A report describes a case of a 14-year-old female with a history of scoliosis and Attention-deficit/hyperactivity disorder (ADHD) who presented for follow-up after receiving a discharge from the hospital seven days after a COVID-19 infection. Initially, she experienced worsening back pain and sore throat with some diarrhea, for which she visited a clinic and was documented as febrile (T 102F) and underwent COVID-19 PCR. In the evening, she started to develop a rash with irregularly shaped, discreet erythematous macules and papules, thus visited urgent care and eventually went to the ED.

In the ED, she was tested positive for COVID-19, received dexamethasone and ibuprofen, and discharge home. However, after coming home, her rash became more pruritic, and she took Benadryl after consulting a doctor. The medication relieved itching, but the patient again visited the ED out of the concern and thus received admission to the pediatric floor.

On admission, her respiratory viral panel was negative; a blood culture showed no growth for five days. Lab investigations revealed elevated AST, ALT, and total and direct bilirubin, consistent with transaminitis and cholestasis secondary to acute COVID-19 infection.

Abdominal Ultrasound revealed coarsened hepatic echotexture, a non-specific indicator of hepatocellular diseases, with no evidence of biliary obstruction or choledocholithiasis. She received vancomycin and ceftriaxone.

On hospital day 2, the patient received Enoxaparin prophylaxis 40 mg subcutaneously as her D-dimer levels increased, and was adviced to take enoxaparin for a month. She also displayed persistently low blood pressure and received a normal saline bolus and intravenous fluids, but she maintained low blood pressure. 

The patient was then transferred to the PICU and received an epinephrine drip. Her electrocardiogram (EKG) showed diffused ST elevations. Her cardiac echocardiogram showed good ventricular function with no evidence of visible valvular vegetation or pericardial effusion. At this time, she showed a change in the appearance of her rash, from macules and papules to confluent erythematous to dark purple patches. She also suffered mild respiratory distress, and her chest X-ray revealed subtle peripheral and basilar parenchymal opacities, representing atelectasis. Thus the patient was put on a high-flow nasal cannula for respiratory support but weaned off to room air as tolerated.

On hospital day 3, the patient received one dose of tocilizumab, Remdesivir (for five days), and dexamethasone (for ten days). She was switched to amoxicillin - 2 g every 12 hours to complete ten days of antibiotics. 

On hospital day 7, she was clinically stable and received a discharge with enoxaparin for one month, amoxicillin to complete a 10-day course, prednisolone to complete a 10-day course, and iron, magnesium, and calcium supplements. She did not develop any further symptoms, and her rash resolved.

Tilak K, Joung K, Apath M. Evolving Skin Rash as a Rare Cutaneous Manifestation in a Pediatric Patient With COVID-19 Infection. Cureus. 2022 Jun 30;14(6):e26477. doi: 10.7759/cureus.26477. PMID: 35919370; PMCID: PMC9339118.