SHARE @ Advocate Health - Midwest - Scientific Day: Pustular Eruption Following SARS-CoV-2 Infection
 

Affiliations

Aurora St. Luke’s Medical Center

Abstract

Introduction/Background:

Cutaneous sequelae of COVID-19 infections and vaccinations are increasingly recognized, with pustular dermatoses emerging as rare manifestations that can mimic generalized pustular psoriasis (GPP) or acute generalized exanthematous pustulosis (AGEP). This report details a case of pustular dermatosis following COVID-19 infection in a 24-year-old male.

Description:

The patient was presented with a three-day history of a painful pustular rash on his face, chest, and back developing 35 days post-COVID infection. No improvement with doxycycline for presumed folliculitis. He had a recent 16-day hospitalization for several multi-systemic post-COVID complications including encephalomyelitis, optic disc edema, and SIADH, which resolved with IVIG, pulsed methylprednisolone, and acetazolamide. Examination revealed multiple tender pustules with erythematous backgrounds, but no mucosal involvement. Laboratory findings were notable for leukocytosis with neutrophilic predominance. Dermatology and infectious disease guided further evaluation. Broad-spectrum antimicrobials, including IV vancomycin, fluconazole, and acyclovir, were initiated. Acetazolamide was discontinued. A punch biopsy spongiosis and ballooning degeneration of keratinocytes with superficial and deep perivascular and periadnexal dense neutrophilic infiltrate, focal sebaceus necrosis. No evidence of viral cytopathic change was seen. HSV and ZVZ PCR and IHC were negative. All other infectious workup was negative, including orthopoxvirus, EBV, CMV, and monkeypox virus. Given the absence of eosinophils in histology, AGEP was deemed unlikely. He was diagnosed with post-infectious COVID-19 pustular eruption. Clinical resolution occurred with symptomatic treatment, and acetazolamide was later reintroduced without recurrence.

Discussion:

This case underscores the diagnostic complexity of pustular eruptions post-COVID-19. Dermatologists should integrate clinical, histopathologic, and multidisciplinary perspectives when evaluating pustular dermatoses, ensuring exclusion of life-threatening infections while considering post-viral inflammatory dysregulation as a potential etiology.

Presentation Notes

Presented at Scientific Day; May 21, 2025; Park Ridge, IL.

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May 21st, 11:41 AM May 21st, 1:15 PM

Pustular Eruption Following SARS-CoV-2 Infection

Introduction/Background:

Cutaneous sequelae of COVID-19 infections and vaccinations are increasingly recognized, with pustular dermatoses emerging as rare manifestations that can mimic generalized pustular psoriasis (GPP) or acute generalized exanthematous pustulosis (AGEP). This report details a case of pustular dermatosis following COVID-19 infection in a 24-year-old male.

Description:

The patient was presented with a three-day history of a painful pustular rash on his face, chest, and back developing 35 days post-COVID infection. No improvement with doxycycline for presumed folliculitis. He had a recent 16-day hospitalization for several multi-systemic post-COVID complications including encephalomyelitis, optic disc edema, and SIADH, which resolved with IVIG, pulsed methylprednisolone, and acetazolamide. Examination revealed multiple tender pustules with erythematous backgrounds, but no mucosal involvement. Laboratory findings were notable for leukocytosis with neutrophilic predominance. Dermatology and infectious disease guided further evaluation. Broad-spectrum antimicrobials, including IV vancomycin, fluconazole, and acyclovir, were initiated. Acetazolamide was discontinued. A punch biopsy spongiosis and ballooning degeneration of keratinocytes with superficial and deep perivascular and periadnexal dense neutrophilic infiltrate, focal sebaceus necrosis. No evidence of viral cytopathic change was seen. HSV and ZVZ PCR and IHC were negative. All other infectious workup was negative, including orthopoxvirus, EBV, CMV, and monkeypox virus. Given the absence of eosinophils in histology, AGEP was deemed unlikely. He was diagnosed with post-infectious COVID-19 pustular eruption. Clinical resolution occurred with symptomatic treatment, and acetazolamide was later reintroduced without recurrence.

Discussion:

This case underscores the diagnostic complexity of pustular eruptions post-COVID-19. Dermatologists should integrate clinical, histopathologic, and multidisciplinary perspectives when evaluating pustular dermatoses, ensuring exclusion of life-threatening infections while considering post-viral inflammatory dysregulation as a potential etiology.

 

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