key: cord-0911348-ocfd91zk
authors: Taşkın, Banu; Vural, Seçil; Altuğ, Elif; Demirkesen, Cüyan; Kocatürk, Emek; Çelebi, İrfan; Ferhanoğlu, Burhan; Alper, Sibel
title: COVID‐19 Presenting with Atypical Sweet’s Syndrome
date: 2020-05-26
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16662
sha: 9129e6e0533e2e5881f1cf8975be603bffdcb60c
doc_id: 911348
cord_uid: ocfd91zk

On March 11, 2020, the first case of the novel coronavirus 2019 disease (COVID‐19) was officially confirmed in Turkey. The disease continues to spread, and the number of patients has risen to 120,000 by the end of April. In this observation, we report an atypical presentation of COVID‐19 in a patient with indurated painful nodules. A‐61‐years‐old woman with a one‐week history of fever (axillary 38°C) and nodules on the cheek was admitted to the hospital with fatigue, arthralgia and myalgia.

Dear Editor, On March 11, 2020, the first case of the novel coronavirus 2019 disease (COVID-19) was officially confirmed in Turkey. The disease continues to spread, and the number of patients has risen to 120,000 by the end of April. In this observation, we report an atypical presentation of COVID-19 in a patient with indurated painful nodules.

A-61-years-old woman with a one-week history of fever (axillary 38 o C) and nodules on the cheek was admitted to the hospital with fatigue, arthralgia and myalgia. There were numerous erythematous nodules on the scalp, extremities, and the trunk. (Figure 1 ). Minor aphthous ulcers were observed on the hard palate and buccal mucosa. The patient's history was unremarkable, and she was not using any medication. She did not have any respiratory symptoms.

In laboratory work-up leukocytosis was detected 13.75 (4.1-11.1 (K/Ul)). Neutrophils constituted 83% of the white blood cells (11.4 (0.0-0.5(K/Ul)). Lymphocyte count was 1.2 (1.2-5.8(K/Ul)).

Eosinopenia was not detected. Acute phase reactants were significantly elevated (Erythrocyte sedimentation rate:101 (0-25 mm/hour), C-reactive protein level: 78.2 (<5.0 (mg/L), fibrinogen:

This article is protected by copyright. All rights reserved (7.74(1.8-3.6 g/L)). The D-dimer level was 1230(<650 ug/L). The first SARS-CoV-2 RT-PCR test from nasopharyngeal swab on admission was negative. Thorax computed tomography (CT) showed paramediastinal, peribronchoalveolar multifocal ground-glass opacities in <30% of lung parenchyma. The patient was treated empirically with hydroxychloroquine, azithromycin, and oseltamivir.

To rule out other causes of fever, the patient underwent an abdominal CT. Abdominal CT did not reveal a mass lesion or a causative location for the fever. Skin biopsy from the right elbow revealed diffuse neutrophilic infiltration in the upper dermis and vascular proliferation with swollen endothelial cells and extravasated erythrocytes (Figure 2a Acute febrile neutrophilic dermatosis (SS) is a rare reactive dermatosis associated with malignancies, inflammatory bowel disease, autoimmune disorders, drugs, and infections [1, 2] . Fever, myalgia, arthralgia, leucocytosis are the typical findings of SS. Oral mucosa involvement is an uncommon finding in Sweet's syndrome (2-12%) [3, 4] . Oral ulcers are the most frequent mucosa involvement as in our patient. An immune reaction against the drugs, tumors or microbiological agents may start a cytokine cascade resulting in the onset of SS [5] . In our case, no other cause except SARS-CoV-2 could be identified. The overlapping symptoms of SS with COVID-19 complicated the diagnosis in this case. Recently, pseudo-chilblain, atypical vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis were

This article is protected by copyright. All rights reserved reported as dermatological findings of COVID-19 [6] . To our knowledge, this is the first reported case of SS associated with COVID-19.

The aberrant host response in COVID-19 infection was proposed to be centred around neutrophils, and neutrophil extracellular traps were shown in the lung [7] . In autopsy specimens, neutrophil infiltration in pulmonary capillaries, extravasation of neutrophils to alveolar space and capillaritis with fibrin deposition were shown [7, 8] . The exaggerated neutrophilic response caused by the COVID-19 in our patient may have triggered SS in the skin. Predominant cells in the inflammatory infiltration of oral aphthous ulcers are the neutrophils, compatible with the inflammation in SS [9] .

We want to draw attention to the overlapping symptoms of reactive neutrophilic dermatosis with COVID-19 and the possibility of concurrent onset. 

Sweet's syndrome (acute febrile neutrophilic dermatosis)

Sweet's syndrome and cancer

Sweet's syndrome--a comprehensive review of an acute febrile neutrophilic dermatosis

Bullous variant of Sweet's syndrome

Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases

Targeting potential drivers of COVID-19: Neutrophil extracellular traps

Vander Heide RS. Pulmonary and Cardiac Pathology in Covid-19: The First Autopsy Series from New Orleans

Polymorphonuclear neutrophil function in recurrent aphthous stomatitis

We would like to thank the patient for giving written informed consent to publication of the case details. We thank Dr. Levent Tabak and Dr. Siran Keske for their clinical assistance.