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Caro-Chang LA, Fung MA. The role of eosinophils in the differential diagnosis of inflammatory skin diseases. Hum Pathol 2023; 140:101-128. [PMID: 37003367 DOI: 10.1016/j.humpath.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
Eosinophils are known to be present in inflammatory skin diseases, but their diagnostic utility is not well established. Upon review of the published status of lesional eosinophils, several categories were identified. 1) Lesional eosinophils highly characteristic such that, in their absence, the pathologist may question the diagnosis. These include arthropod bite reactions and scabies, urticarial dermatitis, and other eosinophilic dermatoses. 2) Lesional eosinophils rare or absent, such that, in their presence, the pathologist may question the diagnosis. These include pityriasis lichenoides, graft versus host disease, and connective tissue disorders. 3) Lesional eosinophils variable and, while in some cases expected, are not required for diagnosis. These include drug reactions, atopic dermatitis and allergic contact dermatitis. 4) Lesional eosinophils variable and not expected but may be seen to a limited extent. These include lichen planus and psoriasis.
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2
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Idiopathic systemic capillary leak syndrome, a unique complement and interferon mediated endotheliopathy syndrome: The role of the normal skin biopsy in establishing the diagnosis and elucidating pathogenetic mechanisms. Ann Diagn Pathol 2022; 61:152028. [DOI: 10.1016/j.anndiagpath.2022.152028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/01/2022]
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3
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Population Characteristics, Symptoms, and Risk Factors of Idiopathic Chilblains: A Systematic Review, Meta-Analysis, and Meta-Regression. BIOLOGY 2022; 11:biology11111651. [DOI: 10.3390/biology11111651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/02/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
Abstract
Background: Chilblains/perniosis is a non-freezing cold injury causing painful inflammatory skin lesions. Its pathogenesis remains poorly understood because it is often studied as secondary to other underlying conditions. Methods: We systematically investigated the population characteristics, symptoms, and predisposing factors of chilblains in healthy adults exposed to cool/cold environments. We screened PubMed, Embase, and Cochrane Library, and we adopted PRISMA reporting guidelines (PROSPERO: CRD42021245307). The risk of bias was assessed by two independent reviewers (RTI item bank). Random-effects model meta-analyses were performed to calculate the pooled prevalence of histopathological features. Mixed-effects meta-regressions were used to assess other sources of between-study heterogeneity. Results: Thirteen studies (477 patients) were included. Chilblains affect more women than men, up to 12% of the body skin surface, and most frequently, the hands and fingers. Meta-analyses of nine studies (303 patients) showed a frequent presence of perivascular lymphocytic infiltrate (81%), basal epidermal-cell layer vacuolation (67%), papillary dermal edema (66%), and perieccrine lymphocytic infiltrate (57%). Meta-regressions (p ≤ 0.05) showed that smoking and frequent occupational exposure to water increase the likelihood of histopathological features. Conclusions: The population characteristics, symptoms, and predisposing factors of chilblains revealed in this analysis should be incorporated in medical care to improve the condition’s diagnosis and management.
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4
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A curious case of ‘COVID toes’ in pregnancy. Obstet Med 2022. [DOI: 10.1177/1753495x221109461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The novel coronavirus of 2019 (COVID-19) can affect multiple organ systems with a wide spectrum of illness severity. Its effect on the respiratory tract is well-documented and has resulted in considerable excess mortality worldwide. However, observed cutaneous manifestations of COVID-19 are rising, ranging from short-lived viral exanthems to vesicular eruptions and urticaria. An unusual subgroup of these manifestations – pseudo-chilblains, also referred to as pernio-like lesions or ‘COVID toes’ – describes the acral areas of erythema and oedema that can affect young individuals following COVID-19. We present a case associated with pustule and vesicle formation occurring in the context of pregnancy.
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5
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Magro C, Nuovo G, Mulvey JJ, Laurence J, Harp J, Crowson AN. The skin as a critical window in unveiling the pathophysiologic principles of COVID-19. Clin Dermatol 2021; 39:934-965. [PMID: 34920833 PMCID: PMC8298003 DOI: 10.1016/j.clindermatol.2021.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiologic agent of coronavirus disease 2019 (COVID-19), is a single-stranded RNA virus whose sequence is known. COVID-19 is associated with a heterogeneous clinical phenotype ranging from asymptomatic to fatal disease. It appears that access to nasopharyngeal respiratory epithelia expressing angiotensin-converting enzyme (ACE) 2, the receptor for SARS-CoV-2, is followed by viral replication in the pulmonary alveolar septal capillary bed. We have demonstrated in earlier studies that incomplete viral particles, termed pseudovirions, dock to deep subcutaneous and other vascular beds, potentially contributing to the prothrombotic state and systemic complement activation that characterizes severe and critical COVID-19. A variety of skin eruptions have been described in the setting of SARS-CoV-2 infection and more recently, after COVID-19 vaccination. The vaccines deliver a laboratory-synthesized mRNA that encodes a protein that is identical to the spike glycoprotein of SARS-CoV-2, allowing the production of immunogenic spike glycoprotein that will then elicit T cell and B cell adaptive immune responses. In this contribution, we review an array of cutaneous manifestations of COVID-19 that provide an opportunity to study critical pathophysiologic mechanisms that underlie all clinical facets of COVID-19, ranging from asymptomatic/mild to severe and critical COVID-19. We classify cutaneous COVID-19 according to underlying pathophysiologic principles. In this regard we propose three main pathways: (1) complement mediated thrombotic vascular injury syndromes deploying the alternative and mannan binding lectin pathways and resulting in the elaboration of cytokines like interleukin 6 from endothelium in the setting of severe and critical COVID-19 and (2) the robust T cell and type I interferon-driven inflammatory and (3) humoral-driven immune complex mediated vasculitic cutaneous reactions observed with mild and moderate COVID-19. Presented are novel data on cutaneous vaccine reactions that manifest a clinical and morphologic parallel with similar eruptions observed in patients with mild and moderate COVID-19 and in some cases represent systemic eczematoid hypersensitivity reactions to a putative vaccine-based antigen versus unmasking subclinical hypersensitivity due to immune enhancing effects of the vaccine. Finally, we demonstrate for the first time the localization of human synthesized spike glycoprotein after the COVID-19 vaccine to the cutaneous and subcutaneous vasculature confirming the ability of SARS-CoV-2 spike glycoprotein to bind endothelium in the absence of intact virus.
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6
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McCleskey PE, Zimmerman B, Lieberman A, Liu L, Chen C, Gorouhi F, Jacobson CC, Lee DS, Sriram A, Thornton A, Herz AM, Mirmirani P, Herrinton LJ. Epidemiologic Analysis of Chilblains Cohorts Before and During the COVID-19 Pandemic. JAMA Dermatol 2021; 157:947-953. [PMID: 34160569 DOI: 10.1001/jamadermatol.2021.2120] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Beginning in March 2020, case reports and case series linked the COVID-19 pandemic with an increased occurrence of chilblains, but this association has not been evaluated in an epidemiologic study. Objective To assess whether a correlation exists between COVID-19 incidence and chilblains incidence. Design, Setting, and Participants A retrospective cohort study was conducted within the Kaiser Permanente Northern California system from January 1, 2016, to December 31, 2020; health plan members of all ages were included. Exposure COVID-19 incidence in 207 location-months, representing 23 geographic locations in northern California across 9 months. Main Outcome and Measures Chilblains incidence was the main outcome. The association of chilblains incidence with COVID-19 incidence across the 207 location-months was measured using the Spearman rank correlation coefficient. Results Of 780 patients with chilblains reported during the pandemic, 464 were female (59.5%); mean (SD) age was 36.8 (21.8) years. COVID-19 incidence was correlated with chilblains incidence at 207 location-months (Spearman coefficient 0.18; P = .01). However, only 17 of 456 (3.7%) patients with chilblains tested during the pandemic were positive for SARS-CoV-2, and only 9 of 456 (2.0%) were positive for SARS-CoV-2 within 6 weeks of the chilblains diagnosis. Test results of 1 of 97 (1.0%) patients were positive for SARS-CoV-2 IgG antibodies. Latinx patients were disproportionately affected by COVID-19 but not by chilblains. Conclusions and Relevance This cohort study found that in northern California, the incidence of chilblains increased during the pandemic but was correlated weakly with the incidence of COVID-19 across 207 location-months. These findings may have resulted from a causal role of COVID-19, increased care-seeking by patients with chilblains during the pandemic, or changes in behavior during shelter in place.
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Affiliation(s)
- Patrick E McCleskey
- Department of Dermatology, The Permanente Medical Group, Northern California, Oakland
| | - Bree Zimmerman
- Department of Dermatology, The Permanente Medical Group, Northern California, Oakland.,Department of Pediatrics, The Permanente Medical Group, Northern California, Oakland
| | - Amara Lieberman
- Department of Dermatology, The Permanente Medical Group, Northern California, Oakland
| | - Liyan Liu
- Division of Research, The Permanente Medical Group, Northern California, Oakland
| | - Cynthia Chen
- Department of Dermatology, The Permanente Medical Group, Northern California, Oakland
| | - Farzam Gorouhi
- Department of Dermatology, The Permanente Medical Group, Northern California, Oakland
| | - Christine C Jacobson
- Department of Dermatology, The Permanente Medical Group, Northern California, Oakland
| | - David S Lee
- Department of Dermatology, The Permanente Medical Group, Northern California, Oakland
| | - Achyuth Sriram
- Department of Pediatrics, The Permanente Medical Group, Northern California, Oakland
| | - Amanda Thornton
- Department of Infectious Disease, The Permanente Medical Group, Northern California, Oakland
| | - Arnd M Herz
- Department of Pediatrics, The Permanente Medical Group, Northern California, Oakland.,Department of Infectious Disease, The Permanente Medical Group, Northern California, Oakland
| | - Paradi Mirmirani
- Department of Dermatology, The Permanente Medical Group, Northern California, Oakland
| | - Lisa J Herrinton
- Division of Research, The Permanente Medical Group, Northern California, Oakland
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7
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Shakshouk H, Johnson EF, Peters MS, Wieland CN, Comfere NI, Lehman JS. Cutaneous eccrine inflammation and necrosis: review of inflammatory disorders affecting the eccrine apparatus including new associations. Hum Pathol 2021; 118:71-85. [PMID: 34450084 DOI: 10.1016/j.humpath.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/30/2021] [Accepted: 08/06/2021] [Indexed: 11/18/2022]
Abstract
Despite being frequently overlooked during the examination of histopathological sections, eccrine sweat glands can offer clues for diagnosing various skin conditions. They provide important functions and can lead to several diseases when inflamed or injured. This review article provides information regarding eccrine physiology as well as well-established and novel entities that occur in association with eccrine gland pathology.
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Affiliation(s)
- Hadir Shakshouk
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Dermatology, Andrology and Venereology, Alexandria University, Alexandria, 21131, Egypt
| | - Emma F Johnson
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Margot S Peters
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Carilyn N Wieland
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Nneka I Comfere
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA.
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8
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Kolivras A, Thompson C, Pastushenko I, Mathieu M, Bruderer P, de Vicq M, Feoli F, Harag S, Meiers I, Olemans C, Sass U, Dehavay F, Fakih A, Lam-Hoai XL, Marneffe A, Van De Borne L, Vandersleyen V, Richert B. A clinicopathological description of COVID-19-induced chilblains (COVID-toes) correlated with a published literature review. J Cutan Pathol 2021; 49:17-28. [PMID: 34272741 PMCID: PMC8444728 DOI: 10.1111/cup.14099] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/14/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022]
Abstract
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).
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Affiliation(s)
- Athanassios Kolivras
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatopathology, Saint-Pierre Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Curtis Thompson
- Departments of Dermatology and Pathology, Oregon Health and Science University, Portland, Oregon, USA.,CTA Pathology, Portland, Oregon, USA
| | - Ievgenia Pastushenko
- Laboratory of Stem Cells and Cancer, Université Libre de Bruxelles, Brussels, Belgium
| | - Marisa Mathieu
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Pascal Bruderer
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatopathology, Saint-Pierre Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marine de Vicq
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatopathology, Saint-Pierre Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Francesco Feoli
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatopathology, Saint-Pierre Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Saadia Harag
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatopathology, Saint-Pierre Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Isabelle Meiers
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatopathology, Saint-Pierre Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Catherine Olemans
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatopathology, Saint-Pierre Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ursula Sass
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatopathology, Saint-Pierre Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Florence Dehavay
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Ali Fakih
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Xuan-Lan Lam-Hoai
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alice Marneffe
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Laura Van De Borne
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Valerie Vandersleyen
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium.,Department of Dermatopathology, Saint-Pierre Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Bertrand Richert
- Department of Dermatology, Saint-Pierre, Brugmann and Queen Fabiola Children's University Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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9
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Bitar C, Menge TD, Chan MP. Cutaneous manifestations of lupus erythematosus: A practical clinicopathologic review for pathologists. Histopathology 2021; 80:233-250. [PMID: 34197657 DOI: 10.1111/his.14440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 11/27/2022]
Abstract
Accurate diagnosis of connective tissue diseases is often challenging and relies on careful correlation between clinical and histopathologic features, direct immunofluorescence studies, and laboratory workup. Lupus erythematosus (LE) is a prototype of connective tissue disease with a variety of cutaneous and systemic manifestations. Microscopically, cutaneous LE is classically characterized by an interface dermatitis, although other histopathologic patterns also exist depending on the clinical presentation, location, and chronicity of the skin lesions. In this article, we review the clinical, serologic, histopathologic, and direct immunofluorescence findings in LE-specific and LE-nonspecific skin lesions, with an emphasis on lesser known variants, newly described features, and helpful ancillary studies. This review will guide general pathologists and dermatopathologists in accurately diagnosing and subclassifying cutaneous LE.
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Affiliation(s)
- Carole Bitar
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tyler D Menge
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - May P Chan
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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10
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Abstract
Immune-related manifestations are increasingly recognized conditions in patients with COVID-19, with around 3,000 cases reported worldwide comprising more than 70 different systemic and organ-specific disorders. Although the inflammation caused by SARS-CoV-2 infection is predominantly centred on the respiratory system, some patients can develop an abnormal inflammatory reaction involving extrapulmonary tissues. The signs and symptoms associated with this excessive immune response are very diverse and can resemble some autoimmune or inflammatory diseases, with the clinical phenotype that is seemingly influenced by epidemiological factors such as age, sex or ethnicity. The severity of the manifestations is also very varied, ranging from benign and self-limiting features to life-threatening systemic syndromes. Little is known about the pathogenesis of these manifestations, and some tend to emerge within the first 2 weeks of SARS-CoV-2 infection, whereas others tend to appear in a late post-infectious stage or even in asymptomatic patients. As the body of evidence comprises predominantly case series and uncontrolled studies, diagnostic and therapeutic decision-making is unsurprisingly often based on the scarcely reported experience and expert opinion. Additional studies are required to learn about the mechanisms involved in the development of these manifestations and apply that knowledge to achieve early diagnosis and the most suitable therapy.
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11
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Olsen TG, Shrit MA, Feeser TA, Wargo JJ. COVID Purpura (Toes) Case Series: A Chilblains-Like Vasculopathy. Am J Dermatopathol 2021; 43:e47-e50. [PMID: 33156022 DOI: 10.1097/dad.0000000000001829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Biopsies were taken from 4 patients who presented to their dermatologist with violaceous papules and plaques of the dorsal toes (COVID Toes) associated with varying degrees of severe acute respiratory syndrome coronavirus 2 exposure and COVID-19 testing. Major histopathologic findings were lymphocytic eccrine inflammation and a spectrum of vasculopathic findings to include superficial and deep angiocentric-perivascular lymphocytic inflammation, lymphocytes in vessel walls (lymphocytic vasculitis), endothelial swelling, red blood cell extravasation, and focal deposits of fibrin in both vessel lumina, and vessel walls. Interface changes were observed to include vacuolopathy and apoptotic keratinocytes at the basement membrane. Immunostains showed a dominant T-cell lineage (positive for T-cell receptor beta, CD2, CD3, CD5, and CD7). B-cells were rare and clusters of CD123-positive dermal plasmacytoid dendritic cells were observed surrounding eccrine clusters and some perivascular zones. The consistent perieccrine and vasculopathic features represent important pathologic findings in the diagnosis of COVID toes and are suggestive of pathogenetic mechanisms. Clinicopathologic correlation, the epidemiological backdrop, and the current worldwide COVID-19 pandemic favor a viral causation and should alert the physician to initiate a workup and the appropriate use of COVID-19 testing.
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Affiliation(s)
- Thomas G Olsen
- Department of Pathology, Wright State University Boonshoft School of Medicine, Fairborn, OH
- Dermatopathology Laboratory of Central States, Dayton, OH
| | - M Atef Shrit
- Department of Pathology, Wright State University Boonshoft School of Medicine, Fairborn, OH
- Compunet Clinical Laboratories, Moraine, OH; and
| | | | - Jeffrey J Wargo
- Department of Pathology, Wright State University Boonshoft School of Medicine, Fairborn, OH
- Division of Dermatology, Ohio State University College of Medicine, Gahanna, OH
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12
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Jindal R, Chauhan P, Goyal D, Shirazi N. Idiopathic perniosis presenting as acral purpuric lesions: Clustering of cases before COVID-19 pandemic and their comparison with chilblain like lesions reported in the literature. Dermatol Ther 2021; 34:e14951. [PMID: 33740317 PMCID: PMC8250052 DOI: 10.1111/dth.14951] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/16/2021] [Accepted: 03/11/2021] [Indexed: 11/29/2022]
Abstract
Perniosis/chilblains are the acral inflammatory skin lesions developing in susceptible individuals as an abnormal reaction to cold. In the absence of a discernible cause, it is labeled as idiopathic perniosis (IP). With the ongoing COVID-19 pandemic, there was an upsurge of reports of chilblain like lesions (CLL) especially in young patients possibly implicated to the SARS-CoV-2 virus. Twelve clinically suspected and histopathologically confirmed cases of IP seen from November 2019 through February 2020 were retrospectively recruited. Clinical, dermoscopic, and histopathological characteristics of these were reviewed and compared with CLL reported in the literature. Mean age of patients was 26.58 ± 15.18 years with an equal male to female ratio. Characteristic histopathology findings were spongiosis (100%), dermal edema (100%), perivascular lymphocytic infiltrate (100%) with peri-eccrine accentuation (66.7%), keratinocyte necrosis (50%), focal basal vacuolar damage (58.3%), and lymphocytic vasculitis (58.3%). Significant dermoscopy findings were variable background color ranging from dull red and violaceous to copper red and brown orange, coiled vessels (44.4%) and orange-red structureless areas (63.9%). Lesions over palms and soles preferentially had white dots/clods and lines (38.9%). There appears no exclusive histopathological as well as dermoscopy features of CLL and IP, yet certain clues can be appreciated. Keratinocyte necrosis and severe dermal edema favors IP, whereas fibrin thrombi with involvement of both superficial and deep dermal vessels favor CLL. Dermoscopically presence of irregular, linear or branching vessels, red/purple dots and clods and gray brown reticule supports CLL while white dots/clods and lines supports IP.
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Affiliation(s)
- Rashmi Jindal
- Department of Dermatology, Venereology and Leprosy, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, India
| | - Payal Chauhan
- Department of Dermatology, Venereology and Leprosy, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, India
| | - Dikshita Goyal
- Department of Dermatology, Venereology and Leprosy, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, India
| | - Nadia Shirazi
- Department of Pathology, HIHT University, Dehradun, India
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13
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Abstract
Raynaud's phenomenon, which is characterized by episodic digital pallor, cyanosis and rubor upon exposure to cold environment or to stress, is relatively common, although the prevalence depends on the climate. Still, it is under-diagnosed, under-treated, and often confused with other conditions. Primary Raynaud's phenomenon (i.e., Raynaud disease) must be distinguished from secondary Raynaud's phenomenon (i.e., Raynaud syndrome) as long-term morbidity and outcomes differ vastly between the two conditions. Additionally, the practitioner must differentiate between Raynaud's phenomenon and related vascular disorders, such as acrocyanosis, pernio, and livedo reticularis. In this article, we review differences between the conditions and suggest an approach to diagnosis and treatment strategy for these disorders.
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Affiliation(s)
- Eunjung Choi
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Stanislav Henkin
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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14
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Gómez-Fernández C, López-Sundh AE, González-Vela C, Ocejo-Vinyals JG, Mayor-Ibarguren A, Salas-Venero CA, Gutiérrez-Larrañaga M, Tejerina-Puente A, Fariñas MC, Cabero-Pérez MJ, López-Hoyos M, González-López MA. High prevalence of cryofibrinogenemia in patients with chilblains during the COVID-19 outbreak. Int J Dermatol 2020; 59:1475-1484. [PMID: 33070314 DOI: 10.1111/ijd.15234] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/06/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Many cutaneous manifestations have been described in possible association with the COVID-19 pandemic, including acral lesions resembling chilblains. The underlying pathomechanisms of COVID-19 chilblains are not fully understood. The aim of this study was to describe the clinical, pathological, and laboratory findings of a series of patients who developed chilblains during the COVID-19 outbreak and to investigate the possible factors that could be involved in the pathogenesis of these lesions. METHODS We conducted a prospective cohort study that included 54 patients who presented with chilblains during the highest peak in the incidence of COVID-19 in Cantabria (northern Spain). Skin biopsies were performed on 10 of these patients who presented with recent lesions. Laboratory investigations, including immunological analysis, serological studies, and the assessment of cryoproteins, were also performed. RESULTS Most patients presented erythematous plaques located on the toes and/or purpuric macules located on the feet. Histopathological findings were compatible with those of idiopathic chilblains. Immunohistochemical evaluation showed C3d and C4d deposits in the vessel walls in seven cases. The autoimmunity panel was negative in most of our series. Cryoprotein testing showed positive cryofibrinogen in two-thirds (66.7%) of the patients assessed. On follow-up, most patients presented almost complete resolution, although six patients required prednisone and antiaggregant drug treatment. CONCLUSIONS This study shows, for the first time to our knowledge, a high prevalence of cryofibrinogenemia in patients with chilblains during the COVID-19 pandemic. Cryofibrinogenemia could be implicated in the pathogenesis of chilblains related to COVID-19.
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Affiliation(s)
- Cristina Gómez-Fernández
- Division of Dermatology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - Ana E López-Sundh
- Division of Dermatology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - Carmen González-Vela
- Division of Pathology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - Javier Gonzalo Ocejo-Vinyals
- Division of Immunology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | | | - Carlos A Salas-Venero
- Division of Microbiology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - María Gutiérrez-Larrañaga
- Division of Immunology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - Ana Tejerina-Puente
- Unit of Pediatrics, Health Center La Marina (Santander), Cantabrian Health Service, Santander, Spain
| | - María Carmen Fariñas
- Unit of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - María Jesús Cabero-Pérez
- Division of Pediatrics, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - Marcos López-Hoyos
- Division of Immunology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - Marcos A González-López
- Division of Dermatology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
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15
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Fabbrocini G, Vastarella M, Nappa P, Annunziata MC, Camela E, Greco V, Gaudiello F, Alessio M, Pierri L, Catzola A, Guarino A. A new dermoscopic pattern for chilblain-COVID-19-like skin lesions in adolescents. JAAD Case Rep 2020; 6:1271-1274. [PMID: 33020736 PMCID: PMC7527790 DOI: 10.1016/j.jdcr.2020.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Gabriella Fabbrocini
- Department of Clinical Medicine and Surgery, Section of Dermatology, University of Naples Federico II, Napoli, Italy
| | - Maria Vastarella
- Department of Clinical Medicine and Surgery, Section of Dermatology, University of Naples Federico II, Napoli, Italy
| | - Paola Nappa
- Department of Clinical Medicine and Surgery, Section of Dermatology, University of Naples Federico II, Napoli, Italy
| | - Maria C Annunziata
- Department of Clinical Medicine and Surgery, Section of Dermatology, University of Naples Federico II, Napoli, Italy
| | - Elisa Camela
- Department of Clinical Medicine and Surgery, Section of Dermatology, University of Naples Federico II, Napoli, Italy
| | - Vincenzo Greco
- Department of Clinical Medicine and Surgery, Section of Dermatology, University of Naples Federico II, Napoli, Italy
| | - Francesca Gaudiello
- Department of Clinical Medicine and Surgery, Section of Dermatology, University of Naples Federico II, Napoli, Italy
| | - Maria Alessio
- Department of Translational Medicine, Section of Pediatrics, University of Naples Federico II, Napoli, Italy
| | - Luca Pierri
- Department of Translational Medicine, Section of Pediatrics, University of Naples Federico II, Napoli, Italy
| | - Andrea Catzola
- Department of Translational Medicine, Section of Pediatrics, University of Naples Federico II, Napoli, Italy
| | - Alfredo Guarino
- Department of Translational Medicine, Section of Pediatrics, University of Naples Federico II, Napoli, Italy
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16
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Magro CM, Mulvey JJ, Laurence J, Sanders S, Crowson AN, Grossman M, Harp J, Nuovo G. The differing pathophysiologies that underlie COVID-19-associated perniosis and thrombotic retiform purpura: a case series. Br J Dermatol 2020; 184:141-150. [PMID: 32779733 PMCID: PMC7405151 DOI: 10.1111/bjd.19415] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2020] [Indexed: 02/07/2023]
Abstract
Background There are two distinctive acral manifestations of COVID‐19 embodying disparate clinical phenotypes. One is perniosis occurring in mildly symptomatic patients, typically children and young adults; the second is the thrombotic retiform purpura of critically ill adults with COVID‐19. Objectives To compare the clinical and pathological profiles of these two different cutaneous manifestations of COVID‐19. Methods We compared the light microscopic, phenotypic, cytokine and SARS‐CoV‐2 protein and RNA profiles of COVID‐19‐associated perniosis with that of thrombotic retiform purpura in critical patients with COVID‐19. Results Biopsies of COVID‐19‐associated perniosis exhibited vasocentric and eccrinotropic T‐cell‐ and monocyte‐derived CD11c+, CD14+ and CD123+ dendritic cell infiltrates. Both COVID‐associated and idiopathic perniosis showed striking expression of the type I interferon‐inducible myxovirus resistance protein A (MXA), an established marker for type I interferon signalling in tissue. SARS‐CoV‐2 RNA, interleukin‐6 and caspase 3 were minimally expressed and confined to mononuclear inflammatory cells. The biopsies from livedo/retiform purpura showed pauci‐inflammatory vascular thrombosis without any MXA decoration. Blood vessels exhibited extensive complement deposition with endothelial cell localization of SARS‐CoV‐2 protein, interleukin‐6 and caspase 3; SARS‐CoV‐2 RNA was not seen. Conclusions COVID‐19‐associated perniosis represents a virally triggered exaggerated immune reaction with significant type I interferon signaling. This is important to SARS‐CoV‐2 eradication and has implications in regards to a more generalized highly inflammatory response. We hypothesize that in the thrombotic retiform purpura of critically ill patients with COVID‐19, the vascular thrombosis in the skin and other organ systems is associated with a minimal interferon response. This allows excessive viral replication with release of viral proteins that localize to extrapulmonary endothelium and trigger extensive complement activation.
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Affiliation(s)
- C M Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - J J Mulvey
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Laurence
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - S Sanders
- Sanders Dermatology, New City, NY, USA
| | - A N Crowson
- Regional Medical Laboratories, Pathology Laboratory Associates and University of Oklahoma, Tulsa, OK, USA
| | - M Grossman
- Department of Dermatology, Yale University, New Haven, CT and Hofstra/Northwell, New Hyde, NY, USA
| | - J Harp
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
| | - G Nuovo
- The Ohio State University Comprehensive Cancer Center, Columbus Ohio and Discovery Life Sciences, Powell, OH, USA
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17
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Ko CJ, Harigopal M, Damsky W, Gehlhausen JR, Bosenberg M, Patrignelli R, McNiff JM. Perniosis during the COVID-19 pandemic: Negative anti-SARS-CoV-2 immunohistochemistry in six patients and comparison to perniosis before the emergence of SARS-CoV-2. J Cutan Pathol 2020; 47:997-1002. [PMID: 32745281 PMCID: PMC7436569 DOI: 10.1111/cup.13830] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Acral inflammatory lesions that have some resemblance to idiopathic or autoimmune-associated perniosis (chilblains) have been described in multiple countries during the COVID-19 pandemic. METHODS We examined histopathologic findings in six consecutive such cases from five patients received in mid-May to mid-June of 2020, evaluating immunohistochemical staining for the SARS-CoV-2 nucleocapsid protein. We compared these six cases to eight cases diagnosed as perniosis between January and June of 2019. RESULTS Five of six lesions with perniosis-like histopathology during the COVID-19 pandemic had distinctive tight cuffing of lymphocytes; intravascular material was present in one case. SARS-CoV-2 immunohistochemical staining using an antibody directed at the nucleocapsid protein was negative in all six cases. Only one of eight specimens with microscopic findings of perniosis received prior to the COVID-19 pandemic had tightly cuffed perivascular lymphocytes, and none had obvious intravascular occlusion. CONCLUSIONS A tightly cuffed pattern of perivascular lymphocytes is a feature of perniosis during the COVID-19 pandemic. The absence of SARS-CoV-2 nucleocapsid protein in these cases suggests against the virus being directly present in these lesions.
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Affiliation(s)
- Christine J Ko
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA.,Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Malini Harigopal
- Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - William Damsky
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA.,Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Jeff R Gehlhausen
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Marcus Bosenberg
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA.,Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Robert Patrignelli
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Jennifer M McNiff
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA.,Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
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18
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López‐Robles J, Hera I, Pardo‐Sánchez J, Ruiz‐Martínez J, Cutillas‐Marco E. Chilblain‐like lesions: a case series of 41 patients during the COVID‐19 pandemic. Clin Exp Dermatol 2020; 45:891-892. [PMID: 32369632 PMCID: PMC9213891 DOI: 10.1111/ced.14275] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 11/28/2022]
Affiliation(s)
- J. López‐Robles
- Department of Dermatology Hospital Morales Meseguer Murcia Spain
- Department of Dermatology Hospital Virgen del Castillo Yecla, Murcia Spain
| | - I. Hera
- Department of Dermatology Hospital de la Vega Lorenzo Guirao Cieza Spain
| | - J. Pardo‐Sánchez
- Dermatology Service Complejo Hospitalario Universitario de Cartagena Murcia Spain
| | - J. Ruiz‐Martínez
- Department of Dermatology Hospital General Universitario Reina Sofia Murcia Spain
- Department of Dermatology Hospital Rafael Mendez Lorca, Murcia Spain
| | - E. Cutillas‐Marco
- Department of Dermatology Hospital General Universitario Reina Sofia Murcia Spain
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19
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Colmenero I, Santonja C, Alonso-Riaño M, Noguera-Morel L, Hernández-Martín A, Andina D, Wiesner T, Rodríguez-Peralto JL, Requena L, Torrelo A. SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases. Br J Dermatol 2020; 183:729-737. [PMID: 32562567 PMCID: PMC7323219 DOI: 10.1111/bjd.19327] [Citation(s) in RCA: 309] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2020] [Indexed: 12/16/2022]
Abstract
Background Chilblains (‘COVID toes’) are being seen with increasing frequency in children and young adults during the COVID‐19 pandemic. Detailed histopathological descriptions of COVID‐19 chilblains have not been reported, and causality of SARS‐CoV‐2 has not yet been established. Objectives To describe the histopathological features of COVID‐19 chilblains and to explore the presence of SARS‐CoV‐2 in the tissue. Methods We examined skin biopsies from seven paediatric patients presenting with chilblains during the COVID‐19 pandemic. Immunohistochemistry for SARS‐CoV‐2 was performed in all cases and electron microscopy in one. Results Histopathology showed variable degrees of lymphocytic vasculitis ranging from endothelial swelling and endotheliitis to fibrinoid necrosis and thrombosis. Purpura, superficial and deep perivascular lymphocytic inflammation with perieccrine accentuation, oedema, and mild vacuolar interface damage were also seen. SARS‐CoV‐2 immunohistochemistry was positive in endothelial cells and epithelial cells of eccrine glands. Coronavirus particles were found in the cytoplasm of endothelial cells on electron microscopy. Conclusions Although the clinical and histopathological features were similar to other forms of chilblains, the presence of viral particles in the endothelium and the histological evidence of vascular damage support a causal relation of the lesions with SARS‐CoV‐2. Endothelial damage induced by the virus could be the key mechanism in the pathogenesis of COVID‐19 chilblains and perhaps also in a group of patients severely affected by COVID‐19 presenting with features of microangiopathic damage. What is already known about this topic? Despite the high number of cases of chilblains seen during the COVID‐19 pandemic, a definite causative role for SARS‐CoV‐2 has not yet been proven. Different pathogenetic hypotheses have been proposed, including coagulation anomalies, interferon release and external factors.
What does this study add? The demonstration of SARS‐CoV‐2 in endothelial cells of skin biopsies by immunohistochemistry and electron microscopy confirms that these lesions are part of the spectrum of COVID‐19. Virus‐induced vascular damage and secondary ischaemia could explain the pathophysiology of COVID‐19 chilblains. Our findings support the hypothesis that widespread endothelial infection by SARS‐CoV‐2 could have a pathogenetic role in the severe forms of COVID‐19.
Linked Comment: Wetter. Br J Dermatol 2020; 183:611.
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Affiliation(s)
- I Colmenero
- Department of Pathology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - C Santonja
- Department of Pathology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - M Alonso-Riaño
- Department of Pathology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - L Noguera-Morel
- Department of Dermatology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - A Hernández-Martín
- Department of Dermatology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - D Andina
- Emergency Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - T Wiesner
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | | | - L Requena
- Department of Dermatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - A Torrelo
- Department of Dermatology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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20
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Kanitakis J, Lesort C, Danset M, Jullien D. Chilblain-like acral lesions during the COVID-19 pandemic ("COVID toes"): Histologic, immunofluorescence, and immunohistochemical study of 17 cases. J Am Acad Dermatol 2020; 83:870-875. [PMID: 32502585 PMCID: PMC7265862 DOI: 10.1016/j.jaad.2020.05.145] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND During the coronavirus disease 2019 pandemic, several acral chilblain-like lesions were observed in young patients with suspected, but mostly unconfirmed, infection with severe acute respiratory syndrome coronavirus 2. The histopathologic aspect of these lesions is as yet poorly known. OBJECTIVE To investigate the pathologic features of chilblain-like lesions. METHODS Biopsies were obtained from 17 cases of chilblain-like lesions during the coronavirus disease 2019 pandemic in France and were studied by routine histologic examination, immunohistochemistry, and direct immunofluorescence. The patients had suspected but unconfirmed infection with severe acute respiratory syndrome coronavirus 2 (negative nasopharyngeal polymerase chain reaction and serologic test results). RESULTS Chilblain-like lesions showed many features in common with those reported in idiopathic and autoimmune-related chilblains, including epidermal necrotic keratinocytes, dermal edema, perivascular and perieccrine sweat gland lymphocytic (predominantly CD3/CD4+) inflammation, and frequent vascular changes (endothelialitis, microthromboses, fibrin deposition, and immunoreactant deposits on vessels). CONCLUSIONS Chilblain-like lesions show histopathologic features similar to those of idiopathic and autoimmune-related chilblains, with a high rate of vascular changes and direct immunofluorescence positivity. The role of severe acute respiratory syndrome coronavirus 2 in the development of these puzzling lesions remains to be elucidated.
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Affiliation(s)
- Jean Kanitakis
- Department of Dermatology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; Department of Anatomic Pathology, Lyon Sud Hospital Center, Pierre Bénite, France.
| | - Cécile Lesort
- Department of Dermatology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Marie Danset
- Department of Dermatology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Denis Jullien
- Department of Dermatology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
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21
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Freeman EE, McMahon DE, Lipoff JB, Rosenbach M, Kovarik C, Takeshita J, French LE, Thiers BH, Hruza GJ, Fox LP. Pernio-like skin lesions associated with COVID-19: A case series of 318 patients from 8 countries. J Am Acad Dermatol 2020; 83:486-492. [PMID: 32479979 PMCID: PMC7260509 DOI: 10.1016/j.jaad.2020.05.109] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/22/2020] [Indexed: 01/26/2023]
Abstract
Background Increasing evidence suggests pernio-like lesions are cutaneous manifestations of coronavirus infectious disease 2019 (COVID-19). Objective To describe clinical and pathologic findings of pernio-like lesions in patients with confirmed or suspected COVID-19. Methods An international dermatology registry was circulated to health care providers worldwide through the American Academy of Dermatology, International League of Dermatologic Societies, and other organizations. Results We documented 505 patients with dermatologic manifestations associated with COVID-19, including 318 (63%) with pernio-like lesions. Patients with pernio-like lesions were generally young and healthy, with relatively mild COVID-19. Of 318 patients with confirmed or suspected COVID-19 by providers, 23 (7%) were laboratory-confirmed COVID-19 positive, and 20 others (6%) were close contacts of patients with confirmed COVID-19. Given current testing criteria, many patients lacked COVID-19 testing access. For 55% of patients, pernio-like lesions were their only symptom. In patients with other COVID-19 symptoms, pernio-like lesions typically appeared after other symptoms. Pernio-like lesions lasted a median of 14 days (interquartile range, 10-21 days). Limitations A case series cannot estimate population-level incidence or prevalence. In addition, there may be confirmation bias in reporting. We cannot exclude an epiphenomenon. Conclusions Pernio-like skin changes of the feet and hands, without another explanation, may suggest COVID-19 infection and should prompt confirmatory testing.
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Affiliation(s)
- Esther E Freeman
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts.
| | - Devon E McMahon
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jules B Lipoff
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carrie Kovarik
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Junko Takeshita
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lars E French
- Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany
| | - Bruce H Thiers
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - George J Hruza
- Department of Dermatology, St. Louis University, St Louis, Missouri
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
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22
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Piccolo V, Neri I, Filippeschi C, Oranges T, Argenziano G, Battarra VC, Berti S, Manunza F, Fortina AB, Di Lernia V, Boccaletti V, De Bernardis G, Brunetti B, Mazzatenta C, Bassi A. Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients. J Eur Acad Dermatol Venereol 2020; 34:e291-e293. [PMID: 32330334 PMCID: PMC7267498 DOI: 10.1111/jdv.16526] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 01/28/2023]
Affiliation(s)
- V Piccolo
- Dermatology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - I Neri
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - C Filippeschi
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - T Oranges
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - G Argenziano
- Dermatology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - V C Battarra
- Dermatology Unit, Department of Medical Sciences, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - S Berti
- Dermatology Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - F Manunza
- Dermatology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - A B Fortina
- Padua Hospital Internal Medicine Department - DIMED, Paediatric Dermatology Unit, University of Padua, Padua, Italy
| | - V Di Lernia
- Dermatology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - V Boccaletti
- Department of Dermatology, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - G De Bernardis
- Dermatologist, Aulss 5 Polesana et 6 Euganea, Veneto, Italy
| | - B Brunetti
- Dermatologist in Private Practice, Salerno, Italy
| | - C Mazzatenta
- Division of Dermatology, Azienda Toscana Nord Ovest, Lucca, Italy
| | - A Bassi
- Division of Dermatology, Azienda Toscana Nord Ovest, Lucca, Italy
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23
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Logan D, So E, Sundling RA. Pernio-Induced Toe Pain in the Setting of Onychocryptosis: A Case Report. J Am Podiatr Med Assoc 2020; 110:Article7. [PMID: 32073325 DOI: 10.7547/18-018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pernio is an inflammatory condition of the skin associated with cold exposure. The dermatologic manifestations may vary, and this entity is frequently misdiagnosed. Its association with systemic disease underscores the importance of accurate diagnosis. The authors describe a case report in which a patient who, after initially presenting with a complaint of pain and an ingrown toenail, was eventually diagnosed with pernio as well.
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Affiliation(s)
- Daniel Logan
- Foot and Ankle Specialists of Central Ohio, Newark, OH
| | - Eric So
- Grant Medical Center, Columbus, OH
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24
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Maheshwari A, Pandit K, Kumar V, Mahto D. COVID 19 and immune phenomenon in children. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2020. [DOI: 10.4103/injms.injms_59_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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25
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Muralidhar A, Venugopal S, Nandini AS. Clinicohistopathologic study of lichenoid interface dermatitis. ARCHIVES OF MEDICINE AND HEALTH SCIENCES 2020. [DOI: 10.4103/amhs.amhs_11_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Abstract
Idiopathic chilblain is a relatively common yet poorly recognized acrosyndrome. This literature review aims to better understand and draw attention to this disorder. Chilblain is a localized inflammation of the skin that occurs on exposure to cold but non-freezing wet weather. It usually resolves spontaneously. The etiology is uncertain, but vasospasm seems to play a role in this abnormal reaction to cold. Diagnosis is most often based on clinical presentation, but a skin biopsy can be useful in dubious cases. In histology, dermal edema and an inflammatory infiltrate are usually present. A distribution of the infiltrate particularly around the eccrine gland is typical. Systemic symptoms and underlying autoimmune disease should be screened. Avoiding cold and keeping extremities warm is the first recommendation for management, as well as smoking cessation. Calcium channel blockers (in particular nifedipine) seems to be the treatment that has been most evaluated in chilblains. However, their effectiveness is not confirmed by all studies. Topical betamethasone is often used but its effect has not been confirmed by randomized clinical trials. Other treatments, such as pentoxifylline, hydrochloroquine and topical nitroglycerin have shown positive effects only in a reduced number of patients. Acupuncture seems to bring a benefit.
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Affiliation(s)
- Astrid Nyssen
- Department of Cardiology, CHR Verviers East Belgium Verviers, Belgium.,Department of Vascular Diseases, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Farida Benhadou
- Department of Dermatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Marc Magnée
- Department of Cardiology, CHR Verviers East Belgium Verviers, Belgium
| | - Josette André
- Department of Dermatology and Dermatopathology, Hôpital Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Caroline Koopmansch
- Department of Dermatology and Dermatopathology, Hôpital Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Claude Wautrecht
- Department of Vascular Diseases, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Wang ML, Chan MP. Comparative Analysis of Chilblain Lupus Erythematosus and Idiopathic Perniosis: Histopathologic Features and Immunohistochemistry for CD123 and CD30. Am J Dermatopathol 2018; 40:265-271. [DOI: 10.1097/dad.0000000000000945] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cold-Associated Perniosis of the Thighs (“Equestrian-Type” Chilblain): A Reappraisal Based on a Clinicopathologic and Immunohistochemical Study of 6 Cases. Am J Dermatopathol 2016; 38:726-31. [DOI: 10.1097/dad.0000000000000477] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Souwer IH, Smaal D, Bor JHJ, Knoers N, Lagro-Janssen ALM. Phenotypic familial aggregation in chronic chilblains. Fam Pract 2016; 33:461-5. [PMID: 27382984 DOI: 10.1093/fampra/cmw052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Our clinical observations and two earlier studies indicate familial clustering to be involved in chronic chilblains. Demonstrating phenotypic familial aggregation is a next step to investigate the origin of familial clustering. OBJECTIVE This study was initiated to assess evidence for phenotypic familial aggregation in chronic chilblains. METHODS Using a case-control family design in a primary care setting, we computed the familial relative risk of at least one episode of chronic chilblains during life with 95% confidence intervals (CIs). The study population consisted of 192 relatives of 31 case probands (at least one confirmed episode of chronic chilblains). The control population consisted of 178 relatives of 31 sex- and age-matched index controls (no history of chronic chilblains). RESULTS The familial relative risk of chronic chilblains was 3.6 (95% CI 1.9-7.3). Additional sensitivity analysis shows similar figures. CONCLUSION We demonstrate robust phenotypic familial aggregation in chronic chilblains.
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Affiliation(s)
- Ibo H Souwer
- Department of Primary and Community Care, Unit Sex and Women's Health, Radboud University Medical Center, Internal Post Code 118, PO Box 9101, 6500 HB Nijmegen, The Netherlands,
| | - Deborah Smaal
- Department of Primary and Community Care, Radboud University Medical Center, Internal Post Code 117, PO Box 9101, 6500 HB Nijmegen, The Netherlands and
| | - Jacobus H J Bor
- Department of Primary and Community Care, Radboud University Medical Center, Internal Post Code 117, PO Box 9101, 6500 HB Nijmegen, The Netherlands and
| | - Nine Knoers
- Department of Medical Genetics, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
| | - Antoine L M Lagro-Janssen
- Department of Primary and Community Care, Unit Sex and Women's Health, Radboud University Medical Center, Internal Post Code 118, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Gordon R, Arikian AM, Pakula AS. Chilblains in Southern California: two case reports and a review of the literature. J Med Case Rep 2014; 8:381. [PMID: 25416648 PMCID: PMC4275761 DOI: 10.1186/1752-1947-8-381] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 09/01/2014] [Indexed: 01/22/2023] Open
Abstract
Introduction Chilblains or perniosis is an acrally located cutaneous eruption that occurs with exposure to cold. Chilblains can be classified into primary and secondary forms. The primary or idiopathic form is not associated with an underlying disease and is clinically indistinguishable from the secondary form. The secondary form is associated with an underlying condition such as connective tissue disease, monoclonal gammopathy, cryoglobulinemia, or chronic myelomonocytic leukemia. Histopathology cannot accurately help distinguish the primary from secondary forms of chilblains. This article will raise the awareness of chilblains by presenting two unusual case reports of chilblains in men from Southern California with discussion of the appropriate evaluation and treatment of this condition. Case presentations Case 1 A 56-year-old Caucasian man presented in January to a Southern California primary care clinic with a report of tingling and burning in both feet, followed by bluish discoloration and swelling as well as blistering. He had no unusual cold exposure prior to the onset of his symptoms. He had a history of “white attacks” in his hands consistent with Raynaud’s phenomenon. His symptoms gradually resolved over a 3-week period. Case 2 A 53-year-old Caucasian man also presented to a Southern California clinic in January with a 3-week history of painful tingling in his toes, and subsequent purplish-black discoloration of the toes in both feet. His symptoms occurred 1 week after a skiing trip. He had partial improvement with warming measures. His symptoms resolved 2 weeks after his initial presentation. Conclusions Chilblains is a relatively uncommon entity in warmer climates but can present during the winter months. Primary care providers in warmer climates such as Southern California in the USA may be unfamiliar with its presentation. It can be diagnosed clinically by the appearance of typical lesions during the cold damp season. Through a thorough history, physical examination and selected laboratory evaluation, underlying connective tissue disease or a mimic such as vasculitis or cutaneous leukemia can be excluded.
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Affiliation(s)
| | - Anne M Arikian
- UCLA Department of Family Medicine Family Health Center, 1920 Colorado Avenue, Santa Monica, CA 90404, USA.
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Cappel JA, Wetter DA. Clinical characteristics, etiologic associations, laboratory findings, treatment, and proposal of diagnostic criteria of pernio (chilblains) in a series of 104 patients at Mayo Clinic, 2000 to 2011. Mayo Clin Proc 2014; 89:207-15. [PMID: 24485134 DOI: 10.1016/j.mayocp.2013.09.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 08/26/2013] [Accepted: 09/30/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To further characterize the clinical features, etiologic associations, laboratory findings, and treatment of pernio. PATIENTS AND METHODS This is a retrospective review of patients with pernio seen at our institution between January 1, 2000, and December 31, 2011. RESULTS Of 104 patients with pernio (mean age at diagnosis, 38.3 years), 82 (79%) were women. Pernio affected the toes in 85 patients (82%) and the fingers in 31 (30%). Thirty-eight patients (37%) had at least 1 abnormal laboratory test result, and test results were positive for cold agglutinins in 11 (55%) of 20 tested patients. Results were negative for cryoglobulins in all tested patients (n=53). Four patients (4%) had connective tissue disease (nonlupus) associated with pernio; 3 patients (3%) had an associated hematologic malignant disease. Conservative treatments (eg, warming, drying, and smoking cessation) provided complete response in 23 (82%) of 28 patients with follow-up data. CONCLUSION To our knowledge, this study represents one of the largest single-center case series of pernio to date. Most of the patients did not have an underlying systemic association with pernio, although a few patients had pernio in association with connective tissue disease or hematologic malignant disease.
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Arribas MP, Albares M, Soro P, Belinchon I. Red and purple papules on the dorsum of fingers and toes in a woman. Int J Dermatol 2013; 52:1295-6. [PMID: 24164150 DOI: 10.1111/ijd.12102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Maria Paloma Arribas
- Department of Dermatology, Hospital general Universitario de Alicante, Alicante, Spain
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Yang AY, Schwartz L, Divers AK, Sternberg L, Lee JB. Equestrian chilblain: another outdoor recreational hazard. J Cutan Pathol 2013; 40:485-90. [DOI: 10.1111/cup.12082] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 12/17/2012] [Accepted: 12/18/2012] [Indexed: 11/29/2022]
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Takci Z, Vahaboglu G, Eksioglu H. Epidemiological patterns of perniosis, and its association with systemic disorder. Clin Exp Dermatol 2012; 37:844-9. [DOI: 10.1111/j.1365-2230.2012.04435.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tomasini D, Mentzel T, Hantschke M, Cerri A, Paredes B, Rütten A, Schärer L, Kutzner H. Plasmacytoid dendritic cells: an overview of their presence and distribution in different inflammatory skin diseases, with special emphasis on Jessner's lymphocytic infiltrate of the skin and cutaneous lupus erythematosus. J Cutan Pathol 2011; 37:1132-9. [PMID: 20659210 DOI: 10.1111/j.1600-0560.2010.01587.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Plasmacytoid dendritic cells (PDC) play a pivotal role in the induction of autoimmune diseases and other skin diseases. The present study focuses on the distribution patterns of PDC in patients with cutaneous lupus erythematosus (LE) and Jessner's lymphocytic infiltrate (LI) of the skin and compares them with other skin diseases. The goal was to scrutinize the involvement of PDC in LI, and to show that PDC present a specific pattern of distribution in various cutaneous disorders. METHODS 353 skin biopsies of LE (various subtypes), LI, and other inflammatory skin diseases as well as two halo melanocytic nevi and 10 epithelial tumors were immunohistochemically investigated for the presence of PDC by employing antibodies against CD123 and CD2AP. RESULTS PDC were constantly detected as distinct perivascular and periadnexal clusters in LE and LI. In other forms of dermatitis, PDC could be found as single cells or scattered throughout the infiltrate or beneath the epidermis. CONCLUSIONS Our data suggest that the distribution of PDC in tumid LE and LI is identical, and this observation suggests that both designations signify one disease. The distinct PDC arrangement in LE represents as useful diagnostic tool in the differential diagnosis with other forms of dermatitis.
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Affiliation(s)
- Dario Tomasini
- Department of Dermatology, Hospital of Busto Arsizio, Busto Arsizio, Italy.
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Ravenscroft JC, Suri M, Rice GI, Szynkiewicz M, Crow YJ. Autosomal dominant inheritance of a heterozygous mutation in SAMHD1 causing familial chilblain lupus. Am J Med Genet A 2010; 155A:235-7. [DOI: 10.1002/ajmg.a.33778] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lutz V, Cribier B, Lipsker D. Chilblains and antiphospholipid antibodies: report of four cases and review of the literature. Br J Dermatol 2010; 163:645-6. [DOI: 10.1111/j.1365-2133.2010.09829.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Raza N, Habib A, Razvi SKA, Dar NR. Constitutional and Behavioral Risk Factors for Chilblains: A Case-Control Study From Pakistan. Wilderness Environ Med 2010; 21:17-21.e1. [DOI: 10.1016/j.wem.2009.12.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lichenoid Tissue Reaction/Interface Dermatitis: Clinical and Histological Perspectives. J Invest Dermatol 2009. [DOI: 10.1038/jid.2009.42] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Sontheimer RD. Lichenoid tissue reaction/interface dermatitis: clinical and histological perspectives. J Invest Dermatol 2009; 129:1088-99. [PMID: 19242512 DOI: 10.1038/sj.jid.2009.42] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A number of uncommon, clinically diverse and poorly understood inflammatory skin diseases are linked by the presence of a set of histopathological elements that have traditionally been referred to as the "lichenoid tissue reaction/interface dermatitis" (LTR/IFD). The prototypic skin disease in this category is lichen planus. However, the LTR/IFD can also be seen in skin disorders associated with systemic illnesses (lupus erythematosus, dermatomyositis), and the skin changes of potentially fatal disorders such as graft-versus-host disease, Stevens-Johnson syndrome, and toxic epidermal necrolysis. It has been traditionally felt that cytotoxic T-lymphocytes represent the final effector cell type for the epidermal basal cell layer injury pattern that is common to LTR/IFD disorders. Recent work has suggested that a number of different LTR/IFD skin disorders share a common inflammatory signaling pathway involving the actions of plasmacytoid dendritic cell-derived IFN-alpha. This signaling pathway appears to amplify cytotoxic T cell injury to the epidermal basal cell compartment. This review will summarize the work implicating this pathway as well as the other cellular and molecular mechanisms that are thought to be responsible for the prototypic LTR/IFD disorder, lichen planus. It is hoped that a better understanding of the immunological commonalities shared by various LTR/IFD disorders will lead to more effective safer treatment options for these illnesses.
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Affiliation(s)
- Richard D Sontheimer
- Department of Dermatology, Richard and Adeline Fleischaker Chair in Dermatology Research, University of Oklahoma Health Sciences Center, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA.
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Piga M, Vacca A, Cauli A, Porru G, Mathieu A. Familial chilblain and late contractural arachnodactyly: a novel association? Joint Bone Spine 2009; 76:205-8. [PMID: 19124263 DOI: 10.1016/j.jbspin.2008.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Accepted: 08/21/2008] [Indexed: 11/17/2022]
Abstract
We report an Italian family suffering from chilblain. Seven members over three generations affected, two of them presenting association with late contractural arachnodactyly. Inflammatory cutaneous lesions following exposure to cold or drop in temperature are called chilblain. Arachnodactyly is an hallmark of hereditary connective tissue disorders such as Marfan's syndrome and Beals' syndrome. The latter, showing joint congenital contractures, is called indeed congenital contractural arachnodactyly. We speculate that an underlying alteration in connective tissue could lead to the association between chilblain lesions and contractural arachnodactyly.
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Affiliation(s)
- Matteo Piga
- Department of Medical Sciences, University of Cagliari and AOU of Cagliari, Italy
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Hirschmann JV, Raugi GJ. Blue (or purple) toe syndrome. J Am Acad Dermatol 2009; 60:1-20; quiz 21-2. [DOI: 10.1016/j.jaad.2008.09.038] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 08/26/2008] [Accepted: 09/03/2008] [Indexed: 01/19/2023]
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Abstract
Interface dermatitis can be classified based upon the cell type that dominates the infiltrate (ie, neutrophilic, lymphocytic, or lymphohistiocytic) or by the intensity of the interface inflammation. Regarding lymphocytic interface dermatitis, there are 2 broad categories: cell-poor interface dermatitis, when only a sparse infiltrate of inflammatory cells is present along the dermoepidermal junction, or cell rich, which typically occurs as a heavy bandlike infiltrate that obscures the basal layers of the epidermis. In the case of lymphocytic interface dermatitis, the latter is often termed a lichenoid interface dermatitis. This review focuses upon the mononuclear cell-predominant forms of interface dermatitis.
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Affiliation(s)
- A Neil Crowson
- Department of Dermatology, University of Oklahoma and Regional Medical Laboratories, St John Medical Center, 1923 S Utica Ave, Tulsa, OK 74104, USA.
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Kolivras A, Aeby A, Crow YJ, Rice GI, Sass U, André J. Cutaneous histopathological findings of Aicardi-Goutières syndrome, overlap with chilblain lupus. J Cutan Pathol 2008; 35:774-8. [PMID: 18422690 DOI: 10.1111/j.1600-0560.2007.00900.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a 2-year-old girl with developmental delay who, from the age of 1 year, developed perniotic lesions of the hands and feet initially diagnosed as chilblain lupus. Histological examination showed features of epidermal necrosis with intraepidermal bulla formation, interface dermatitis, lymphocytic vasculitis with fibrinoid necrosis and thrombi formation, both superficial and deep dermal lymphocytic infiltrate, lymphocytic eccrine hidradenitis and absence of marked dermal edema. Subsequent investigations suggested a clinical diagnosis of Aicardi-Goutières syndrome (AGS), a rare genetic leukoencephalopathy. Recently, both AGS and familial chilblain lupus, an autosomal dominant form of systemic lupus erythematosus (SLE), have been shown to be allelic thus suggesting a common pathogenic basis. In addition, a phenotypic overlap is apparent between SLE and AGS. To our knowledge, this is the first comprehensive dermatopathological report of the cutaneous lesions seen in AGS, and our paper highlights the importance of considering AGS in the differential diagnosis of perniosis and chilblain lupus.
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Affiliation(s)
- Athanassios Kolivras
- Département Interhospitalier Universitaire de Dermatologie, Brugmann/HUDERF/Saint-Pierre Hospitals, Université Libre de Bruxelles (ULB), Brussels, Belgium.
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Carlson JA, Chen KR. Cutaneous Vasculitis Update: Neutrophilic Muscular Vessel and Eosinophilic, Granulomatous, and Lymphocytic Vasculitis Syndromes. Am J Dermatopathol 2007; 29:32-43. [PMID: 17284960 DOI: 10.1097/01.dad.0000245198.80847.ff] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Most biopsies of cutaneous vasculitis will exhibit a small vessel neutrophilic vasculitis [leukocytoclastic vasculitis (LCV)] that is associated with immune complexes on direct immunofluorescence examination or, less commonly, antineutrophilic cytoplasmic antibodies (ANCA) by indirect immunofluorescence testing. Is in uncommon for skin biopsy to reveal solely a neutrophilic arteritis signifying the presence of cutaneous polyarteritis nodosa or, if accompanied by significant lobular panniculitis, nodular vasculitis/erythema induratum. In other cases, cutaneous vascular damage (fibrinoid necrosis, muscular vessel wall disruption, or endarteritis obliterans) will be mediated by a nonneutrophilic inflammatory infiltrate. Eosinophilic vasculitis can be a primary (idiopathic) process that overlaps with hypereosinophilic syndrome, or it can be a secondary vasculitis associated with connective tissue disease or parasite infestation. Authentic cutaneous granulomatous vasculitis (versus vasculitis with extravascular granulomas) can represent a cutaneous manifestation of giant cell arteritis, an eruption secondary to systemic disease such as Crohn's disease or sarcoidosis, or a localized disorder, often a post-herpes zoster (HZ) phenomenon. Lymphocytic vasculitis is a histologic reaction pattern that correlates with broad clinical differential diagnosis, which includes connective tissue disease - mostly systemic lupus erythematosus (SLE), endothelial infection by Rickettsia and viruses, idiopathic lichenoid dermatoses such as perniosis or ulcerative necrotic Mucha-Habermann disease, and angiocentric cutaneous T-cell lymphomas. Skin biopsy extending into the subcutis, identifying the dominant inflammatory cell and caliber of vessels affected, extravascular histologic clues such as presence of lichenoid dermatitis or panniculitis, and correlation with clinical data allows for accurate diagnosis of these uncommon vasculitic entities.
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Affiliation(s)
- J Andrew Carlson
- Division of Dermatology, Albany Medical College, MC-81, Albany, NY 12208, USA.
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Carlson JA, Ng BT, Chen KR. Cutaneous Vasculitis Update: Diagnostic Criteria, Classification, Epidemiology, Etiology, Pathogenesis, Evaluation and Prognosis. Am J Dermatopathol 2005; 27:504-28. [PMID: 16314707 DOI: 10.1097/01.dad.0000181109.54532.c5] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Vasculitis, inflammation of the vessel wall, can result in mural destruction with hemorrhage, aneurysm formation, and infarction, or intimal-medial hyperplasia and subsequent stenosis leading to tissue ischemia. The skin, in part due to its large vascular bed, exposure to cold temperatures, and frequent presence of stasis, is involved in many distinct as well as un-named vasculitic syndromes that vary from localized and self-limited to generalized and life-threatening with multi-organ disease. To exclude mimics of vasculitis, diagnosis of cutaneous vasculitis requires biopsy confirmation where its acute signs (fibrinoid necrosis), chronic signs (endarteritis obliterans), or past signs (acellular scar of healed arteritis) must be recognized and presence of extravascular findings such as patterned fibrosis or collagenolytic granulomas noted. Although vasculitis can be classified by etiology, many cases have no identifiable cause, and a single etiologic agent can elicit several distinct clinicopathologic expressions of vasculitis. Therefore, the classification of cutaneous vasculitis is best approached morphologically by determining vessel size and principal inflammatory response. These histologic patterns roughly correlate with pathogenic mechanisms that, when coupled with direct immunofluorescent examination, anti-neutrophil cytoplasmic antibody (ANCA) status, and findings from work-up for systemic disease, allow for specific diagnosis, and ultimately, more effective therapy. Herein, we review cutaneous vasculitis focusing on diagnostic criteria, classification, epidemiology, etiology, pathogenesis, and evaluation of the cutaneous vasculitis patient.
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Affiliation(s)
- J Andrew Carlson
- Division of Dermatology, Albany Medical College, Albany, New York 12208, USA.
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