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You can add enanthem, or a rash inside the body, such as in the mouth, to the ever-lengthening list of symptoms with which COVID-19 patients can present, researchers in Spain suggested.

Six of 21 patients with an exterior skin rash also had these lesions, which seemed to appear about 2 weeks after symptom onset, reported Juan Jimenez-Cauhe, MD, of Hospital Universitario Ramon y Cajal in Madrid, and colleagues, in a research letter in

Skin rashes and other lesions have been described in prior research among patients with severe COVID-19 infection, but the authors noted that "whether these manifestations are directly related to COVID-19 remains unclear, since both viral infections and adverse drug reactions are frequent causes of exanthem" or rashes occurring on the outside of the body.

They also noted how prior research found erythematovesicular and petechial patterns were most commonly associated with viral infections.

But patients with confirmed or suspected COVID-19 are often not examined for enanthem, since the oral cavity is not examined due to safety concerns, they noted.

Researchers examined 21 consecutive patients from a tertiary care hospital in Spain with skin rash who both tested positive for SARS-CoV-2 via real-time reverse transcriptase polymerase chain reaction (real RT-PCR) testing, and required a dermatology consult from March 30 to April 8. Patients with skin rash had their oral cavities examined.

Notably, the mean range of time between symptom onset and the appearance of lesions was 12.3 days, with a range of -2 to 24. No drug intake or laboratory findings were associated with any type of enanthem.

The six patients with enanthem ranged in age from 40 to 69, and four of six were women. Specifically, the authors noted no enanthem was observed in patients with urticarial or typical maculopapular rashes.

Enanthem was located on the palate in all patients, and three of six were macular with petechiae, while two were petechial and one was macular. No patient had an erythematovesicular enanthem, the authors noted. They also said the latency was shorter in patients with petechial enanthem versus macular lesions with petechiae appearance.

The authors noted that five of six patients had petechiae as part of the enanthem, which is consistent with prior research. Also, two patients with petechial lesions developed them "2 days before and 2 days after" the onset of COVID-19 symptoms, meaning an association with drug intake was "unlikely."

The authors acknowledged the small number of cases in their series, but still concluded that "the presence of enanthem is a strong clue that suggests a viral etiology rather than a drug reaction, especially when a petechial pattern is observed."

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