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Bullous pemphigoid rash in a woman with COVID-19

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    17 September 2021

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a single-stranded RNA virus that suppers through aerosolized droplets and enters host cells through the ACE2 receptor.

It is significant to consider the dermatologic appearances of SARS-CoV-2 as they might help to guide physicians towards the analysis of COVID-19 among other respiratory viruses. 

We discuss a case with a rare dermatological presentation of bullous pemphigoid (BP) in a known COVID-19-positive patient.

A 42-year-old woman came with a past medical history of class III obesity, type II diabetes mellitus, and hypertension. 

She is tested positive for COVID-19 preceding to hospitalization and presented to the hospital with severe, persistent, pruritic rash meeting dermatopathological, serologic, and clinical criteria for bullous pemphigoid diagnosis. Histopathology H&E punch biopsy from her left flexor wrist demonstrated epidermal keratinocyte necrosis, subepidermal vesiculation with eosinophils, gossamer stranding of the papillary dermis, and subepidermal edema. 

Antigen-specific serology was consistent with BP. There was no earlier reported cutaneous association of COVID-19 infection with bullous pemphigoid making this case an important addition to the body of evidence helping to identify bullous pemphigoid in the setting of viral infection.

This case presents a unique dermatologic presentation of COVID-19 and recent literature on potential pathophysiology of BP in COVID-19-positive patients. SARS-CoV-2 enters the host cell through the ACE2 receptor, which is found on multiple cell types including dermatological cells. Once it enters into a host cell, the virus activates complement, and, in turn, inflammatory cells are recruited to the cell eliciting a response. There has been speculation as to the contributing etiology of bullous pemphigoid, and this case brings to light new evidence of COVID-19 as a potential triggering event in patients with BP and should be studied further.

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