A clinicopathological description of COVID-19-induced chilblains (COVID-toes) correlated with a published literature review.

BACKGROUND: The abundance of publications of COVID-19-induced chilblains has resulted in a confusing situation. METHODS: This is a prospective single-institution study from 15 March to 13 May 2020. Thirty-two patients received PCR nasopharyngeal swabs. Of these, 28 patients had a thoracic CT-scan, 31 patients had blood and urine examinations, 24 patients had skin biopsies including immunohistochemical and direct immunofluorescence studies, and four patients had electron microscopy. RESULTS: COVID-19-induced chilblains are clinically and histopathologically identical to chilblains from other causes. Although intravascular thrombi are sometimes observed, no patient had a systemic coagulopathy or severe clinical course. The exhaustive clinical, radiological, and laboratory work-up in this study ruled-out other primary and secondary causes. Electron microscopy revealed rare, probable viral particles whose core and spikes measured from 120 to 133 nm within endothelium and eccrine glands in two cases. CONCLUSION: This study provides further clinicopathologic evidence of COVID-19-related chilblains. Negative PCR and antibody tests do not rule-out infection. Chilblains represent a good prognosis, occurring later in the disease course. No systemic coagulopathy was identified in any patient. Patients presenting with acral lesions should be isolated, and chilblains should be distinguished from thrombotic lesions (livedo racemosa, retiform purpura, or ischemic acral necrosis).

Understanding the role that 'COVID toe' has in recognizing the potential extent of COVID-19 infections: a case study.

Dermatological manifestations have shown to be associated with COVID-19 infections. The numbers of papers have quadrupled within May 2020 alone. One particular cutaneous manifestation named pseudo chilblains (COVID toe), expressed mostly in otherwise asymptomatic younger patients, has had particular media attention. Public health bodies, on the other hand, have been slow to recognize it as a symptom. This article will be discussing two case studies to demonstrate the lack of public knowledge and of public health guidance associated with this symptom. We will further explore the use of COVID toe in the epidemiology of COVID-19 and its utility as a sign for total cases and contact tracing.

Cytomegalovirus (CMV)-related cutaneous necrotizing vasculitis: case report and literature review

Cytomegalovirus (CMV) infection is usually asymptomatic in immunocompetent patients. A mononucleosis-like syndrome may develop in some patients. Various organ involvements (eg: encephalitis, meningitis, retinitis, myocarditis, pneumonia, hepatitis, enterocolitis, neuritis), which rarely occur in immunocompetent patients, have also been reported. Cutaneous necrotizing vasculitis caused by CMV infection has been reported very rarely in the literature. Here, a case with a very rare clinical form of CMV infection, presenting with persistent fever and livedo reticularis on the extremities and cutaneous necrotizing vasculitis of the toes, is described, and the relevant literature is reviewed. This case report aims to highlight the possibility of CMV infection to be a cause of cutaneous necrotizing vasculitis.

Cytomegalovirus (CMV)-related cutaneous necrotizing vasculitis: case report and literature review.

Cytomegalovirus (CMV) infection is usually asymptomatic in immunocompetent patients. A mononucleosis-like syndrome may develop in some patients. Various organ involvements (e.g.: encephalitis, meningitis, retinitis, myocarditis, pneumonia, hepatitis, enterocolitis, neuritis), which rarely occur in immunocompetent patients, have also been reported. Cutaneous necrotizing vasculitis caused by CMV infection has been reported very rarely in the literature. Here, a case with a very rare clinical form of CMV infection, presenting with persistent fever and livedo reticularis on the extremities and cutaneous necrotizing vasculitis of the toes, is described, and the relevant literature is reviewed. This case report aims to highlight the possibility of CMV infection to be a cause of cutaneous necrotizing vasculitis.

Association of human papillomavirus 7 with warts in toe webs.

BACKGROUND: There have been no studies on the prevalence of types of human papillomavirus (HPV) in cutaneous warts that focus on warts in toe webs (WTW). There is no documented association between HPV 7 and WTW. OBJECTIVES: To explore the clinical and histopathological features of WTW, and the distribution of HPV genotypes in patients with WTW. METHODS: The study group consisted of 20 patients with WTW; 31 patients with typical verruca vulgaris (VV) were enrolled as the disease control group, and 53 patients with tinea pedis and 48 healthy volunteers were enrolled as the disease-negative control group. Tissue specimens were analysed for clinical and histological features and distribution of HPV genotypes. Polymerase chain reaction (PCR)-based direct sequencing, TA cloning and type-specific PCR (TS-PCR) were performed in the WTW and VV groups. Interdigital scale specimens from patients with tinea pedis and from healthy volunteers were analysed for HPV DNA by nested PCR and TS-PCR (HPV 7). RESULTS: All the patients with WTW were male and nearly all were immunocompetent; their mean age was 41 +/- 10 years. The lesions presented mainly as soft, friable and vegetating clusters. HPV 7 was the predominant genotype in WTW with a frequency of 80% (16/20). Fourteen specimens were taken for histopathological examination. The most frequent histological results (seven out of 14) revealed characteristics of HPV 7 infections such as heavily stained cells containing medium-sized keratohyaline granules and a pronounced hyperkeratosis with parakeratosis. TA cloning showed that the sequence shared 90% or more homology with the HPV genotype in direct sequencing. No HPV 7 DNA was found in the scales taken from toe webs without warts. CONCLUSIONS: This is the first study evaluating the prevalence of HPV types in WTW and the first report of the association between HPV 7 and specific subgroups of patients with warts.

Indolent herpetic whitlow of the toe in an elderly patient with diabetic neuropathy.

We report a case of indolent herpetic whitlow of the toe occurring in an elderly male patient with poorly controlled diabetes mellitus. In this case, the mechanism of transmission was not clear, although he was in a habit of taking a hot spring bath. This patient's symptoms were unusual for herpes simplex; he had no pain in the presence of diabetic neuropathy. The standard therapeutic dose of acyclovir was not effective in suppressing the lesions, and a higher dose was required to induce complete healing.