Alice Serafini et.al. report the case of a 32-year-old female nurse who complained of mild tiredness and an extremely itchy erythematous rash that first appeared on the patient’s extremities and then spread to her whole body. She developed a fever and watery diarrhoea 7 days after the onset of the rash and later on a dry cough. Her RT-PCR done subsequently turned positive for COVID-19. The rash disappeared after 10 days but even after 31 days, she had small papules on her arms without pruritus. The case presents an early cutaneous manifestation of COVID-19, the identification of which is pivotal in case isolation and further treatment.
The patient is a 32-year-old female nurse of Caucasian ethnicity. She works in a private clinic in Emilia Romagna, a region in northern Italy that borders Lombardy. At the time of publication, Emilia Romagna was the Italian region with the second highest total number of confirmed cases and deaths in all of Italy. On March 13, 2020, the first day of her symptoms’ onset, Emilia Romagna had 299 confirmed cases, and by the time of the first submission of this article (April 11, 2020), Italian government data reported a total of 3263 confirmed cases in the region; the latest update of the total number of cases, dated September 8, 2020, reported 32.760 cases.
On March 13, 2020, the patient started to feel mildly tired and presented with an extremely itchy erythematous rash. Small, folliculocentric papules, associated with pruritus, appeared first on the patient’s extremities (hands, feet, forearm, legs, and back surface of the ears) and then spread to her whole body, sparing only her face, scalp, and abdomen. The itch worsened during the night, making it difficult for her to rest. Psychological factors are known to worsen pruritus. At first, the patient herself associated the development of symptoms with psychological stress and the changes in her working environment. As a result, she continued working without asking for medical advice.
Seven days after the onset of the skin rash, the patient developed a fever (37.5 °C, axillary) and watery diarrhoea (three to four episodes per day). As a result of these developments, she called her general practitioner (GP), who performed a comprehensive remote telephone assessment and identified her as a suspected COVID-19 case. This diagnosis was based on the presence of fever, a typical and well-known symptom of COVID-19, and due to her epidemiological high-risk profile (being a healthcare professional exposed to several patients with known COVID-19).
It should be noted that the patient did not have any chronic disease and had no personal or family history of autoimmune illness, atopy, or other skin problems. She did not smoke or consume alcohol. Furthermore, she did not have any ongoing chronic treatments, nor had she taken any new drugs in the weeks before the symptoms’ onset.
The GP evaluated the patient’s skin rash during this first remote consultation via pictures the patient took herself. The patient was told to quarantine at home, ensure an appropriate fluid intake, and self-medicate with paracetamol 500 mg if needed to manage the symptoms. To treat the skin rash, her GP prescribed an oral H1-antihistamine (cetirizine 10 mg once per day). As the patient was living alone (she was already living in self-isolation in order to reduce the possibility of infecting her family members), her GP started telemonitoring her case via scheduled follow-up calls at 3-day intervals.
During the first week of her remote monitoring, the patient began gradually experiencing a dry cough. The fever showed an intermittent trend during the day, higher in the evening but never higher than 37.5 °C. Her diarrhoea gradually improved (from watery diarrhoea to occasional episodes of unformed stool rushes). The itchy rash improved with the administration of oral H1-antihistamine, disappearing after 10 days.
Thirteen days after the onset of symptoms and 7 days after the appearance of fever, the patient was tested for SARS-CoV-2 infection with an oropharyngeal swab (real-time polymerase chain reaction [RT-PCR]), and her results were positive. During the whole period of remote monitoring, the vital signs of the patient remained stable, and she never reported dyspnoea.
When this article was first submitted, 31 days after the first appearance of the patient’s rash, she was still experiencing a dry cough, headaches, and moderate fatigue. Furthermore, even though she was not experiencing pruritus anymore, she reported the persistence of small papules on her arms, imparting a stippled appearance to the skin resembling gooseflesh, similar to keratosis pilaris. The patient described these lesions as distinctly palpable; however, they were not visible in the remote assessment. These small, palpable papules gradually disappeared over time. During her remote consultation on April 30, 2020, her GP ascertained, for the first time since the onset of the disease, an absence of cutaneous symptoms. The patient then had negative test results of two consecutive oropharyngeal swabs (April 26 and 30, 2020). The dry cough persisted for several more weeks and disappeared only very gradually, finally subsiding completely at the end of May (May 20–22, 2020). At this time, the patient returned to work, although a moderate sense of exhaustion persisted until July 2020. She described herself as completely recovered only at the end of August 2020.