Dermatological Manifestations in COVID-19 and Post COVID-19 Patients: An Observational Study

Background: In December 2019, a new infection termed severe acute respiratory syndrome coronavirus 2 was recognised in Wuhan China. In literature only few studies exist on cutaneous manifestations in COVID-19 and post-COVID-19 phase. Hence the present study is conducted to know the most common cutaneous manifestations. Material(s) and Method(s): The present study included total of 60 patients presented with skin manifestations during COVID-19 and post COVID-19 phase of both in-patients and out-patients from October 2020 to June 2021. The patients aged more than 18yrs, tested positive for SARS CoV2 with dermatological manifestation during the infection and 3wks after testing negative for SARS CoV2 up to 3 months were included. The dermatological manifestations were recorded during the active COVID-19 infection and during post-COVID-19 period. Result(s): Among the 60 patients the common pattern was maculopapular rash in 24 patients (40%), urticaria seen in 8 patients (13.3%), chilblain seen in 4 patients (6.66%) and livedo reticularis seen in 2 patient (3.33%), during post COVID-19 were acneiform eruption seen in 16 patients (26.4%), vesicular lesions seen in 4 patients (6.66%) and lichen plan us observed in 2 patients (3.33%). Conclusion(s): There is significant association of presence of the dermatological manifestations among the patients with COVID-19 and post COVID-19 period. Study of these dermatological manifestations and their pathogenesis and their significance in human health is useful in avoiding misdiagnosis and proper treatment.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Cutaneous manifestations of COVID-19.

COVID - 19 can be accompanied by a variety of cutaneous abnormalities, which mainly include vascular lesions chilblain - like lesions, livedo reticularis, purpura, ecchymosis, acral cyanosis, gangrene, etcand inflammatory lesionsdiffuse erythema, morbilliform exanthem, acute urticaria, varicella- like exanthem, etc. Some types of skin lesions may be the first symptom or the only clinical manifestation of COVID-19.Copyright © 2022 Chinese Journal of Dermatology. All rights reserved.

Livedoid vasculopathy - A diagnostic and therapeutic challenge.

Livedoid vasculopathy is a rare, chronic-recurrent occlusive disorder in the microcirculation of dermal vessels. The clinical appearance is characterized by Livedo racemosa, painful ulceration, located in the distal parts of the lower extremities, followed by healing as porcelain-white, atrophic scars, the so-called Atrophie blanche. Different conditions that can promote a hypercoagulable state, such as inherited and acquired thrombophilias, autoimmune connective-tissue diseases and neoplasms, can be associated with livedoid vasculopathy. Therefore, livedoid vasculopathy is currently considered to be a coagulation disorder, clearly distinguished from inflammatory vasculitis. Although there are hints to hypercoaguability and secondary inflammation, pathophysiology is not completely understood. Diagnosis is made by synopsis of history, clinical and histopathological findings. Early and adequate therapy is essential to maintain life quality and avoid irreversible complications. Better understanding of molecular mechanisms is required to establish appropriate therapy regimens. This article presents the current state of knowledge about livedoid vasculopathy and proposes an algorithmic approach for diagnosis and therapy.

A comprehensive narrative review of the cutaneous manifestations associated with COVID-19.

The systemic and respiratory clinical manifestations of coronavirus disease 2019 (COVID-19) include fever, coughing, sneezing, sore throat, rhinitis, dyspnea, chest pain, malaise, fatigue, anorexia and headache. Moreover, cutaneous manifestations have been reported in 0.2% to 20.4% of cases. Early diagnosis of COVID-19 leads to a better prognosis; knowledge of its cutaneous manifestations is one way that may help fulfil this goal. In this review, PubMed and Medline were searched with the terms "dermatology", "skin" and "cutaneous", each in combination with "SARS-CoV-2" or "COVID-19". All articles, including original articles, case reports, case series and review articles published from the emergence of the disease to the time of submission, were included. In this comprehensive narrative review, we tried to provide an analysis of the cutaneous manifestations associated with COVID-19, including maculopapular rash, urticaria, Chilblain-like, vesicular lesions, livedo reticularis and petechiae in asymptomatic/symptomatic COVID-19 patients that might be the first complication of infection after respiratory symptoms. Immune dysregulation, cytokine storms, side effects of antiviral drugs, environmental conditions and high-dose intravenous immunoglobulin (IVIG) therapy might be involved in the pathogenesis of the cutaneous manifestations in COVID-19 patients. Therefore, knowledge of cutaneous COVID-19 manifestations might be vital in achieving a quick diagnosis in some COVID-19 patients, which would help control the pandemic. Further research is very much warranted to clarify this issue.

Cutaneous manifestations of COVID⁃19

COVID ⁃ 19 can be accompanied by a variety of cutaneous abnormalities, which mainly include vascular lesions （chilblain ⁃ like lesions, livedo reticularis, purpura, ecchymosis, acral cyanosis, gangrene, etc）and inflammatory lesions（diffuse erythema, morbilliform exanthem, acute urticaria, varicella⁃ like exanthem, etc）. Some types of skin lesions may be the first symptom or the only clinical manifestation of COVID⁃19. © 2022 Chinese Journal of Dermatology. All rights reserved.

Livedo reticularis following administration of ChAdOx1 nCoV-19 vaccine (AZD1222): a report of two cases.

The cutaneous appearance of transient or persistent livedo reticularis is characterized by violaceous, mottled, ring-shaped interconnecting lesions that form a reticular or net-like pattern. It can occur physiologically in response to cold exposure, such as in cutis marmorata, but can also be induced by pathological conditions such as vascular obliterans or venodilation. We report two cases of livedo reticularis that occurred on the lower limbs of two patients post ChAdOx1 nCoV-19 vaccination. As the patients had no other likely causes of livedo reticularis, the reticular skin lesions were suspected to occur in association with the ChAdOx1 nCoV-19 vaccination. Livedo reticularis is an uncommon adverse reaction, with few cases being reported post ChAdOx1 nCoV-19 vaccination.

COVID-19 manifestations in the skin

Skin changes are seen in up to 20% of patients with COVID-19 and vary widely in presentation. The most common include maculopapular eruptions, 'COVID toes', urticaria and most concerningly vaso- occlusive rashes, such as livedo reticularis and retiform purpura. Some of these skin signs are indicators of disease progression or severity.

Cutaneous Manifestations of Coronavirus Disease 2019: Skin Narratives and Dialogues

BACKGROUND: Although the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is primarily responsible for respiratory symptoms, an increasing number of cutaneous manifestations have been reported. Cutaneous manifestations are reported by patients following disease recovery. OBJECTIVE: We sought to document various skin lesions relating to COVID-19 symptoms either before, during, or after infection with severe acute respiratory syndrome coronavirus 2. METHODS: This was a descriptive study with 273 patients who had cutaneous manifestations after recovering from COVID-19. Each patient provided a thorough medical history and underwent a general physical examination. Following polymerase chain reaction analysis, all participants were confirmed to be COVID-19 patients. RESULTS: Acral lesions were the most common, accounting for 39% of all cases. An erythematous maculopapular rash was found in 21% of cases and was the second most common after urticaria, with fewer cases of erythema multiform, vesicular rash (9%), vascular livedo reticularis, figurate erythema, and flexural rash documented. CONCLUSION: The most common cutaneous changes seen in patients with COVID-19 were pseudo-chilblain acral lesions, which had a good prognosis. Vascular rashes within the spectrum of livedo/purpura/necrosis were seen with severe forms of COVID-19.

MYOCARDIAL INVOLVEMENT IN ANTI-PHOSPHOLIPID SYNDROME: A CASE OF AYOUNG BREASTFEEDING WOMAN

Introduction: In Antiphospholipid Syndrome (APS) myocardial tissue can be involved through immune-mediated or thrombotic mechanisms, giving chest pain and increase of myocardial cytolysis markers. This may occur without any signs of myocardial injury at the moment of echocardiography, coronarography and cardiac magnetic resonance (CMR). The aim is to increase the awareness about this life-threating condition.Case summary. We present the case of 26-year-old woman few days after childbirth, affected by APS in anticoagulant therapy with previous deep vein thrombosis and without any other cardiovascular risk factors. She was symptomatic for intermittent chest-epigastric pain, fever and skin livedo reticularis. Lab Tests: TnI 750 ng/L, C-reactive protein 9.6 mg/dL, D-dimer 1693 μg/L;anemia;Antithyroid Antibodies and ANA 1:160 (SSB/LA). Blood cultures and COVID test were negative.Results. Echocardiography showed normal left/right ventricular function, but minimal pericardial effusion was present. Pulmonary Angio-CT revealed small thromboembolic event, ground-glass lungs compatible with hemorrhagic alveolitis.After a few days, the patient presented increased epigastric pain, headache, vomiting up to presenting a comatose state. Thrombotic or hemorrhagic events with cerebral CT and MR were excluded. Total-body CT was negative, except for peri-splenic and recto-uterine pouches.For the increase of TnI up to 4741 ng/L, the patient underwent coronary angiography which demonstrated non-obstructive coronary arteries. The assembled Neuro-Cardio-Rheumatology team suspected a rapidly developing Catastrophic APS which was developing quickly with multi-organ and life-threatening involvement.The patient underwent 4 cycles of plasmapheresis, intravenous human IgG and corticosteroids, with rapid clinical improvement. CMR subsequently demonstrated a small transmural late enhancement area on lateral left ventricle wall.The patient was discharged from the hospital on Day 6 post- therapies.Conclusions. APS may involve more organs, including myocardial tissue with different mechanisms of damage and high mortality rate. The presented case poses a multidisciplinary challenge, because thrombotic multiorgan microangiopathy may be not always diagnosed. Imaging methods such as CMR could be optimized with adenosine stress-CMR. Clinical attention is required among women with APS, to reach early diagnosis of myocardial thrombotic microangiopathy and to establish the best effective treatment.

Peripheral vascular lesions with the development of hand and foot skin necrosis in a patient with COVID-19: a case report

In the presented case report, 36-year-old female patient, who was hospi talized in the rheumatology department, developed thrombotic microangiopathy and sepsis-related coronavirus disease 2019 (COVID-19). In the department, hereditary thrombophilia was revealed: heterozygous polymorphism in the coagulation factor 5 gene (Factor V Leiden). Livedo reticularis. It is known that in October 2020, the patient had COVID-19 with bilateral pneumonitis on chest computed tomography. On examination, dry gangrene of 1, 2, 4, 5 fingers of the right hand, 2 finger of the left hand, as well as 2, 3, 4, 5 fingers of the right and left feet were diagnosed. Necrosis of the nasal tip. Surgery was performed with amputation of the affected fingers and distal feet with autodermoplasty.

Transient breast livedo reticularis-like exanthem in an adolescent with COVID-19.

Livedo reticularis-like eruptions have been described in different viral infections. In patients with COVID-19, livedo reticularis-like rashes are usually mild, typically present in a symmetric distribution and mostly involve the lower limbs. A case of livedo reticularis located exclusively on the breasts of a girl with mild systemic symptoms of COVID-19 is presented. Coagulation studies were normal and findings disappeared within 1 week.

Dermatological Manifestations in Patients with COVID-19 Pneumonia in Veracruz, Mexico

Background. A large number of viral infections are characterized by the presence of cutaneous manifestations. Multiple dermatological manifestations have been observed in patients with COVID-19. Dermatological lesions in patients infected by SARS-CoV-2 such as livedo reticularis, rash and vascular lesions may represent manifestations of secondary phenomena such as paraviral rashes or by participation of the innate or adaptive immune system that cause vasodilation, vascular leakage or procoagulant effects Methods. Descriptive and observational study, adult patients with COVID-19 pneumonia were selected, confirmed by RT-PCR and chest CT. General symptoms, hematic cytometry results, pneumonia severity, prognosis as well as dermatological manifestations are characterized. Results. 100 patients were entered into the study, with an average age of 49.4 years, 54% male. The general symptoms with the highest incidence were: fever, cough and dyspnea characteristic of SARS-CoV-2 infection, followed by chest pain, headache, anosmia and dysgeusia. The main alteration of the hemogram was lymphopenia, no leukopenia or plaquetopenia was demonstrated. 54% of those affected had mild pneumonia, the rest severe pneumonia. 75% progressed towards improvement and 25% died. Among the dermatological manifestations identified, all occurred in cases with severe pneumonia, the one with the highest incidence was the morbilliform viral exanthema in 18%, the presence of diffuse partial alopecia in 7% as well as manifestations of lividity and maceration in 1%. Regarding alopecia, in 6% it was reversible androgenetic alopecia, having manifested during the acute stage of pneumonia (all men), in 1% it presented alopecia areata (male) that has been persistent beyond the acute phase and in frank recovery Demographic and clinical variables Conclusion. The incidence of dermatological manifestations is low in this study population, the most frequent being the morbilliform viral exanthema expected in a virus, however they present manifestations of low incidence such as reversible androgenetic alopecia associated with severity of the disease, a finding that has been documented recently as a manifestation associated with COVID-19.

Cutaneous manifestations of COVID-19 in Mexican patients: A case series and review of literature.

China officially recognized atypical pneumonia outbreak in December 2019; on 11 March 2020, the World Health Organization declared COVID-19 as a pandemic that is produced by a new coronavirus, named SARS-CoV-2, of rapid transmissibility, which can be asymptomatic, with mild to severe respiratory symptoms, and with cardiovascular, neurological, gastrointestinal, and cutaneous complications. Considering that the pandemic prolonged more than initially expected was prognostic, it is essential for the medical community to identify the signs and symptoms of COVID-19. Thus, this work's objectives were to present cases of cutaneous lesions observed in COVID-19 Mexican patients. We register cutaneous lesions in COVID-19 patients referred from internal medicine and otorhinolaryngology services to dermatology. We presented four interesting cases with cutaneous lesions, including exanthema morbilliform, urticaria, chilblains, ecchymosis, and facial edema, and review the available literature. The most frequent cutaneous markers are rash, chilblains, and urticaria. Skin lesions may be the first manifestation of COVID-19, accompany initial respiratory symptoms, or appear during the disease course. Symptoms associated with vascular changes (livedo reticularis and vasculitis) are considered of poor prognosis.

Livedo reticularis as a late sign of COVID-19 temporally related multisystem inflammatory syndrome (MIS-C): A case series

Introduction: In children, the dermatologic features appear to occur early with other COVID-19 manifestations. Dermatologists play a key role in the early diagnosis of COVID-19. Multi-system inflammatory syndrome in children (MIS-C) shows a presentation mimicking Kawasaki Disease (KD), with mucocutaneous signs. However, late onset dermatological signs are poorly described. Objectives: to evaluate children with MIS-C during the follow-up and to describe late dermatological signs in these patients. Methods: We followed 14 children (3M;11 F) with MIS-C, with clinical, biochemical, imaging data. Autoantibodies, D-Dimer, CRP, ESR, C3, C4, ferritin, serum amyloid, IgA, IgM, IgG were detected 1-2 months after the resolution of the clinical manifestations of MIS-C. Results: 8/14 children (58%) showed livedo reticularis at the legs, arms, trunk. The livedo was more evident at the legs in all the patients. The livedo started at the remission, after normalization of CRP, ESR, D-Dimer;the sign lasted also for 1-2 months after the discontinuation of steroids and the normalization of haematochemical parameters. 4/8 showed low-title positive autoimmune tests (ANA in 2;ENA anti-Sm in 2;anti-cardiolipin IgG in 1;ASCA in 2). Conclusion: In our series, 8/14 patients showed a livedo reticularis, more marked in the legs, however in some cases with a wide distribution to arms and the trunk. Low-title autoantibodies were transiently positive in 50% of these cases, negative in later detections. Livedo reticularis was a late sign, linked to MIS-C related vasculitis, persisting 1-2 months after the resolution of MIS-C. A different treatment regimen (IVIG plus steroids at 1-2 or 30 mg/Kg/day) did not influence the progress of this clinical manifestation. In 50% of children we documented a transient autoimmune response.

COVID-19 Skin Manifestations in Skin of Colour.

Coronavirus disease (COVID-19) skin manifestations have been increasingly reported in medical literature. Recent discussions have identified a lack of images of skin of color (SOC) patients with COVID-19 related skin findings despite people with skin of color being disproportionately affected with the disease. There have been calls to prioritize the identification of COVID-19 skin manifestations in patients with SOC and disseminate these findings. The objective of this article is to review the existing literature on COVID-19 skin manifestations and, where possible, discuss how they may present differently in patients with SOC. Further research is needed to allow primary care physicians and dermatologists to be aware of and easily identify patients with cutaneous findings that may be secondary to COVID-19. Patients presenting with idiopathic dermatologic manifestations should be considered for COVID-19 testing and follow public health guidelines for self-isolation.

A retrospective study on the prevalence of anti-phospholipid antibodies, thrombotic events and cutaneous signs of vasculopathy in 173 hospitalized COVID-19 patients.

BACKGROUND: Hypercoagulability is a risk factor of thromboembolic events in COVID-19. Anti-phospholipid (aPL) antibodies have been hypothesized to be involved. Typical COVID-19 dermatological manifestations of livedo reticularis and digital ischemia may resemble cutaneous manifestations of anti-phospholipid syndrome (APS). OBJECTIVES: To investigate the association between aPL antibodies and thromboembolic events, COVID-19 severity, mortality, and cutaneous manifestations in patients with COVID-19. METHODS: aPL antibodies [anti-beta2-glycoprotein-1 (B2GP1) and anti-cardiolipin (aCL) antibodies] were titered in frozen serum samples from hospitalized COVID-19 patients and the patients' clinical records were retrospectively analyzed. RESULTS: 173 patients were enrolled. aPL antibodies were detected in 34.7% of patients, anti-B2GP1 antibodies in 30.1%, and aCL antibodies in 10.4%. Double positivity was observed in 5.2% of patients. Thromboembolic events occurred in 9.8% of patients, including 11 pulmonary embolisms, 1 case of celiac tripod thrombosis, and six arterial ischemic events affecting the cerebral, celiac, splenic, or femoral-popliteal arteries or the aorta. aPL antibodies were found in 52.9% of patients with vascular events, but thromboembolic events were not correlated to aPL antibodies (adjusted OR = 1.69, p = 0.502). Ten patients (5.8%) had cutaneous signs of vasculopathy: nine livedo reticularis and one acrocyanosis. No significant association was observed between the presence of cutaneous vasculopathy and aPL antibodies (p = 0.692). CONCLUSIONS: Anti-phospholipid antibodies cannot be considered responsible for hypercoagulability and thrombotic events in COVID-19 patients. In COVID-19 patients, livedo reticularis and acrocyanosis do not appear to be cutaneous manifestations of APS.

Cutaneous manifestations of coronavirus disease 2019 in 458 confirmed cases: A systematic review.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has affected the whole world for a short span of time. As it is a novel virus, its manifestations have been slowly revealed. Cutaneous manifestations of COVID-19 have gradually been reported from different regions of the world. However, their significance in diagnosis, as well as predicting prognosis, remains to be established. OBJECTIVE: This review describes the cutaneous manifestations of COVID-19 patients from diverse regions with the aim of highlighting any important associations. METHODS: A literature search was conducted using "PubMed" for original articles, case series, and case reports using the search terms "cutaneous manifestations" and "skin manifestations" in combination with "COVID-19" published up to 31 May. RESULTS: Nine original research articles and 35 case series or case reports were identified, including 458 confirmed COVID-19 cases. The ratio of male to female patients was 0.94, and the patients' age ranged from 2 months to 84 years. In 10% of cases, skin lesions appeared before systemic manifestations. The most common cutaneous manifestation was macular/maculo-papular rash (42.5%), followed by acute urticaria (17.9%), vesicular rash (15.3%), pseudo-chilblain or acral purpuric lesions (15.1), and livedo-reticularis (4.4%). The majority of reported cases were located in Spain, Italy, and France. These manifestations do not seem to be sex-, age-, or country-specific. CONCLUSION: It is necessary to conduct worldwide registries and prospective studies to assess the true incidence of cutaneous manifestations of COVID-19 and to streamline their categorization based on their pathogenesis. There appears to be no specific manifestation at present, but a high index of suspicion can help in the diagnosis of patients presenting with cutaneous lesions as the first manifestation.

Investigating the spectrum of dermatologic manifestations in COVID-19 infection in severely ill patients: A series of four cases.

COVID-19, an infectious disease caused by the novel coronavirus, was initially identified in Wuhan, China, in December 2019. By March 2020, it was declared a pandemic by the World Health Organization. Although most findings have been reported in the lungs, primarily due to catastrophic respiratory decline, other organs, including the skin, are affected. Recent reports have been published describing the clinical spectrum of COVID-19-related lesions. In addition, recent case series have described a subset of these lesions having underlying thrombotic microangiopathy with increased complement activation characterized by increased C4d deposition within the blood vessel walls. Herein, we describe a series of COVID-19-related cutaneous manifestations found at autopsy examination and their underlying histopathologic findings. Although the clinical manifestations seen in these lesions vary widely, the underlying etiology of thrombotic microangiopathy remains consistent and reproducible.