COVID-19-associated dermatologic manifestations: Difference between revisions
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** Hypoxia-related accumulation of deoxygenated blood in blood vessels. | ** Hypoxia-related accumulation of deoxygenated blood in blood vessels. | ||
** Vasculopathy with deposition of C5b-9 and C4d. | ** Vasculopathy with deposition of C5b-9 and C4d. | ||
**Degeneration and necrosis of parenchymal cells and formation of hyaline thrombi in small vessels were observed in lung and other organs.<ref name="pmid32172546">{{cite journal| author=Yao XH, Li TY, He ZC, Ping YF, Liu HW, Yu SC | display-authors=etal| title=[A pathological report of three COVID-19 cases by minimal invasive autopsies]. | journal=Zhonghua Bing Li Xue Za Zhi | year= 2020 | volume= 49 | issue= 5 | pages= 411-417 | pmid=32172546 | doi=10.3760/cma.j.cn112151-20200312-00193 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32172546 }} </ref>. | |||
== Histology == | == Histology == | ||
| Line 54: | Line 57: | ||
**Acute acro-ischemia in the child | **Acute acro-ischemia in the child | ||
***the presentations of acro-ischemia including finger/toe cyanosis, skin bulla and dry gangrene.<ref name="pmid32447934">{{cite journal| author=Zhang Y, Cao W, Xiao M, Li YJ, Yang Y, Zhao J | display-authors=etal| title=[Clinical and coagulation characteristics in 7 patients with critical COVID-2019 pneumonia and acro-ischemia]. | journal=Zhonghua Xue Ye Xue Za Zhi | year= 2020 | volume= 41 | issue= 4 | pages= 302-307 | pmid=32447934 | doi=10.3760/cma.j.issn.0253-2727.2020.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32447934 }} </ref>. | ***the presentations of acro-ischemia including finger/toe cyanosis, skin bulla and dry gangrene.<ref name="pmid32447934">{{cite journal| author=Zhang Y, Cao W, Xiao M, Li YJ, Yang Y, Zhao J | display-authors=etal| title=[Clinical and coagulation characteristics in 7 patients with critical COVID-2019 pneumonia and acro-ischemia]. | journal=Zhonghua Xue Ye Xue Za Zhi | year= 2020 | volume= 41 | issue= 4 | pages= 302-307 | pmid=32447934 | doi=10.3760/cma.j.issn.0253-2727.2020.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32447934 }} </ref>. | ||
***they could be the expression of secondary microthrombosis due to endothelial damage and vascular disorders.<ref name="pmid32447934">{{cite journal| author=Zhang Y, Cao W, Xiao M, Li YJ, Yang Y, Zhao J | display-authors=etal| title=[Clinical and coagulation characteristics in 7 patients with critical COVID-2019 pneumonia and acro-ischemia]. | journal=Zhonghua Xue Ye Xue Za Zhi | year= 2020 | volume= 41 | issue= 4 | pages= 302-307 | pmid=32447934 | doi=10.3760/cma.j.issn.0253-2727.2020.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32447934 }} </ref>. | |||
**COVID-19 Toes. | **COVID-19 Toes. | ||
***similar to the type of cold related changes we have seen in the feet of people for many years, but often occurring in places where the conditions are not cold and damp. These seem to happen more commonly in younger patients. | ***similar to the type of cold related changes we have seen in the feet of people for many years, but often occurring in places where the conditions are not cold and damp. These seem to happen more commonly in younger patients. | ||
| Line 62: | Line 65: | ||
== Laboratory Findings == | == Laboratory Findings == | ||
Acute acro-ischemia in the child lab results: | |||
**D-dimer, fibrinogen and fibrinogen degradation product (FDP) were significantly elevated in most patients. | |||
**Prothrombin time was prolonged in 4 patients. D-dimer and FDP levels progressively elevated consistent with COVID-2019 exacerbation. | |||
**Four patients were diagnosed with disseminated intravascular coagulation (DIC) . | |||
**Low molecular weight heparin (LMWH) was administrated in 6 patients, which reduced D-dimer and FDP rather than improved clinical symptoms.<ref name="pmid32447934">{{cite journal| author=Zhang Y, Cao W, Xiao M, Li YJ, Yang Y, Zhao J | display-authors=etal| title=[Clinical and coagulation characteristics in 7 patients with critical COVID-2019 pneumonia and acro-ischemia]. | journal=Zhonghua Xue Ye Xue Za Zhi | year= 2020 | volume= 41 | issue= 4 | pages= 302-307 | pmid=32447934 | doi=10.3760/cma.j.issn.0253-2727.2020.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32447934 }} </ref> | |||
== Diagnostic studies == | == Diagnostic studies == | ||
Revision as of 23:40, 15 June 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2] Ogechukwu Hannah Nnabude, MD
Overview
COVID-19 infections is caused by the novel corona virus or also known as SARS-2 virus. The disease is believed to incline towards respiratory organs due to the high expression of ACE receptors. However, skin rashes have been uncommonly described in patients with COVID-19 infection. Dermatologic manifestations of COVID-19 include an erythematous exanthem (including a lacy pattern and a petechial, dengue-like rash), livedo reticularis, cutaneous vasculitis acute urticaria, chickenpox-like blisters.
Pathophysiology
- The exact mechanisms of COVID-19 induced cutaneous manifestations are not yet well known,
- The viral particles present in the cutaneous blood vessels could lead to a lymphocytic vasculitis.
- Keratinocytes may be a secondary target after Langerhans cells activation.
- Immune response to infection leads to Langerhans cells activation, resulting in a state of vasodilation and spongiosis.
- Microthrombosis and DIC originating in other organs results in livedo reticularis.
- Hypoxia-related accumulation of deoxygenated blood in blood vessels.
- Vasculopathy with deposition of C5b-9 and C4d.
- Degeneration and necrosis of parenchymal cells and formation of hyaline thrombi in small vessels were observed in lung and other organs.[1].
Histology
On microscopic histopathological analysis characteristic findings of dermatologic manifestations of COVID-19 include:
- Classic dyskeratotic cells
- Ballooning multinucleated cells
- Sparse necrotic keratinocytes with lymphocytic satellitosis
- Parakeratosis
- Acanthosis
- Pseudo-herpetic features
Differentiating COVID-19 Dermatologic manifestations with other Diseases
- COVID-19 can present with a rash and be mistaken for Dengue.[2]
Epidemiology and Demographics
- The incidence of dermatologic manifestations with COVID-19 infections increases with age; the median age at diagnosis is 53 years.
- Males are more commonly affected than females.
Risk Factors
History and Symptoms
- The timing of skin lesions depends on various factors and not really known but 3 days before diagnosis to 13 days after diagnosis.
- The most common cutaneous manifestation of COVID-19 is a maculopapular exanthem (morbilliform).
- Majority of lesions were localized on the trunk, however, some patients experienced cutaneous manifestations in the hands and feet. .
- Skin lesion development occurred before the onset of respiratory symptoms or COVID-19 diagnosis in some of the patients , and lesions spontaneously healed in all patients within 10 days
- The other cutaneous manifestations included:
- morbilliform rash as the primary presenting symptoms.[3].
- Papulovesicular rash
- Urticaria
- Painful acral red purple papules
- Livedo reticularis lesions
- Livedo reticularis is caused by conditions, including disseminated intravascular coagulation (DIC), that reduce blood flow through the cutaneous microvasculature system leading to deoxygenated blood accumulation in the venous plexus.[4].
- petechial skin rash.[2]
- Acral eruption of erythemato‐violaceous papules and macules, with possible bullous evolution, or digital swelling.
- Acute acro-ischemia in the child
- COVID-19 Toes.
- similar to the type of cold related changes we have seen in the feet of people for many years, but often occurring in places where the conditions are not cold and damp. These seem to happen more commonly in younger patients.
- chilblain‐like lesions.
- The pseudo‐chilblain pattern frequently appears late in the evolution of the COVID‐19 disease.
- the lesion was red–purple papules on the dorsal aspect of the fingers on both hands and diffused erythema in the subungual area of thumb.[6]
Laboratory Findings
Acute acro-ischemia in the child lab results:
- D-dimer, fibrinogen and fibrinogen degradation product (FDP) were significantly elevated in most patients.
- Prothrombin time was prolonged in 4 patients. D-dimer and FDP levels progressively elevated consistent with COVID-2019 exacerbation.
- Four patients were diagnosed with disseminated intravascular coagulation (DIC) .
- Low molecular weight heparin (LMWH) was administrated in 6 patients, which reduced D-dimer and FDP rather than improved clinical symptoms.[5]
Diagnostic studies
Prognosis
Treatment
References
- ↑ Yao XH, Li TY, He ZC, Ping YF, Liu HW, Yu SC; et al. (2020). "[A pathological report of three COVID-19 cases by minimal invasive autopsies]". Zhonghua Bing Li Xue Za Zhi. 49 (5): 411–417. doi:10.3760/cma.j.cn112151-20200312-00193. PMID 32172546 Check
|pmid=value (help). - ↑ 2.0 2.1 Joob B, Wiwanitkit V (2020). "COVID-19 can present with a rash and be mistaken for dengue". J Am Acad Dermatol. 82 (5): e177. doi:10.1016/j.jaad.2020.03.036. PMC 7156802 Check
|pmc=value (help). PMID 32213305 Check|pmid=value (help). - ↑ Hunt, Madison; Koziatek, Christian (2020). "A Case of COVID-19 Pneumonia in a Young Male with Full Body Rash as a Presenting Symptom". Clinical Practice and Cases in Emergency Medicine. 4 (2). doi:10.5811/cpcem.2020.3.47349. ISSN 2474-252X.
- ↑ Idler DR, Burton MP (1976). "The pronephroi as the site of presumptive interrenal cells in the hagfish Myxine glutinosa L." Comp Biochem Physiol A Comp Physiol. 53 (1): 73–7. doi:10.1016/s0300-9629(76)80014-x. PMID S0190-9622(20)30558-2 Check
|pmid=value (help). - ↑ 5.0 5.1 5.2 Zhang Y, Cao W, Xiao M, Li YJ, Yang Y, Zhao J; et al. (2020). "[Clinical and coagulation characteristics in 7 patients with critical COVID-2019 pneumonia and acro-ischemia]". Zhonghua Xue Ye Xue Za Zhi. 41 (4): 302–307. doi:10.3760/cma.j.issn.0253-2727.2020.008. PMID 32447934 Check
|pmid=value (help). - ↑ Alramthan A, Aldaraji W (2020). "Two cases of COVID-19 presenting with a clinical picture resembling chilblains: first report from the Middle East". Clin Exp Dermatol. doi:10.1111/ced.14243. PMC 7264553 Check
|pmc=value (help). PMID 32302422 Check|pmid=value (help).
3. Fu Y, Cheng Y, Wu Y. Understanding SARS-CoV-2-mediated inflammatory responses: from mechanisms to potential therapeutic tools [epub ahead of print]. Virol Sin. 2020:1-6. https://doi.org/10.1007/s12250-020-00207.
4. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective [epub ahead of print]. J Eur Acad Dermatol Venereol. 2020. https://doi.org/10.1111/jdv.16387.
5. Joob B, Wiwanitkit V. COVID-19 can present with a rash and be mistaken for dengue. J Am Acad Dermatol. 2020;82(5):e177.https://doi.org/10.1016/j.jaad.2020.03.036
6. Hoehl S, Rabenau H, Berger A, et al. Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China. N Engl J Med. 2020;382(13):1278-1280.
7.https://dermatology.ca/public-patients/covid-19-patient-updates/ Ryan Rivera-Oyola, MS, Merav Koschitzky, BA, Rachel Printy, PA-C, Stephanie Liu, DO, MBA, Roselyn Stanger, MD, Alexandra K. Golant, MD, and Mark Lebwohl, MD (2020)."Dermatologic findings in 2 patients with COVID-19" https://doi.org/10.1016/j.jdcr.2020.04.027
8.Yan Ling Apollonia Tay, Medical Student, University of Otago, Wellington, New Zealand. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. March 2020. Reviewed by Dr Louise Reiche, Dermatologist, Palmerston North, New Zealand. Latest update 12 June 2020. "COVID-19 and dermatology patients" https://dermnetnz.org/topics/covid-19/
10.https://www.jaadcasereports.org/article/S2352-5126(20)30310-6/fulltext
11.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189855/
12.https://onlinelibrary.wiley.com/doi/10.1111/bjd.19163
13.https://jamanetwork.com/journals/jamadermatology/fullarticle/2765612