Erythema multiforme in a young adult following COVID-19 infection and vaccination in Tanzania

Background

COVID-19 has protean manifestations. Knowledge of cutaneous COVID-19 manifestations is still evolving, especially in a country like ours that has a low disease burden and minimal public health measures to mitigate the COVID-19 pandemic. This report is important for highlighting and raising awareness regarding the heterogeneity of the clinical presentation of COVID-19, and the heterogeneity of responses to COVID-19 vaccination.

Case presentation

We report the case of a healthy, young female adult in her early 20s with no comorbidities.

The patient tested positive for COVID-19 and 2 weeks later she tested negative by reverse transcriptase (RT)-PCR, despite still having some symptoms. During the interim period, she experienced post-COVID-19 symptoms, such as fatigue, breathlessness, headaches, body soreness and low mood.

Eight weeks after the initial COVID-19 positive test, she received the Janssen COVID-19 vaccine (also known as Johnson & Johnson) at a designated health facility in Dar es Salaam. This vaccine has been advocated in Tanzania since 3 August 2021. Within 24 hours following vaccination, she started experiencing symptoms of severe nausea, body soreness and fatigue.

Two weeks later, she developed a skin rash (figure 1A), which was initially diagnosed as a fungal infection. The patient had travelled very briefly to a natural rainforest 3 days prior to the onset of these rashes.

On the third week post-vaccination, she developed face and neck rashes, and rashes in the abdomen and genital area. These were vesicular, at places bullous, and increasingly itchy (figure 1B). For the subsequent 2–3 days, the rashes increased in number and were associated with significant itch, pain and discomfort (figure 2). The patient had not been exposed to any common medicine associated with such rashes, such as carbamazepine, hydroxychloroquine, isoniazid or sulfonamides.

On the fourth week post-vaccination and second week from the onset of rashes, the patient experienced excruciating pain on touch all over the body rashes, including in her palms and soles, and major discomfort on contact with water, clothing, etc. The rashes were intensely pruritic. The maculo-papular rashes were erythematous, some scaly, with central dark areas and irregular margins (figures 3 and 4). Moreover, the rashes on her hands and soles were sore.

Laboratory tests were suggestive of a viral infection, because the patient’s lymphocyte count was elevated. Following a second review, a differential diagnosis of possible varicella infection was made, and blood was taken to test for varicella infection. This test was sent to India with a turnaround time of 2 weeks. In the meantime and while awaiting for the results, the patient was treated with acyclovir 800 mg every 8 hours, an antihistamine and topical calamine lotion.

On the fifth and sixth week post-vaccination, the patient’s symptoms worsened. Yellowish serous discharge was observed coming out from some rashes. Bleeding was observed from her gums, and extensive sores were present on her palms and soles. Some sores had blistered open and were sensitive. The cutaneous lesions were associated with generalised body pain, dry mouth and significant insomnia.

A clinical diagnosis of erythema multiforme was made, and the patient was treated with prednisolone for 5 days. A significant relief was observed following prednisolone treatment, with cessation of new lesions. The patient’s skin became dry and started peeling (figure 5A,B), although the itchiness persisted for a while longer. The fever, extreme exhaustion and body pain started to resolve around the 10th week post-vaccination.

Investigations

Laboratory tests:

• Complete blood count: increased lymphocytes at presentation, normal neutrophil counts.

• C reactive protein was raised to 42 IU (normal: 0–10 IU) on the fifth week.

• Varicella antibodies were raised: IgG levels of 1757.00 mIU/mL (normal: <150 mIU/mL).

• IgE levels were normal.

• Additional tests such as D-dimer, ferritin and lactate dehydrogenase were not performed.

Differential diagnosis

Mucocutaneous drug eruption or Stevens-Johnson syndrome was unlikely because there were no obvious mucocutaneous lesions and the urine output remained normal.

Likewise, the visit to the natural rainforest was brief, and the onset of rashes of this type is not related to any acute exposure.

Treatment

The treating physician prescribed acyclovir for viral exanthem, followed by treatment with prednisolone for 5 days, and with Celestamine (betamethasone 0.25 mg and dexchlorpheniramine maleate 2 mg, an anti-inflammatory and anti-allergic combination) for 10 days.

Outcome and follow-up

The patient experienced a full recovery. The lesions resolved with desquamation and mild itchiness.