Urticarial eruption in COVID‐19 infection

Coronavirus disease (COVID-19) is spreading quickly across the world, until a pandemic condition was announced by the WHO on March.1, 2 Many clinical manifestations of this virus are described, and new symptoms are emerging particularly outside respiratory sphere, such as anosmia and ageusia3 which are recent ORL published symptoms. About skin manifestation, few cases of rashes on patients with laboratory-confirmed COVID-19 were described in two Chinese cohorts.4, 5 We read with great interest the recent publication of S.RECALCATI6 who explores the cutaneous manifestations in hospitalized COVID-19 patients in a hospital in Italy. The author remarks cutaneous manifestation in 20.4% of patients, some of them on the onset of disease and the other after the hospitalization, with three cases of widespread urticaria. As him, we observed some skin manifestations in COVID-19-infected patients and we write this letter in order to add a new element to these observations: one case of appearance of urticarial eruption before the onset of any fever or respiratory symptom. A 27-year-old woman with no history, medical resident at the hospital, presented an odynophagia followed by diffuse arthralgia and pruritic disseminated erythematous plaques eruption with particular face and acral involvement (Fig. 1), without cough or fever. The diagnosis of urticaria was confirmed by a dermatologist. No triggers except for the viral context were found, and common viral serology was negative. An antihistaminic treatment was established. Forty-eight hours later, she reported chills, chest pain and fever up to 39.2 °C. She had a moderate lymphopenia, hepatic workup was normal, and CRP level was 49 mg/L. She was tested positive for COVID-19 (PCR SARS-CoV-2). She was treated with paracetamol, and antihistamines were kept with slow improvement of the symptoms. The particular interest of this case is the inaugural appearance of a cutaneous manifestation, before fever or any respiratory symptom. It is essential to take into account and promote the potential recognition among clinicians of this possible skin manifestation of COVID-19 and lead to think about testing COVID-19 in these cases. The patients in this manuscript have given written informed consent to the publication of their case details.