Erythema Multiforme-Like Lesions as the Initial Symptom of Coronavirus Disease 2019 Infection in Infant
Article information
Abstract
Cutaneous manifestations in pediatric patients with coronavirus disease 2019 (COVID-19) are generally mild, with chilblains being the most commonly reported. Erythema multiforme (EM)-like lesions are rare, especially as initial or isolated symptoms. We report a case of an infant who presented with widespread EM-like targetoid erythematous papules without other systemic symptoms. Severe acute respiratory syndrome coronavirus 2 infection was confirmed using reverse transcription-polymerase chain reaction. This case highlights the need to consider COVID-19 in infants presenting with acute skin eruptions, even in the absence of typical systemic features.
Introduction
Although coronavirus disease 2019 (COVID-19) has transitioned to an endemic phase, sporadic infections continue to occur, and various cutaneous manifestations have been observed in affected patients, both with and without systemic symptoms. The cutaneous manifestations of COVID-19 vary but are usually mild, especially in the pediatric population [1]. The reported incidence of dermatological manifestations of COVID-19 is diverse, ranging from 0.2% to 29% in adults and more than 8% in hospitalized children [2,3]. Common dermatological manifestations in adults include urticarial, morbilliform, vesicular, and petechial eruptions, as well as vasospastic lesions, such as livedo reticularis and acral ischemic lesions. In contrast, the most frequently observed cutaneous manifestation in pediatric patients with COVID-19 is chilblains, followed by urticaria, erythema multiforme (EM)-like papulovesicular eruptions, and maculopapular rashes [1]. Although many reports have described chilblains associated with COVID-19 in children, relatively few have documented EM. Moreover, EM or EM-like rashes have rarely been reported as initial or isolated presentations of COVID-19.
Herein, we present a case of EM-like skin eruption as the first clinical manifestation of COVID-19 in a 1-month-old infant.
Case report
A 1-month-old female infant presented to the emergency department with a progressive skin rash that had worsened over three days. The rash initially appeared as urticaria-like lesions on the face but spread to the whole body by the day of presentation. The skin rash was consistent with EM and was characterized by erythematous, papular targetoid lesions without vesicles or pustules (Fig. 1). Five days prior to presentation, the patient had a mild fever with body temperature of 37.7°C, accompanied by slightly decreased activity. After the fever resolved, a rash appeared three days prior to presentation. At the time of the hospital admission, her general appearance was good, and she did not appear acutely ill. No associated systemic symptoms such as cough, vomiting, or diarrhea were observed.
Findings on the third day of skin rash.
She was the second baby of twins born at 36 weeks of gestation and with a birth weight of 2,480 g. No notable complications occurred during pregnancy or delivery, except when the mother was receiving treatment for hypothyroidism. The patient received Bacillus Calmette-Guérin vaccination after birth, as scheduled. Neither her cohabiting caregivers nor her twin sibling exhibited any signs of viral illness, and all tested negative for COVID-19.
Reverse transcription-polymerase chain reaction (PCR) testing of a nasopharyngeal swab from the patient was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Serological testing for immunoglobulin M and PCR assays for herpes simplex virus and cytomegalovirus were negative. Multiplex PCR tests for respiratory viruses and bacterial pathogens in the nasopharyngeal swab specimens were also negative. Other diagnostic evaluations, including bacterial cultures (blood, urine, and skin), routine blood and urine tests, and chest radiography were within normal limits.
The patient was treated with methylprednisolone (1 mg/kg/day), and the skin lesions showed marked improvement after three days of therapy. The patient was discharged without complications.
Discussion
EM is a delayed-type hypersensitivity reaction that is clinically characterized by distinctive skin eruptions of macules and papules with erythematous target lesions. In both children and adults, systemic infections are the most common cause of EM, accounting for up to 90% of cases, whereas medications and vaccinations are implicated in fewer than 10% of cases [4].
EM associated with COVID-19 has been reported across all age groups; however, pediatric cases constitute only 16.7% (6/36) of reported cases in individuals aged < 18 years [5]. Most cases of EM (78%) associated with COVID-19 develop after the onset of typical COVID-19 symptoms and usually involve only the skin surface without mucosal involvement [5]. Additionally, EM has been reported in conjunction with other cutaneous findings, especially chilblains, and has been identified in approximately 18% of cases with chilblains [6]. Although patients may present with characteristic targetoid lesions that are clinically consistent with EM, numerous cases have been reported in which histopathological examination failed to demonstrate the hallmark features of EM, such as necrotic keratinocytes. These cases are referred to as EM-like lesions, reflecting the clinical appearance of EM, despite the absence of definitive histological findings [7]. Pediatric patients often present with EM or EM-like lesions in the context of multisystem inflammatory syndrome in children or Kawasaki disease, both of which are triggered by viral infections, including SARS-CoV-2 [6].
Most previously reported pediatric cases of isolated EM or EM-like lesions associated with COVID-19 occurred in older children and presented with localized lesions on the palms, soles, and other extremities (Table 1) [5,8-13]. In our case, unlike in previous reports in which EM was localized or accompanied by chilblains, the patient presented with generalized EM-like lesions involving the entire body as the sole cutaneous manifestation. The initial COVID-19 symptoms were mild fever and skin rash, without any other systemic symptoms of COVID-19.
Cases of isolated erythema multiforme in children with COVID-19
The primary treatment for EM is the identification and elimination of the causative factors. Systemic corticosteroids have been suggested as adjuvant therapy because of their immunosuppressive effects. Although the efficacy of systemic corticosteroids for EM in children remains controversial, some reports have suggested that their use could reduce disease severity in the early stages, while others have associated them with delayed recovery and increased complications [14]. Systemic corticosteroids could be beneficial in some severe or atypical cases, such as in neonates and young infants [15]. In previously reported cases of COVID-19–associated EM, symptomatic treatment with topical or oral corticosteroids has been sufficient in most cases [1].
This case is limited by the absence of histopathological confirmation, as a skin biopsy was not performed. However, given rapid clinical improvement, there was neither an indication nor an opportunity to perform a biopsy.
Considering the ongoing but sporadic occurrence of COVID-19, clinicians should maintain a high index of suspicion for viral etiologies, including SARS-CoV-2, when evaluating infants with acute cutaneous eruptions.
Notes
Acknowledgements
None.
Ethics approval
This case report was approved by the Institutional Review Board (IRB) of the Keimyung University Dongsan Hospital (approval number: 2025-07-011). The requirement for informed consent was waived by the IRB.
Conflict of interest
The authors have nothing to disclose.
Funding
None.