COVID-19 associated severe mucocutaneous blistering eruptions: A case series

Introduction: Mucocutaneous eruptions are associated with many viral processes and present as erythema multiforme (EM), reactive infectious mucocutaneous eruption (RIME), Stevens Johnson syndrome (SJS) or toxic epidermal necrosis (TEN). Limited reports have described the association of COVID-19 and mucocutaneous eruptions in children and adults to date. Method(s): This was a multicenter descriptive case series performed at six tertiary medical centers. Inclusion required a clinical diagnosis of EM, RIME, SJS or TEN and a positive COVID-19 test (rapid antigen or PCR) less than 4 weeks prior to onset of dermatologic manifestation. Data was collected at time of each patient encounter. Result(s): A total of 7 patients met criteria and had a median age of 15 years for pediatric patients (<18 years of age) and 36 years for adult patients (>18 years of age). Patients were found to have a diagnosis of RIME in 85.7% of cases. Oral mucosal involvement was the most common clinical finding (100%), followed by ocular (57.1%), urogenital (57.1%) and skin (42.9%) involvement. 71.4% of cases required hospitalization for their cutaneous eruption. No patients died from their inflammatory condition. Discussion(s): This case series highlights the development of mucocutaneous eruptions in association with COVID-19 infection. Within our cohort, RIME was the most commonly identified COVID-associated eruption. These findings provide additional evidence that abnormalities in host immune response to viral pathogens play a role in severe mucocutaneous blistering conditions. Further investigation will aid our understanding of this disease to improve diagnostics and advance targeted treatments for patients in the future.

Assessing Craniofacial Team Functioning During Virtual Multidisciplinary Team Meetings

Background/Purpose: The craniofacial team meeting represents a critical timepoint at which a diverse group of disciplines assemble in quorum to discuss the complex medical and psychosocial issues facing their patients and create treatment plans to address them. Professionals from not only different disciplines but from entirely different fields must efficiently amalgamate their expertise to create one intricate plan for their unique patient population. It is this diversity of disciplines represented and the complexity of subject matter that makes craniofacial team meetings ideal for studying team functioning during multidisciplinary meetings. The global pandemic necessitated a shift of these complex meetings to the virtual setting. While providing direct patient care (i.e. tele-health) has been studied extensively, the literature on virtual team meetings is lacking. The authors of this study evaluated the team functioning of one craniofacial team by studying their virtual team meetings. Methods/Description: Ten virtual team meetings, including 94 patient case discussions, from a 3-month period in late 2020 were recorded and scored individually by three members of the research team using modified versions of the standardized multidisciplinary team Meeting Observational Tool (MOT) and the Metric of Decision-Making (MODe). The mean score amongst the three observers for each category of team functioning was used for analysis. Participants' subjective assessments of team meetings were elicited through monthly Qualtrics surveys. Results: Our results indicate that team functioning during virtual team meetings was high for providing case history, exhibiting optimal team behavior, and providing a treatment plan for individual case discussions. Patient-centered and psychosocial categories received lower scores. Survey respondents generally regarded their team as highly functioning during team meetings, with lower marks given only for decision-making efficiency and full participation from all disciplines. The meeting technology and equipment received a high score on average. Additionally, participants indicated that the virtual format did not enhance or hinder team functioning during team meetings. Conclusions: Amidst the ongoing COVID-19 pandemic it is important to study the effectiveness of multidisciplinary team meetings held in a virtual format. Our findings suggest that virtual setting allows for high team functioning as measured by both objective and subjective assessments and should therefore be considered a viable alternative to in-person meetings. The team performed best in discussing clinical topics, generating treatment plans, and team behavior, including equality among disciplines. Psychosocial matters and patient perspectives were not discussed as extensively as clinical topics and the team overestimated their coverage of both psychosocial matters and patient perspectives, consistent with previous studies on team functioning.

In people with type 2 diabetes most risk factors for covid-19 mortality are shared with pneumonia, however ethnicity related risk is very different

Aims: Previous UK population research identified multiple risk factors for increased covid-19 mortality in people with type 2 diabetes but it is unclear if these are general to respiratory infections or specific to covid-19. We aimed to compare risk factors associated with death from covid-19 (pre-vaccination roll-out) and pneumonia. Methods: In UK routine primary care data (CPRD), we followed adults with type 2 diabetes from 01/09/2019-31/ 01/2020 (pneumonia mortality cohort n = 609,079) and 01/02/2020-31/ 10/2020 (covid-19 mortality cohort n = 587,933). Multivariable Cox proportional hazards models were used to identify risk factors in each cohort. Results: We observed 2,690 deaths (0.5%) due to covid- 19, and 1,612 deaths due to pneumonia (0.3%). For covid- 19 mortality, we replicated previously reported risk factor associations for male sex, older age, higher deprivation, higher BMI, renal impairment, previous stroke and cardiovascular disease. These features were also associated with higher pneumonia mortality. A differential effect was observed for ethnicity: compared to people of white ethnicity, black and south Asian groups had higher covid-19 mortality (adjusted hazard ratio [aHR] 2.07 [95%CI 1.81-2.38], p < 0.001, and 1.50 [1.33-1.70], p < 0.001 respectively), but lower pneumonia mortality (aHR 0.43 [95%CI 0.31-0.60], p < 0.001, and 0.54 [0.43-0.68], p < 0.001 respectively). Higher HbA1c was a stronger risk factor for covid-19 mortality than pneumonia mortality (aHRs [95%CI] HbA1c >86 vs 48-53 mmol: 1.30 [1.09-1.54], p = 0.004 for covid- 19, 1.10 [0.86-1.42], p = 0.442 for pneumonia). Conclusions: In type 2 diabetes, clinical risk factors for covid-19 and pneumonia mortality are largely similar, but non-white ethnicities have disproportionately higher risk of covid-19 mortality compared to lower risk of pneumonia mortality, which needs further exploration.

SARS-CoV-2-associated ‘covid toes:’ multiplex immunofluorescent characterization of pathophysiology

Coincident with the start of the COVID-19 pandemic, dermatologists worldwide have reported an uncharacteristic increase in pernio or chilblains (aka ‘COVID toes’). However, the lack of systemic illness, low PCR positivity and lack of consistent seroconversion have led some authors to postulate an epiphenomenon. SARS-CoV-2 spike protein has been identified in a limited number of skin biopsies in few publications, yet there remain conflicting reports regarding other SARS-CoV-2 associated proteins, the presence or absence of viral RNA, and a unifying pathophysiology. In cooperation with the COVID Human Genome Effort, our “COVID toes” biobank was established to identify both the genetic and immunologic basis and provide clinically relevant insights into targeted therapeutics. As of March 2021, we have enrolled 96 patients, creating a prospective biorepository with clinical data, saliva, serial blood collection, and skin biopsies. Here we aim to comprehensively investigate the conflicting findings, detail the inflammatory response, and identify the source of interferon signaling with multiplex immunofluorescence (IFA) and the RNAscope fluorescent assay to detect viral mRNA. Median patient age was 17 (range 2 – 72) and 44/96 (46%) were male. Preliminary IFA results demonstrate detection of SARS-CoV-2 components, robust MxA detection and plasmacytoid dendritic cell (pDC) colocalization, identifying PDCs as the likely primary source of IFN-I production and implicates an excessive localized IFN-I response in affected patients.