Viral exanthema as manifestation of SARS-CoV-2 infection
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A 41-year-old woman attended the Emergency Department for fever, myalgias, dysphagia, nasal congestion, headache, symptoms present for 2 days before presentation. She declares that she was in contact with a person who tested positive for SARS-CoV-2 a week before the presentation. On physical examination, she was found to be of normal weight, with a temperature of 38.3°C, pharyngitis, bilateral submandibular microlymphadenopathy, oxygen saturation of 98% in ambient air, blood pressure of 110/60 mm Hg, heart rate of 88/minute. The nasopharyngeal swab tested by rt-PCR for COVID -9 was positive and the patient was admitted.

Treatment (as per the national protocol) with Hydroxychloroquine 400 mg twice a day on the first day, then 200 mg twice a day until day 10, Azithromycin 500 mg/day for 5 days, with antifungal protection, and Lopinavir/Ritonavir 200/50 mg 2 tablets twice a day for 7 days was initiated. The patient became apyrexial on the second day of treatment.

On the third day of treatment, anosmia occurred (persisted for 6 weeks) and on the fourth day, she reported dry cough, mild dyspnea, and diarrhea. Crepitations were heard on auscultation of both lung bases. The oxygen saturation was within normal limits (96%–98%). Systemic pulse corticosteroid therapy was given (methylprednisolone 120 mg intravenous daily for 3 days), under which the dyspnea and cough improved and no more rales are heard. The patient was discharged after a two-week hospital stay, following 2 negative SARS-CoV-2 tests (performed 24 hours apart). Diarrhea resolved 1 month after onset. One day after discharge an erythematous rash appeared initially on the trunk and disseminated over the next 5 days, centrifugally, to the proximal limbs.

Dermatological examination describes a disseminated erythematous maculopapular rash, purpuric in appearance, mildly pruritic, with a tendency to confluency. The clinical appearance suggests a viral exanthema in the context of SARS-CoV-2 infection. Vitamin C and topical corticosteroids of medium potency were administered during the first days, followed by emollient, hydrating lotion thereafter. The rash extended centrifugally but spared the face, palms, and soles, as well as the mucous membranes. After 5 days of treatment the papule disappeared, the erythema improved but the purpuric appearance and mild pruritus persisted, along with the residual pink-brown macule. After 10 days, the exanthema disappeared almost completely, except for the persistence of discrete pink macule on the abdomen. Follow-up at 1 month showed complete resolution of the rash, no respiratory symptoms but persistence of anosmia. The sense of smell returned partially 6 weeks after the onset of anosmia.