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A Regal Rash

A 56-year-old Filipino-American woman returned to her job as a nurse in the emergency department after a brief disability leave for a torn rotator cuff. Shortly before, she had enrolled in a COVID-19 study in which she tested negative with salival and nasopharyngeal swabs for polymerase chain reaction and serology tests. After 5 days of returning to work in the emergency department, she began feeling fatigued and achy, but attributed this to readjusting to late night shifts. The next day, she was cooking a meal with aromatic ingredients including vinegar and spices, and suddenly realized that shewas unable to smell anything. Upon eating, she found that she was unable to taste as well. Over the next few days, she developed a loss of appetite and weight loss. In addition, she experienced low-grade fevers that only occurred during the nighttime. During these episodes, she would become anxious and restless. Her highest fever was on the second night of her newly onset symptoms, and spiked at 102.3°F (39.1°C). She had no shortness of breath or cough. About 4 days after her initial loss in smell, her fevers went away and she regained her smell and most of her taste. She felt much better. When she began to eat again, she experienced loose stool immediately after meals. Three days later, she noticed a cluster of well-circumscribed, erythematous, homogeneous, pruritic lesions in her groin area (<1 cm in diameter). These lesions were itchy and became raised and painful after scratching. At this point, the patient decided to see her primary care physician. Her bloodwork was notable for a high platelet count (486/μL) and mildly elevated glucose (102 mg/dL) but were otherwise normal. Besides the rash, the rest of the physical examination was unremarkable. Over the course of the next week, she noted that isolated and clustered lesions began to appear in other areas as well. The patient noted that the clusters continued to appear on the left side of her body, including her upper back, axilla, ribs, and under the breast. Of note, she had 2 isolated lesions in the popliteal region of her left knee. Toward the end of the week, she continued to discover similar lesions, including an isolated lesion on the first right interphalangeal webbed space (Fig. 1), an isolated lesion in the center of her right palm, and a cluster on the buttocks. About a month later, she began to notice lesions on the dorsal and palmar sides of her feet as well. All lesions followed the same evolution. The lesions grew in size to about the size of a quarter (>1 cm in diameter), with sharply demarcated, nonblanchable red borders and a blanchable paler purple center (Fig. 2). Eventually, the clusters of lesions coalesced together and formed a more diffuse macular erythema. The patient attempted to treat the rashes with diphenhydramine, but this did not help with the itching or the extinction of the rashes.