Infectious-mononucleosis-like exanthema associated with COVI
Get authentic, real-time news that helps you fight COVID-19 better.
Install PlexusMD App for doctors. It's free.
Cutaneous manifestations of childhood COVID-19 differ from those of adults. Maculopapular rash is not specific and could be mistaken with other viral exanthema. A nasopharyngeal swab is strongly recommended to confirm the possible COVID-19 diagnosis.

A three-year-old girl presented with a 3-day history of continuous fevers greater than 38.5°C and sore throat. She was previously fit and well. Her past medical history was unremarkable. Her mother had a headache and diarrhea lasting a week. Clinical examination revealed pseudomembranous angina. The child was put on amoxicillin. Fever lasted five more days, and she developed a skin eruption. On examination, she was systemically well with normal vital signs. She was still feverish and had a generalized maculopapular morbilliform exanthema.

Nikolsky sign was negative. No mucosal involvement was noted. Infectious mononucleosis (IM) was suspected. We performed serologic tests of Epstein-Barr virus (EBV). IgM and IgG antibodies to the viral capsid antigen and antibodies to the nuclear antigen were not detected. Viral tests for cytomegalovirus and parvovirus B19 were negative. The patient was examined by our colleagues at the National Pharmacovigilace center. The role of amoxicilline was excluded. Patch tests were programed later. Routine blood tests, including complete blood count and liver transaminases, showed no abnormalities. C-reactive protein (CRP) level was elevated (160 mg/L).

The patient had a nasopharyngeal swab to test for SARS-CoV-2 using reverse transcription-polymerase chain reaction, which was positive. Due to prolonged fever, exanthema and biological inflammatory syndrome, pediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS) was suspected. The patient immediately received a dose of 2 g/kg of intravenous immunoglobulin. Other investigations including troponin T, procalcitonin, ferritin, D-Dimer, fibrinogen, lactate, triacylglycerol, chest X-ray, and echocardiography were normal. After one dose of immunoglobulin, fever and exanthema disappeared and no complementary treatments were needed.

In conclusion, clinical course of COVID-19 infection in children is mild and the diagnosis could be misdiagnosed. Skin manifestations such as maculopapular rash are not specific and could be mistaken with other viral exanthema. In this time of global pandemic and in order to break the chain of transmission immediately, we would strongly recommend a nasopharyngeal swab to confirm the possible COVID-19 diagnosis.