Cutaneous lesions and COVID‐19: Cystic painful lesion in a case with positive SARS‐CoV‐2

Dear Editor, The spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a global emergency since its outbreak in December 2019. Coronavirus disease 2019 (COVID-19) usually engages with the respiratory system. Moreover, other organs like the central nervous system could also be affected. Nevertheless, there might be a shift in the chief complaints in COVID-19 patients to the less common symptoms, such as gastrointestinal symptoms, olfactory dysfunction, vertigo, otalgia, and skin rash. An emerging area, in which there is little information, is the COVID-19-related cutaneous manifestations. Studies have described five and six classifications in a Spanish population and in a universal review article about skin lesions in COVID-19 patients, respectively. Here, we report the case of a COVID-19 patient with painful cutaneous lesions on posterior auricular for the first time in the ear, which is included in the classification review studies. A 34-year-old male (newspaper office clerk with no past medical history and no exposure to COVID-19 patients to his best knowledge) with a chief complaint of posterior auricular pain visited the emergency room of Shahid Modarres Hospital (Saveh, Iran). During the initial assessment, the patient reported having a high fever (>39 C) 10 days before, which was relieved by self-treatment and using over-thecounter agents, that is, acetaminophen (Figure 1). Productive cough started 2 days after the onset of fever. He used conservative treatments; however, his condition did not improve. On the third day, cutaneous lesions in the form of cystic eruptions appeared on his body. The lesions were distributed first on his trunk, then appeared on the legs and feet, and lastly on the left posterior auricular. At the day of visit, he had a 1-inch lesion on the posterior auricular with painful ears and reddening of the mucosa of the tympanic membrane on both sides. The auricular lesion has been growing slowly for the past 5 days and eventually caused the pain. At the time of examination, the auricular lesion was tender and warm, and without any secretion or itching. In the emergency room, the patient did not have fever and had a normal respiratory rate and oxygen saturation level, heart rate, and blood pressure. His skin examination was normal, except on his left posterior auricular. According to the patient's medical history, and the current circumstances of the global pandemic, COVID-19 was suspected. Realtime reverse transcription polymerase chain reaction (rRT-PCR) for SARS-CoV-2 was performed, which showed positive results on 10 April 2020. After receiving laboratory confirmation for COVID-19, the patient was treated according to the national treatment protocol at the time (hydroxychloroquine 200 mg per os (PO) q12h and oseltamivir 75 mg PO q12h, both for 5 days). He was examined 7 days after his first visit. All symptoms were totally recovered and retested with rRT-PCR for COVID-19, which showed negative results (Figure 2).