ABSTRACT
A wide range of extrapulmonary manifestations in patients with COVID-19 has been reported during the ongoing pandemic, thus making the clinical spectrum of this new disease very heterogeneous. While COVID-19-associated vasculitis and vasculopathy have been described, cutaneous leukocytoclastic vasculitis (cLcV) due to SARS-CoV-2 has rarely been reported, and if it has, with relatively mild courses. We present the case of a 93-year-old man who, after having survived classic COVID-19 infection, developed a fulminant cLcV leading to extensive skin necrosis and tissue damage that resulted in his death. Considering the negative workup for other triggers of vasculitis, we find that cLcV is a secondary manifestation of COVID-19, even though SARS-CoV-2 polymerase chain reaction in the skin biopsy was not present in the tissue. We hypothesize this by providing a pathophysiologic rationale (eg, SARS-CoV-2-induced endotheliitis, complement activation, and interleukin 6 dominant intra- and perivascular inflammation).
Subject(s)
COVID-19 , Skin Diseases, Vascular , Vasculitis, Leukocytoclastic, Cutaneous , Vasculitis , Aged, 80 and over , COVID-19/complications , Humans , Interleukin-6/adverse effects , Male , Necrosis/pathology , SARS-CoV-2 , Skin/pathology , Skin Diseases, Vascular/pathology , Vasculitis/complications , Vasculitis, Leukocytoclastic, Cutaneous/etiologySubject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Eosinophils/immunology , Skin Diseases, Vascular/chemically induced , Vasculitis, Leukocytoclastic, Cutaneous/etiology , Adult , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/immunology , Dermoscopy/methods , Eosinophils/pathology , Female , Histamine Antagonists/therapeutic use , Humans , Purpura/diagnosis , Purpura/etiology , SARS-CoV-2/genetics , SARS-CoV-2/immunology , Skin Diseases, Vascular/pathology , Treatment Outcome , Vasculitis, Leukocytoclastic, Cutaneous/diagnosisABSTRACT
Retiform purpura has been described as a relatively frequent cutaneous finding in patients with coronavirus disease 2019 (COVID-19). The etiology is hypothesized to be related to thrombotic vasculopathy based on lesional biopsy specimen findings, but the pathogenesis of the vasculopathy is not completely understood. Here, we present a case of a retiform purpuric patch on the sacrum/buttocks in a hospitalized patient prior to subsequent diagnosis of COVID-19 and an eventual fatal disease course. Two lesional biopsy specimens at different time points in the disease course revealed thrombotic vasculopathy, despite therapeutic anticoagulation. Detailed histopathologic evaluation using immunohistochemical markers suggest the etiology of the vasculopathy involves both persistent complement activation and platelet aggregation, which possibly promote ongoing thrombus formation. This case highlights that sacral/buttock retiform purpuric patches may be a presenting sign of infection with SARS-CoV-2 virus and may represent an ominous sign supporting a future severe disease course. In addition, biopsy specimen findings at separate time points demonstrate that cutaneous vasculopathy may persist despite adequate systemic anticoagulation, possibly due to the combination of persistent complement and platelet activation. Finally, occlusive thrombi in sacral/buttock retiform purpuric patches may contribute to future ulceration and significant cutaneous morbidity in patients who survive COVID-19.