A case report of toxic epidermal necrolysis (TEN) in a patient with COVID-19 treated with hydroxychloroquine: are these
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Clinical and Molecular Allergy Open Access
CASE REPORT
A case report of toxic epidermal necrolysis (TEN) in a patient with COVID‑19 treated with hydroxychloroquine: are these two partners in crime? Carlo Maria Rossi1, Flavio Niccolò Beretta2* , Grazia Traverso1, Sandro Mancarella1 and Davide Zenoni3
Abstract Background: Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is the most Serious Cutaneous Adverse Reaction (SCAR) often with a fatal outcome. Coronavirus Disease (COVID-19) is caused by Severe Acute Respiratory Syndrome–Coronavirus—2 (SARS-COV2) and is an emergent pandemic for which no cure exist at the moment. Several drugs have been tried often with scant clinical evidence and safety. Case presentation: Here we report the case of 78-years-old woman with cardiometabolic syndrome and COVID19. A multidrug regimen including others hydroxychloroquine, antibiotics, dexamethasone and paracetamol, lowmolecular-weight-heparin and potassium canrenoate was started. After almost 3 weeks, the patient started to display a violaceous rash initially involving the flexural folds atypical targetoid lesions and showing a very fast extension, blister formation and skin detachments of approximately 70% of the total body surface area and mucous membranes involvement consistent with toxic epidermal necrolysis (TEN). The ALDEN algorithm was calculated inserting all drugs given to the patient in the 28 days preceding the onset of the skin manifestations. The highest score retrieved was for hydroxychloroquine. Other less suspicious drugs were piperacillin/tazobactam, ceftriaxone and levofloxacin. Conclusions: To our knowledge, this is the first case of TEN in a patient suffering from COVID-19 probably associated with hydroxychloroquine. Given the activation of the immune system syndrome induced by the virus and the widespread off-label use of this drug, we suggest a careful monitoring of skin and mucous membranes in all COVID-19 positive patients treated with hydroxychloroquine in order to early detect early signs of toxicities. Keywords: COVID 19, SARS-CoV- 2, Toxic Epidermal Necrolysis (TEN), Hydroxychloroquine, Severe Cutaneous Adverse Reactions (SCAR), Adverse Drug Reaction (ADR), Stevens–Johnson Syndrome (SJS), ALDEN Algorithm, SCORTEN Score, Pharmacovigilance Background Toxic Epidermal Necrolysis (TEN) is a rare Serious Cutaneous Adverse Reaction (SCAR). It displays an acute onset and is characterized by erythematous or violaceous *Correspondence: [email protected] 2 Scuola di Specializzazione in Farmacia Ospedaliera, Università degli Studi di Milano, Via L. Mangiagalli 25, 20133 Milan, MI, Italy Full list of author information is available at the end of the article
patches, atypical targetoid lesions, bullae, erosions and skin detachment. It differs from Stevens-Johnson Syndrome (SJS) only in the percentage of skin involvement, which in TEN is greater than 30% of the body surface [1]. Etiopathogenetically, it results from the combination of drug and host genetic factors (such as drug metaboli
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