems in children: A great imitator Age patterns and transmission characteristics of hand, foot and mouth disease in China Practice Essentials, Background, Pathophysiology