SEPTAL PANNICULITIS AS A MANIFESTATION of COVID-19 INFECTION

ABSTRACT

Objectives: to study the clinical and laboratory features of septal panniculitis in the form of erythema nodosum (EN) in a cohort of patients with COVID-19 referred to a rheumatological center. Methods: In 2020-2021 we examined 21 patients (18 women and 3 men, average age 43.2±11.4 years) with EN and polyarthralgia/arthritis. Depending on the time of EN and articular syndrome associated with COVID-19 development, patients were divided into three groups 1) up to 4 weeks-acute COVID (symptoms potentially associated with infection);2) from 4 to 12 weeks-ongoing symptomatic COVID and 3) more than 12 weeks-post-COVID syndrome (persistent symptoms not associated with an alternative diagnosis). All patients underwent a comprehensive clinical, laboratory and instrumental examination, including ultrasound of the joints and chest computed tomography (CT), as well as pathomorphological examination of skin and subcutaneous adipose tissue from the node area (in 9 cases). Results: Based on the history data, COVID-19 in the study cohort had mild (in 3 patients), moderate (12) and severe (6) severity. Two patients (21 and 23 years old) with a mild severity of the disease on the 2nd-3rd day of the development of the respiratory symptom for the frst time noted red painful (45 mm on a visual analogue scale) nodes on the legs and polyarthralgia. In 9 patients (52.3%), similar skin changes were detected 24.5 ± 7. 6 days after stopping active COVID-19, i.e. during the period of ongoing symptomatic COVID. In 8 patients (38%), including 6 with moderate severity of the disease, nodules appeared after 85.6 ± 12.3 days, which corresponded to post-COVID syndrome. At the time of examination, 100 and 71.4% of patients complained of skin rashes and joint pain, respectively. Shortness of breath, weakness, cough, sweating and myalgia disturbed 67% of patients. An increase in body temperature to subfebrile was observed in 43% of cases, mainly with ongoing symptomatic COVID. In the overwhelming majority of cases (86%), UE was located on the anterior and lateral surfaces of the legs, less often on the posterior and medial surfaces. It is noteworthy that the lesion of more than 50% of the surface of the lower and upper extremities was associated with the number of nodes (p <0.02), CRP level (p <0.03) and post-COVID syndrome (p <0.2). Sixteen patients (76.1%) had signs of arthralgia, mainly ankle (81%) and knee (56%) joints. In a laboratory study, the median ESR was 39 [14;62] mm/h, the level of CRP was 17 [2;79] mg/l. The results of the polymerase chain reaction for SARS-CoV-2 were negative in 90.4 % of patients. In 90.4 % of cases, IgG antibodies were detected and in 52.3%-IgM to the SARS-CoV-2 virus. At CT of the chest, ≤25% of lung lesions were detected in 51% of patients, from 25 to 50%-in 33% and from 50% to 75%-in 9.5 % of cases. Pathomorphological examination of the nodes showed signs of septal panniculitis. Conclusion: When EN associated with SARS-CoV-2 appears it is important to timely suspect a post-infectious manifestation, based on the clinical picture of the disease and to determine the scope of further examination and adequate treatment.