At first, this case with myalgia, skin rash, high ESR and muscle enzyme levels without fever brought this idea to our minds that we may be encountered with a connective tissue disease or vasculitis for example polymyositis-dermatomyositis. We didn t find heliotrope rash or any rash on her face but there was severe muscle tenderness in all extremities. Laboratory tests revealed no rhabdomyolysis or myoglobinuria and renal function was normal. In addition, common urticaria, allergy, drug eruptions and viral infections particularly regarding to rising titer of liver and muscle enzymes were considered in differential diagnosis. As, patient was otherwise healthy and didn t take any medication the diagnosis of drug induced rashes was excluded. Hepatitis B, C and HIV infections were ruled out by specific tests. At the next step, COVID-19 antibodies and nasopharyngeal swab test for COVID-19 RNA amplification were requested that resulted positive (high IGM level). On the other hand, histologic examination of skin rash revealed mild superficial and deep lymphocytic infiltration, compatible with common urticaria. Finally, Covid-19 infection was confirmed as the cause of patient s symptoms.

In literature, COVID-19 may show various cutaneous manifestations including: maculopapular exanthema, papulovesicular rash, urticaria, painful acral red purple papules, livedo reticularis lesions and petechiae, predominantly in trunk and with less prevalence in acral parts 1. Skin lesions may present before the onset of respiratory symptoms or as the first or only symptom of the disease (17% and 21%, respectively). However, there is no correlation between disease severity and cutaneous involvement. There are some theories for explanation of skin lesions including: virus particle induced vasculitis, immune complex mediated vasculitis and Langerhans cell activation following immune complex mediated cytokine release resulting in vasodilation 1234.