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Brahimi N, Croitoru D, Saidoune F, Zabihi H, Gilliet M, Piguet V. From Viral Infection to Skin Affliction: Unveiling Mechanisms of Cutaneous Manifestations in COVID-19 and Post-COVID Conditions. J Invest Dermatol 2025; 145:257-265. [PMID: 39665720 DOI: 10.1016/j.jid.2024.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 12/13/2024]
Abstract
COVID-19 skin manifestations are multifaceted, ranging from urticaria, morbilliform or papulovesicular rash, livedoid purpuric lesions, and to pseudochilblains (also called COVID toes). Recent insights into the mechanism of these manifestations have highlighted that morbilliform, papulovesicular, and livedoid/purpuric rashes are related to virus-induced endothelial cell damage and linked to moderate-to-severe disease, whereas pseudochilblains are related to an exaggerated IFN-1 production by plasmacytoid dendritic cells in protected individuals. In this paper, we will review the clinical and physiopathological features of cutaneous COVID-19 manifestations in relation to the direct viral cytopathic effects and dysregulated IFN-1 responses. We will also review the emerging insights into post-COVID conditions (also termed long COVID) and how they may be implicated in the persistence of COVID-19-associated skin diseases.
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Affiliation(s)
- Nesrine Brahimi
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada; Division of Dermatology, Women's College Hospital, Toronto, Canada
| | - David Croitoru
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada; Division of Dermatology, Women's College Hospital, Toronto, Canada
| | - Fanny Saidoune
- Department of Dermatology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Haleh Zabihi
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Michel Gilliet
- Department of Dermatology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
| | - Vincent Piguet
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Canada; Division of Dermatology, Women's College Hospital, Toronto, Canada.
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de Aguiar BRL, Ferreira EB, De Luca Canto G, Guerra ENS, Dos Reis PED. Prevalence of skin manifestations in patients with COVID-19: a systematic review and meta-analysis. Front Med (Lausanne) 2024; 11:1390775. [PMID: 39234048 PMCID: PMC11371801 DOI: 10.3389/fmed.2024.1390775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 08/07/2024] [Indexed: 09/06/2024] Open
Abstract
Background COVID-19 presents extrapulmonary manifestations that can aid in the diagnosis. Skin manifestations have been reported but their characteristics are not yet clear. Health professionals need information about its prevalence and main characteristics. Methods This systematic review followed the PRISMA criteria. The protocol was registered in the PROSPERO (number CRD42020193173). Seven electronic databases and the gray literature were searched independently by two researchers. Observational analytical studies that presented data on the prevalence of skin manifestations in patients aged 19 or older with COVID-19 were included. Prevalence estimates were synthesized through a meta-analysis using random-effects models. Association meta-analysis and comparisons were performed for individual characteristics. Results We included 31 studies with 10,934 patients, of which 10,121 tested positive for COVID-19. The general prevalence of skin manifestations was 29% (95% CI: 17.0-43.0; I2: 99%), the most in Africa, with a mean duration between 7 and 9 days and the most frequently affecting feet+hands (75%) and the trunk (71%). Patients with mild/moderate COVID-19 had more of chilblain-like+pernio-like lesions (97%) and inflammatory lesions (86%) than patients with severe or critical COVID-19. Manifestations of vascular origin were only in elderly patients and were significant with the severity of COVID-19 (p = 0). Conclusion The global prevalence of skin manifestations is similar to other signs and symptoms of COVID-19. Skin assessment should be considered when investigating and diagnosing COVID-19 in adult and elderly patients.Systematic review registration: PROSPERO, identifier CRD42020193173, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020193173.
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Affiliation(s)
- Beatriz Regina Lima de Aguiar
- Health Science Graduate Program, School of Health Sciences, University of Brasilia, Brasília, Brazil
- Interdisciplinary Laboratory of Research Applied to Clinical Practice in Oncology, School of Health Sciences, University of Brasilia, Brasília, Brazil
| | - Elaine Barros Ferreira
- Interdisciplinary Laboratory of Research Applied to Clinical Practice in Oncology, School of Health Sciences, University of Brasilia, Brasília, Brazil
| | - Graziela De Luca Canto
- Department of Dentistry, Brazilian Centre for Evidence-Based Research, Federal University of Santa Catarina, Florianopolis, Brazil
| | - Eliete Neves Silva Guerra
- Health Science Graduate Program, School of Health Sciences, University of Brasilia, Brasília, Brazil
- Interdisciplinary Laboratory of Research Applied to Clinical Practice in Oncology, School of Health Sciences, University of Brasilia, Brasília, Brazil
- Laboratory of Oral Histopathology, School of Health Sciences, University of Brasilia, Brasília, Brazil
| | - Paula Elaine Diniz Dos Reis
- Health Science Graduate Program, School of Health Sciences, University of Brasilia, Brasília, Brazil
- Interdisciplinary Laboratory of Research Applied to Clinical Practice in Oncology, School of Health Sciences, University of Brasilia, Brasília, Brazil
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Pouxe M, Abdulkarim A, de Vallière S, Seremet T, Favrat B, Kokkinakis I. Diagnosis and management of COVID toes in outpatients: a case report. J Med Case Rep 2024; 18:307. [PMID: 38937799 PMCID: PMC11212274 DOI: 10.1186/s13256-024-04626-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 06/07/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Since the beginning of the coronavirus disease 2019 pandemic, the most common skin lesions observed due to infection with the severe acute respiratory syndrome coronavirus 2 are pseudochilblains (or coronavirus disease toes). However, this pathology remains infrequent and difficult to diagnose, as no specific test exists. CASE PRESENTATION Two Caucasian women, 30 and 22 years old, presented to our General Medicine Unit with perniosis lesions on the feet during the first two waves of the coronavirus disease 2019 pandemic. They did not have respiratory or general symptoms of severe acute respiratory syndrome coronavirus 2 infection, the reverse transcription polymerase chain reaction on nasopharyngeal swabs was negative, and the serology was positive only in the first case. The clinical presentation differed for the two cases, as the second patient suffered from swelling and burning after cold application. The diagnosis was based on clinical presentation, temporality, exclusion of other differential diagnoses, and blood test results (positive serology in the first case and high level of CXCL13 and VEGF in the second), supported by current literature. Lesions resolved spontaneously in the first patient. The second case was hospitalized for pain management and received corticosteroid therapy with resolution of the symptoms. CONCLUSION These two cases with different clinical presentations illustrate the diagnostic approach to coronavirus disease 2019, a challenging disease with diverse manifestations, including, in some cases, coronavirus disease toes. We present a literature review that illustrates the progression of scientific research. Skin lesions associated with coronavirus disease 2019 infection could be the expression of an important interferon type 1 response and should be considered in the differential diagnosis in a primary care setting.
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Affiliation(s)
- Marie Pouxe
- University Center for Primary Care and Public Health, Unisanté, Lausanne, Switzerland
| | - Aziz Abdulkarim
- University Center for Primary Care and Public Health, Unisanté, Lausanne, Switzerland
| | - Serge de Vallière
- University Center for Primary Care and Public Health, Unisanté, Lausanne, Switzerland
- Service of Infectious Diseases, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Teofila Seremet
- Service of Dermatology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Bernard Favrat
- University Center for Primary Care and Public Health, Unisanté, Lausanne, Switzerland
| | - Ioannis Kokkinakis
- University Center for Primary Care and Public Health, Unisanté, Lausanne, Switzerland.
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Kocatürk E, Abrams EM, Maurer M, Mitri J, Oppenheimer J, Vestergaard C, Zein J. COVID-19 and Its Impact on Common Diseases in the Allergy Clinics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3289-3303. [PMID: 37660731 DOI: 10.1016/j.jaip.2023.08.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 09/05/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is a highly contagious viral disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has various effects on asthma, allergic rhinitis, atopic dermatitis, and urticaria and may change the course of the disease depending on the severity of the infection and control status of the disease. Conversely, these diseases may also impact the course of COVID-19. Patients with chronic urticaria and atopic dermatitis may have COVID-19-induced disease exacerbations and biological treatments reduce the risk of exacerbations. Poor asthma control is linked to severe COVID-19 while allergic asthma is associated with lower risk of death and a lower rate of hospitalization due to COVID-19 compared with nonallergic asthma. The use of intranasal corticosteroids is associated with lower rates of hospitalization due to COVID-19 in patients with allergic rhinitis, whereas the effect of inhaled corticosteroids is confounded by asthma severity. These observations reinforce the importance of keeping allergic diseases under control during pandemics. The use of biologicals during COVID-19 is generally regarded as safe, but more evidence is needed. The pandemic substantially changed the management of allergic disorders such as home implementation of various biologicals, allergen immunotherapy, food introduction, and increased use of telemedicine and even home management of anaphylaxis to reduce emergency department burden and reduce risk of infection. Physicians need to be aware of the potential impact of COVID-19 on allergic diseases and educate their patients on the importance of continuing prescribed medications and adhering to their treatment plans to maintain optimal control of their disease.
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Affiliation(s)
- Emek Kocatürk
- Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey; Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Marcus Maurer
- Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.
| | - Jad Mitri
- Department of Medicine, Saint Elizabeth Medical Center, Boston, Mass
| | - John Oppenheimer
- UMDNJ-Rutgers Department of Medicine, Division of Allergy and Immunology, Newark, NJ
| | | | - Joe Zein
- The Respiratory Institute, The Cleveland Clinic, Cleveland, Ohio
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Kocatürk E, Muñoz M, Elieh-Ali-Komi D, Criado PR, Peter J, Kolkhir P, Can P, Wedi B, Rudenko M, Gotua M, Ensina LF, Grattan C, Maurer M. How Infection and Vaccination Are Linked to Acute and Chronic Urticaria: A Special Focus on COVID-19. Viruses 2023; 15:1585. [PMID: 37515272 PMCID: PMC10386070 DOI: 10.3390/v15071585] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Since more than a century ago, there has been awareness of the connection between viral infections and the onset and exacerbation of urticaria. Our knowledge about the role of viral infection and vaccination in acute and chronic urticaria improved as a result of the COVID-19 pandemic but it has also highlighted knowledge gaps. Viral infections, especially respiratory tract infections like COVID-19, can trigger the onset of acute urticaria (AU) and the exacerbation of chronic urticaria (CU). Less frequently, vaccination against viruses including SARS-CoV-2 can also lead to new onset urticaria as well as worsening of CU in minority. Here, with a particular focus on COVID-19, we review what is known about the role of viral infections and vaccinations as triggers and causes of acute and chronic urticaria. We also discuss possible mechanistic pathways and outline the unmet needs in our knowledge. Although the underlying mechanisms are not clearly understood, it is believed that viral signals, medications, and stress can activate skin mast cells (MCs). Further studies are needed to fully understand the relevance of viral infections and vaccinations in acute and chronic urticaria and to better clarify causal pathways.
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Affiliation(s)
- Emek Kocatürk
- Institute of Allergology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, 12203 Berlin, Germany (D.E.-A.-K.)
- Department of Dermatology, Koç University School of Medicine, Istanbul 34010, Turkey
| | - Melba Muñoz
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, 12203 Berlin, Germany (D.E.-A.-K.)
- Department of Dermatology, Koç University School of Medicine, Istanbul 34010, Turkey
| | - Daniel Elieh-Ali-Komi
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, 12203 Berlin, Germany (D.E.-A.-K.)
- Department of Dermatology, Koç University School of Medicine, Istanbul 34010, Turkey
| | - Paulo Ricardo Criado
- Department of Dermatology, School of Medicine, Centro Universitário Faculdade de Medicina do ABC (CUFMABC), Santo André 09060-870, Brazil
| | - Jonny Peter
- Lung Institute, Division of Allergy and Clinical Immunology, Groote Schuur Hospital, University of Cape Town, Cape Town 7925, South Africa
| | - Pavel Kolkhir
- Institute of Allergology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, 12203 Berlin, Germany (D.E.-A.-K.)
| | - Pelin Can
- Department of Dermatology, Bahçeşehir University, Istanbul 34070, Turkey;
| | - Bettina Wedi
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Hannover Medical School, 30625 Hannover, Germany
| | | | - Maia Gotua
- Center of Allergy and Immunology, David Tvildiani Medical University, Tbilisi 0159, Georgia
| | - Luis Felipe Ensina
- Division of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo 01308-000, Brazil
| | - Clive Grattan
- Guy’s Hospital, St John’s Institute of Dermatology, London SE1 7EP, UK
| | - Marcus Maurer
- Institute of Allergology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, 12203 Berlin, Germany (D.E.-A.-K.)
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Bianchi S, Fappani C, Gori M, Canuti M, Colzani D, Monti MC, Torriani C, Raviglione MC, Zuccotti G, Tanzi E, Amendola A. Serological investigation of SARS-CoV-2 infection in patients with suspect measles, 2017-2022. Virol J 2023; 20:160. [PMID: 37474969 PMCID: PMC10357797 DOI: 10.1186/s12985-023-02117-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/06/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Several studies suggested that SARS-CoV-2 was already spreading worldwide during the last months of 2019 before the first outbreak was detected in Wuhan, China. Lombardy (Northern Italy) was the first European region with sustained SARS-CoV-2 transmission and recent investigations detected SARS-CoV-2-RNA-positive patients in Lombardy since late 2019. METHODS We tested for anti-SARS-CoV-2 IgG all serum samples available in our laboratory (N = 235, collected between March 2017 and March 2022) that we received within the framework of measles/rubella surveillance from measles and rubella virus-negative patients. RESULTS Thirteen of 235 samples (5.5%) were IgG-positive. The positivity rate increased starting in 2019 and was significantly different from the expected false positive rate from 2019 onwards. Additionally, in 2019 the percentage of IgG-positive patients was significantly lower among SARS-CoV-2 RNA-negative patients (3/92) compared to SARS-CoV-2 RNA-positive patients (2/7, p = 0.04). The highest percentage of IgG positivity in the pre-pandemic period was recorded during the second half of 2019. This coincided with an increase in negativity for measles and a widening of the peak of the number of measles discarded cases per 100,000 inhabitants, indicating a higher-than-normal number of measles-negative patients experiencing fever and rash. This also coincided with the first patient positive for SARS-CoV-2 RNA (September 12th, 2019); this patient was also positive for anti-SARS-CoV-2 IgG and IgM. CONCLUSIONS Although the number of samples was low and one cannot conclusively establish that the virus started circulating in Lombardy around September 2019, our findings should stimulate similar research investigating the possibility of undetected SARS-CoV-2 pre-pandemic circulation.
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Affiliation(s)
- Silvia Bianchi
- Department of Health Sciences, Universita' degli Studi di Milano, Milan, Italy
- Coordinated Research Center "EpiSoMI", Universita' degli Studi di Milano, Milan, Italy
| | - Clara Fappani
- Department of Health Sciences, Universita' degli Studi di Milano, Milan, Italy
- Coordinated Research Center "EpiSoMI", Universita' degli Studi di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, Milan, Italy
| | - Maria Gori
- Department of Health Sciences, Universita' degli Studi di Milano, Milan, Italy
- Coordinated Research Center "EpiSoMI", Universita' degli Studi di Milano, Milan, Italy
| | - Marta Canuti
- Coordinated Research Center "EpiSoMI", Universita' degli Studi di Milano, Milan, Italy.
- Department of Pathophysiology and Transplantation, Universita' degli Studi di Milano, Milan, Italy.
- Centre for Multidisciplinary Research in Health Science (MACH), Universita' degli Studi di Milano, Milan, Italy.
| | - Daniela Colzani
- Department of Health Sciences, Universita' degli Studi di Milano, Milan, Italy
| | - Maria Cristina Monti
- Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Camilla Torriani
- Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Mario C Raviglione
- Department of Pathophysiology and Transplantation, Universita' degli Studi di Milano, Milan, Italy
- Centre for Multidisciplinary Research in Health Science (MACH), Universita' degli Studi di Milano, Milan, Italy
| | - Gianvincenzo Zuccotti
- Department of Paediatrics, Children Hospital V. Buzzi, Universita' degli Studi di Milano, Milan, Italy
- Romeo and Enrica Invernizzi Pediatric Research Center, Universita' degi Studi di Milano, Milan, Italy
| | - Elisabetta Tanzi
- Department of Health Sciences, Universita' degli Studi di Milano, Milan, Italy
- Coordinated Research Center "EpiSoMI", Universita' degli Studi di Milano, Milan, Italy
- Centre for Multidisciplinary Research in Health Science (MACH), Universita' degli Studi di Milano, Milan, Italy
| | - Antonella Amendola
- Department of Health Sciences, Universita' degli Studi di Milano, Milan, Italy
- Coordinated Research Center "EpiSoMI", Universita' degli Studi di Milano, Milan, Italy
- Centre for Multidisciplinary Research in Health Science (MACH), Universita' degli Studi di Milano, Milan, Italy
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Öztaş Kara R, Demir S, Saraç E, Sevimli Dikicier B, Ünal D, Gelincik A, Thomsen SF, Maurer M, Kocatürk E. Features of Chronic Spontaneous Urticaria Induced by COVID-19. Int Arch Allergy Immunol 2023; 184:792-796. [PMID: 37231846 DOI: 10.1159/000530610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/04/2023] [Indexed: 05/27/2023] Open
Affiliation(s)
- Rabia Öztaş Kara
- Department of Dermatology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Semra Demir
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Esra Saraç
- Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey
| | - Bahar Sevimli Dikicier
- Department of Dermatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Derya Ünal
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aslı Gelincik
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Simon Francis Thomsen
- Department of Dermatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Marcus Maurer
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Emek Kocatürk
- Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
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Examining Violaceous Skin Discoloration during the COVID-19 Pandemic: Conducting Research in Resource Scarcity. Adv Skin Wound Care 2023; 36:137-141. [PMID: 36812078 DOI: 10.1097/01.asw.0000911988.75204.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE To describe the observed patterns and presentations of violaceous discoloration that appeared to be related to the COVID-19 disease process. METHODS This retrospective observational cohort study included adults who were COVID-19 positive with purpuric/violaceous lesions in pressure-adjacent areas of the gluteus without preexisting pressure injury. Patients were admitted to an ICU at a single quaternary academic medical center between April 1 and May 15, 2020. Data were compiled by review of the electronic health record. The wounds were described by location, tissue type (violaceous, granulation, slough, eschar), wound margin (irregular, diffuse, nonlocalized), and periwound condition (intact). RESULTS A total of 26 patients were included in the study. Purpuric/violaceous wounds were found predominantly on White (92.3%) men (88.0%) aged 60 to 89 years (76.9%) with a body mass index 30 kg/m2 or higher (46.1%). The majority of wounds were located on the sacrococcygeal (42.3%) and fleshy gluteal regions (46.1%). CONCLUSIONS Wounds were heterogeneous in appearance (poorly defined violaceous skin discoloration of acute onset), and the patient population had clinical characteristics similar to acute skin failure (eg, concomitant organ failures and hemodynamic instability). Additional larger population-based studies with biopsies may assist in finding patterns related to these dermatologic changes.
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9
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Starkey SY, Kashetsky N, Lam JM, Dutz J, Mukovozov IM. Chilblain-Like Lesions (CLL) Coinciding With the SARS-CoV-2 Pandemic in Children: A Systematic Review. J Cutan Med Surg 2023. [DOI: 10.1177/12034754231158074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Chilblain-like lesions (CLL) coinciding with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection have been described in the literature. Available reviews of the literature suggest that CLL are associated with younger age, an equal sex ratio, negative testing for SARS-CoV-2, and mild to no extracutaneous manifestations (ECM) associated with COVID-19 infection. This systematic review aims to provide a summary of reports of CLL associated with the early SARS-CoV-2 pandemic in children to clarify the prevalence, clinical characteristics, and resolution outcomes of these skin findings. Sixty-nine studies, published between May 2020 and January 2022, met inclusion criteria and were summarized in this review, representing 1,119 cases of CLL. Available data showed a slight male predominance (591/1002, 59%). Mean age was 13 years, ranging from 0 to 18 years. Most cases had no ECM (682/978, 70%). Overall, 70/507 (14%) of patients tested positive for COVID-19 using PCR and/or serology. In the majority the clinical course was benign with 355/415 (86%) of cases resolving, and 97/269 (36%) resolving without any treatment. This comprehensive summary of pediatric CLL suggests these lesions are rarely associated with COVID-19 symptoms or test positivity.
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Affiliation(s)
- Samantha Y. Starkey
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nadia Kashetsky
- Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, Canada
| | - Joseph M. Lam
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jan Dutz
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
- BC Children’s Hospital Research Institute, British Columbia, Canada
| | - Ilya M. Mukovozov
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
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Nie Y, Liu L, Xue S, Yan L, Ma N, Liu X, Liu R, Wang X, Wang Y, Zhang X, Zhang X. The association between air pollution, meteorological factors, and daily outpatient visits for urticaria in Shijiazhuang, Hebei Province, China: a time series analysis. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023; 30:10664-10682. [PMID: 36076138 DOI: 10.1007/s11356-022-22901-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/02/2022] [Indexed: 06/15/2023]
Abstract
The associations of air pollution and meteorological factors with the outpatient visits of urticaria remain poorly studied. This study aimed to assess the association between air pollution, meteorological factors, and daily outpatient visits for urticaria in Shijiazhuang, China, during 2014-2019. Daily recordings of air pollutant concentrations, meteorological data, and outpatient visits data for urticaria were collected during the 6 years. Descriptive research methods were used to describe the distribution characteristics and demographic features of urticaria. A combination of the generalized linear regression model (GLM) and distribution lag nonlinear model (DLNM) was used to evaluate the lag association between environmental factors and daily outpatient visits for urticaria. Stratified analyses by gender (male; female) and age (< 18 years; 18-39 years; > 39 years) were further conducted. The dose-response relationship between daily urticaria visits and CO, NO2, O3, temperature, and relative humidity was nonlinear. High concentrations of CO, NO2, O3, and high temperatures increased the risk of urticaria outpatient visits. The maximum cumulative association of high concentrations of CO, NO2, and O3 was lag 0-14 days (CO: RR = 1.10, 95%CI: 1.06, 1.31; NO2: RR = 1.09, 95%CI: 1.01, 1.08; O3: RR = 1.16, 95%CI: 1.08, 1.25), and high temperatures was lag 0-7 days (RR = 1.27, 95%CI: 1.14, 1.41). Low concentrations of NO2, O3, and high humidity, on the other hand, act as protective factors for urticaria outpatient. The maximum cumulative association of low concentrations of NO2 was the 0-day lag (RR = 0.97, 95%CI: 0.95, 0.99), O3 was lag 0-5 days (RR = 0.94, 95%CI: 0.88, 0.99), and high humidity was lag 0-10 days (RR = 0.93, 95%CI: 0.89, 0.98). Stratified analyses showed that the risk of urticaria outpatient visits was higher for the males and in the < 18 years age group. In conclusion, we found that the development of urticaria in Shijiazhuang has a distinct seasonal and cyclical nature. Air pollutants and meteorological factors had varying degrees of influence on the risk of urticaria outpatient visits. This study provides indirect evidence for a link between air pollution, meteorological factors, and urticaria outpatient visits.
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Affiliation(s)
- Yaxiong Nie
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, 361 Zhongshan East Road, Shijiazhuang, 050017, China
| | - Lijuan Liu
- Department of Dermatology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shilin Xue
- School of Basic Medical Sciences, Peking University, Peking University Health Science Center, Beijing, China
| | - Lina Yan
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, 361 Zhongshan East Road, Shijiazhuang, 050017, China
| | - Ning Ma
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, 361 Zhongshan East Road, Shijiazhuang, 050017, China
| | - Xuehui Liu
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, 361 Zhongshan East Road, Shijiazhuang, 050017, China
| | - Ran Liu
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, 361 Zhongshan East Road, Shijiazhuang, 050017, China
| | - Xue Wang
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, 361 Zhongshan East Road, Shijiazhuang, 050017, China
| | - Yameng Wang
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, 361 Zhongshan East Road, Shijiazhuang, 050017, China
| | - Xinzhu Zhang
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, 361 Zhongshan East Road, Shijiazhuang, 050017, China
| | - Xiaolin Zhang
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, 361 Zhongshan East Road, Shijiazhuang, 050017, China.
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11
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Huynh T, Sanchez-Flores X, Yau J, Huang JT. Cutaneous Manifestations of SARS-CoV-2 Infection. Am J Clin Dermatol 2022; 23:277-286. [PMID: 35247198 PMCID: PMC8897723 DOI: 10.1007/s40257-022-00675-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the coronavirus disease 2019 (COVID-19) pandemic, affecting people worldwide. SARS-CoV-2 infection is a multisystem disease with potential for detrimental effects on various systemic organs. It affects people of all ages with varying degrees of disease severity. Patients with SARS-CoV-2 infection commonly present with dry cough, fever, and fatigue. A clinical spectrum of skin findings secondary to SARS-CoV-2 has also been reported. The most common cutaneous patterns associated with COVID-19 are chilblain-like lesions (CBLL), maculopapular lesions, urticarial lesions, vesicular lesions, and livedoid lesions. Other skin findings secondary to SARS-COV-2 infection are erythema multiforme (EM)-like lesions and skin findings associated with multisystem inflammatory syndrome in children (MIS-C) and rarely multisystem inflammatory syndrome in adults (MIS-A). Physician awareness of skin manifestations of SARS-CoV-2 infection can help with early identification and treatment. This narrative review provides an update of various skin manifestations reported with SARS-CoV-2 infection, including clinical presentation, proposed pathogenesis, histopathology, prognosis, and treatment options.
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Affiliation(s)
- Thy Huynh
- Dermatology Section, Boston Children's Hospital, 300 Longwood Avenue, Fegan 6, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Xavier Sanchez-Flores
- Dermatology Section, Boston Children's Hospital, 300 Longwood Avenue, Fegan 6, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Judy Yau
- Tufts University School of Medicine, Boston, MA, USA
| | - Jennifer T Huang
- Dermatology Section, Boston Children's Hospital, 300 Longwood Avenue, Fegan 6, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
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12
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Fong JH, Koay SMA, Foo EHW, Mah YL, Eu WC. Coronavirus Disease 2019 (COVID-19) and Ecchymosis: A Case Report. Cureus 2022; 14:e23326. [PMID: 35464524 PMCID: PMC9015065 DOI: 10.7759/cureus.23326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2022] [Indexed: 11/05/2022] Open
Abstract
Extrapulmonary symptoms such as cutaneous manifestations are increasingly being reported in coronavirus disease 2019 (COVID-19) infection. The rashes of COVID-19 are usually livedo and purpuric and have been classified into six main patterns. This is the first case reported in Malaysia of ecchymosis associated with COVID-19 occurring on a patient without prior history of coagulopathy. The report of this rare clinical association could have a potential pathophysiological implication and contributes to the current data of the cutaneous manifestations of COVID-19. Further knowledge regarding these cutaneous lesions could help in the diagnosis of COVID-19 related complications and earlier management.
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13
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Sugai T, Fujita Y, Inamura E, Maya Y, Shimizu S. Prevalence and patterns of cutaneous manifestations in 1,245 COVID-19 patients in Japan: a single-centre study. J Eur Acad Dermatol Venereol 2022; 36:e522-e524. [PMID: 35274364 PMCID: PMC9114903 DOI: 10.1111/jdv.18062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/25/2022] [Accepted: 03/04/2022] [Indexed: 12/01/2022]
Affiliation(s)
- T Sugai
- Department of Dermatology, Sapporo City General Hospital, Sapporo, Japan
| | - Y Fujita
- Department of Dermatology, Sapporo City General Hospital, Sapporo, Japan
| | - E Inamura
- Department of Dermatology, Sapporo City General Hospital, Sapporo, Japan
| | - Y Maya
- Department of Dermatology, Sapporo City General Hospital, Sapporo, Japan
| | - S Shimizu
- Department of Dermatology, Sapporo City General Hospital, Sapporo, Japan
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Sediqi AW, Nemat A, Raufi N, Asady A. The Third Wave of the COVID-19 Arrived in Afghanistan: A Severe Case with Skin Manifestation. Int Med Case Rep J 2021; 14:761-764. [PMID: 34795537 PMCID: PMC8593341 DOI: 10.2147/imcrj.s335452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/05/2021] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 is an ongoing global pandemic that has put the world in a devastating situation. The virus is able to attack multiple body systems and cause a variety of clinical problems ranging from asymptomatic to critical cases. Although young individuals are more likely to suffer milder forms of the disease, critical cases also might happen. Recent literature has revealed that, along with other clinical symptoms, skin manifestations have also progressively grown. In Afghanistan where COVID-19 has entered into a third wave, many people do not take the initial mild symptoms seriously to prevent further spreading in the community. We report symptoms of skin rash, fatigue, muscle pain, dry cough and fever at the onset of the disease, followed by rapid lung damage in a 23-year-old young adult, who did not have any preexisting risk factors. This case highlights the importance of urgent skin assessment of the COVID-19 patient complaining of any skin symptoms.
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Affiliation(s)
- Abdul Wahed Sediqi
- Department of Cardiology, Ariana Medical Complex, Kabul, Afghanistan.,Department of Cardiology, Ali Abad Teaching Hospital, Kabul University of Medical Sciences, Kabul, Afghanistan
| | - Arash Nemat
- Department of Microbiology, Kabul University of Medical Sciences, Kabul, Afghanistan
| | - Nahid Raufi
- Department of Dermatology, Maiwand Teaching Hospital, Kabul University of Medical Sciences, Kabul, Afghanistan
| | - Abdullah Asady
- Department of Microbiology, Kabul University of Medical Sciences, Kabul, Afghanistan
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15
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Seque CA, Enokihara MMSES, Porro AM, Tomimori J. Skin manifestations associated with COVID-19. An Bras Dermatol 2021; 97:75-88. [PMID: 34857407 PMCID: PMC8577992 DOI: 10.1016/j.abd.2021.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/20/2021] [Accepted: 08/22/2021] [Indexed: 01/08/2023] Open
Abstract
This article will address the main aspects of skin manifestations associated with COVID-19, based on a review of the literature published to date. Since the beginning of the pandemic, more than 1,500 articles have been published on the subject. Regarding the pathophysiology, it is believed that the same mechanisms responsible for the disease in the main target organs also act in the skin, although they are not yet fully elucidated. The actual frequency of dermatological manifestations remains uncertain – it can range from 0.2% to 45%, being close to 6% in systematic reviews. Pioneering studies of large case series conducted in European countries and the USA provide the first information on the main skin manifestations associated with COVID-19 and propose classifications regarding their clinical presentation, pathophysiology, as well as their frequencies. Although there is yet no consensus, maculopapular eruptions are considered the most frequent presentations, followed by erythema pernio-like (EPL) lesions. Manifestations such as urticaria, vesicular conditions and livedo/purpura/necrosis are rare. The time of onset, severity, need for specific treatment and prognosis vary according to the clinical presentation pattern. The increasing histopathological description of skin conditions can contribute to the diagnosis, as well as to the understanding of the pathophysiology. Also, in the dermatological field, the relationship between COVID-19 and androgens has been increasingly studied. Despite all the generated knowledge, the actual biological meaning of skin manifestations remains uncertain. Therefore, the exclusion of the main differential diagnoses is essential for the correlation between skin manifestation and COVID-19.
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Affiliation(s)
- Camila Arai Seque
- Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | | | - Adriana Maria Porro
- Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Jane Tomimori
- Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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16
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Hoff NP, Freise NF, Schmidt AG, Firouzi-Memarpuri P, Reifenberger J, Luedde T, Bölke E, Meller S, Homey B, Feldt T, Jensen BEO, Keitel V, Schmidt L, Maas K, Haussmann J, Tamaskovics B, Budach W, Fischer JC, Buhren BA, Knoefel WT, Schneider M, Gerber PA, Pedoto A, Häussinger D, Grebe O, van Griensven M, Braun SA, Salzmann S, Rezazadeh A, Matuschek C. Delayed skin reaction after mRNA-1273 vaccine against SARS-CoV-2: a rare clinical reaction. Eur J Med Res 2021; 26:98. [PMID: 34433495 PMCID: PMC8386154 DOI: 10.1186/s40001-021-00557-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023] Open
Abstract
Background The coronavirus disease 2019 (COVID‐19) is associated with a wide clinical spectrum of skin manifestations, including urticarial, vesicular, vasculitic and chilblain‐like lesions. Recently, delayed skin reactions have been reported in 1% individuals following mRNA vaccination against SARS-CoV-2. The exact pathophysiology and the risk factors still remain unclear. Patients and methods 6821 employees and patients were vaccinated at our institutions between February and June 2021. Every patient received two doses of the mRNA-1273 vaccine in our hospitals, and reported back in case of any side effects which were collected in our hospital managed database. Results Eleven of 6821 vaccinated patients (0.16%) developed delayed skin reactions after either the first or second dose of the mRNA-1273 vaccine against SARS-CoV-2. Eight of 11 patients (73%) developed a rash after the first dose, while in 3/11 (27%), the rash occurred after the second dose. More females (9/11) were affected. Four of 11 patients required antihistamines, with two needing additional topical steroids. All the cutaneous manifestations resolved within 14 days. None of the skin reactions after the first dose of the vaccine prevented the administration of the second dose. There were no long-term cutaneous sequelae in any of the affected individuals. Conclusion Our data suggests that skin reactions after the use of mRNA-1273 vaccine against SARS-CoV-2 are possible, but rare. Further studies need to be done to understand the pathophysiology of these lesions.
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Affiliation(s)
- Norman-Philipp Hoff
- Department of Dermatology, University Hospital Düsseldorf, Medical Faculty, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - Noemi F Freise
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Albrecht G Schmidt
- Department of Radiation Oncology, University Hospital Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Parnian Firouzi-Memarpuri
- Department of Dermatology, University Hospital Düsseldorf, Medical Faculty, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - Julia Reifenberger
- Department of Dermatology, University Hospital Düsseldorf, Medical Faculty, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, University Hospital Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Stephan Meller
- Department of Dermatology, University Hospital Düsseldorf, Medical Faculty, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - Bernhard Homey
- Department of Dermatology, University Hospital Düsseldorf, Medical Faculty, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - Torsten Feldt
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Björn Erik Ole Jensen
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Verena Keitel
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Livia Schmidt
- Department of Radiation Oncology, University Hospital Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Kitti Maas
- Department of Radiation Oncology, University Hospital Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Jan Haussmann
- Department of Radiation Oncology, University Hospital Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Balint Tamaskovics
- Department of Radiation Oncology, University Hospital Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, University Hospital Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Johannes C Fischer
- Institute for Transplant Diagnostics and Cell Therapeutics, Heinrich Heine University, Düsseldorf, Germany
| | | | - Wolfram Trudo Knoefel
- Department of Surgery and Interdisciplinary Surgical Intensive Care Unit Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Marion Schneider
- Division of Experimental Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Peter Arne Gerber
- Medical Faculty, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - Alessia Pedoto
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Olaf Grebe
- Department of Cardiology and Rhythmology, Petrus Hospital, Wuppertal, Germany
| | - Martijn van Griensven
- Department cBITE, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, The Netherlands
| | - Stephan A Braun
- Department of Dermatology, University Hospital Düsseldorf, Medical Faculty, Heinrich-Heine-University, 40225, Düsseldorf, Germany.,Department of Dermatology, University Hospital Münster, Münster, Germany
| | - Stefan Salzmann
- Department of Dermatology, University Hospital Münster, Münster, Germany
| | - Amir Rezazadeh
- Department of Radiation Oncology, University Hospital Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, University Hospital Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
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