Two cases of COVID-19 presenting with a clinical picture resembling chilblains: first report from the Middle East

In Silico analysis unveils rs2109069 of DPP9 as a potential catalyst for COVID-19 severity and risk of inflammatory symptoms

BACKGROUND

During the COVID-19 pandemic, the viral illness caused by SARS-CoV-2 spread through respiratory droplets, resulting in a global pandemic with a range of symptoms from mild to severe. Pathological inflammation posed a critical issue, yet the genetic mechanisms behind the excessive activation of inflammatory responses remained unclear. To uncover the genetic and regulatory basis of the pathogenesis, we first explored possible genetic mechanisms from phenome-wide association studies (PWAS) with different severity levels of COVID-19. PWAS is a genetic research approach that identifies pleiotropic risk variants that contribute to elucidating potential physiological mechanisms from different traits.

METHODS

We used the PWAS approach to link the multiple clinical symptoms to the variants. We discovered a common variant, rs2109069, in dipeptidyl peptidase 9 (DPP9), which relates to the elevated odds ratio of developing severe illness from COVID-19. Interestingly, the proxy of rs2109069 has been identified as the susceptible locus of interstitial lung disease (ILD) and idiopathic pulmonary fibrosis (IPF). We thus examined the DPP9 expression patterns in selected organs, including the lungs, blood vessels, and skin.

RESULTS

In silico analysis revealed conserved driver activation between COVID-19-induced inflammation and the association with ILD and IPF. Multi-omics analysis further verified the association of DPP9 with abnormal inflammatory responses in COVID-19. Lastly, gene homology analysis inferred a potential regulatory role of DPP9 in inhibiting inflammasome activation, which suggests that DPP9 deficiency may exacerbate inflammation observed in some COVID-19 patients.

CONCLUSIONS

Our in silico findings reveal that severe COVID-19 inflammatory responses and inflammatory lung diseases share the same genetic risk loci, helping to elucidate the underlying physiological mechanisms of severe COVID-19 inflammation. Additionally, the individual differences in immune sensitivity may contribute to the varying multi-organ inflammatory effects among patients. The rs2109069 of DPP9 could be a genetic marker to predict the risk of specific COVID-19 symptoms and severity.

Cutaneous Manifestation in COVID-19: A Lesson Over 2 Years Into the Pandemic

Cutaneous manifestations related to Coronavirus Disease-19 (COVID-19) have been reported over 2 years since the pandemic began. This research aimed to review articles published in English that describe cutaneous manifestations related to COVID-19/SARS-CoV-2. A data search for case reports, original studies, and review articles from the onset of the current COVID-19 pandemic to December 31, 2022, was performed using PUBMED, Cochrane Library, ResearchGate, and Google search engines. Keywords were "coronavirus", "novel coronavirus 2019", "COVID-19", "SARS-CoV-2", and "2019-nCoV" in combination with "cutaneous", "skin" and "dermatology" The extracted data included authors, region, sex, age, number of participants with skin signs, cutaneous signs, its location, symptoms, extracutaneous/associated symptoms, suspected or confirmed status for COVID-19, timeline, and healing duration. Six authors independently reviewed the abstracts and full-texts to identify publications providing these details concerning cutaneous manifestations related to COVID-19. A total of 139 publications with full text (122 case reports, 10 case series, and 7 review articles) that reported cutaneous manifestations were identified, and reviewed from 5 continents. The most common cutaneous manifestations of COVID-19 were maculopapular, followed by chilblain-like lesion, urticarial, livedoid/necrotic, vesicular, and other/non-descript rashes/skin lesions. After 2 years into the COVID-19 pandemic, we can conclude that there is no pathognomonic cutaneous manifestation of COVID-19, since it can be also found in other viral infections.

Manifestaciones dermatológicas por Covid-19 y su aporte en la comprensión de la enfermedad

La enfermedad por coronavirus (Covid-19) presenta compromiso multisistémico y hasta en el 20% de los casos puede exhibir signos dermatológicos. Se realiza una revisión narrativa de la literatura acerca de las principales manifestaciones mucocutáneas asociadas a la infección por Covid-19. También se describen brevemente los mecanismos fisiopatológicos y se lleva a cabo una clasificación de las lesiones en maculopapulares, urticariales, vesiculoampollosas, tipo pernio, livedo necróticas, vasculíticas, con compromiso del folículo piloso, ungular u oral. Se presentan sus principales características clínicas, histopatológicas y tratamientos.

Characteristics of herpes zoster infection in patients with COVID-19: a systematic scoping review

BACKGROUND

Although there is literature reporting correlations between varicella zoster virus (VZV) infections and COVID-19, insufficient evidence exists in this regard. This scoping review aims to identify the existing evidence regarding clinical characteristics of primary VZV infection or reactivation in COVID-19.

METHODS

Following the PRISMA Extension for Scoping Reviews, MEDLINE and EMBASE were searched for all peer-reviewed articles with relevant keywords including "Zoster," "Herpes," and "COVID-19" from their inception to November 20, 2021.

RESULTS

A total of 19 articles with three observational studies and 16 case reports or series were included. Primary VZV infections or reactivation were observed in 25 patients. Forty-eight percent of the patients had disseminated VZV infection. The median time of VZV-related rash after the onset of respiratory symptoms was 7.0 days (interquartile range: 0-18.8). Those with COVID-19 and primary VZV infection or reactivation had low lymphocyte counts with a median of 0.67 × 103 /μl.

CONCLUSION

This scoping review identified uncertainty and a lack of strong evidence to see the association between primary VZV infection or reactivation and COVID-19. However, those with COVID-19 may be more likely to have disseminated VZV, which poses an additional challenge from an infection prevention standpoint. Future studies are warranted to determine the association between primary VZV infection or reactivation and long-term consequences related to COVID-19.

SARS-CoV-2 and Skin: New Insights and Perspectives

The SARS-CoV-2 pandemic has disrupted global health systems and brought the entire globe to its knees. Although born as a disease of the respiratory system, COVID-19 can affect different parts of the body, including the skin. Reports of ongoing skin manifestations of COVID-19 have gradually multiplied, pushing researchers to investigate the etiopathogenic mechanisms underlying these phenomena in more depth. In an attempt to investigate the possible association between SARS-CoV-2, ACE2, TMPRSS2 and skin manifestations, we performed immunohistochemical investigations of the ACE2 receptor and TMPRSS2 in nine skin samples from SARS-CoV-2-positive patients compared to a cohort of healthy controls. Furthermore, after consulting public databases regarding ACE2 mRNA expression in various cell populations resident in the skin, we conducted a literature review aimed at outlining the current state of this topic. We did not find statistically different immuno-expression of ACE2 and TMPRSS2 between the group of SARS-CoV-2-positive patients (nine skin biopsies) and the control group. Regarding ACE2, major immunolabeling was present in the epidermal keratinocytes and, rarely, in the fibroblasts and in the adenomeres of the eccrine sweat glands. Regarding the immune expression of TMPRSS2, we found no significant differences between the two groups, with a weak immune staining only in some skin cytotypes. From the review of the literature, we isolated 35 relevant articles according to the inclusion criteria adopted. ACE2 appears to be a target of SARS-CoV-2, although, other receptor molecules may potentially be implicated, such as TMPRSS2. Future studies with large cases and different molecular investigative methods are needed to further elucidate the mechanisms underlying the skin manifestations of SARS-CoV-2.

COVID-19 and New Onset IgA Vasculitis: A Systematic Review of Case Reports

INTRODUCTION

Immunoglobulin A vasculitis is historically more commonly found in children after certain viral infections such as Epstein-Barr, varicella virus, and parvovirus B19. COVID-19 has not been formally established in literature as a trigger for immunoglobulin A vasculitis. However, a main pathogenetic mechanism of COVID-19 is vascular damage, which makes it likely that vasculitis associated with COVID-19 (ie, COVID-19-mediated immunoglobulin A vasculitis) could be biologically plausible, with serious implications, especially for adults. The purpose of this review is to assist emergency nurses in gaining knowledge on the pathophysiology, symptoms, and treatment of COVID-19-mediated immunoglobulin A vasculitis.

METHODS

A systematic search for case reports of COVID-19-associated immunoglobulin A vasculitis was conducted in the PubMed and Scopus electronic databases. The search terms used were COVID-19, coronavirus 2019, SARS COVID-19, and IgA vasculitis, case reports. The following were the inclusion criteria: publication dates between December 1, 2019, and December 1, 2021; full-text article, clinical case studies, and letters to the editor available electronically in English. The following were exclusion criteria: a summary of reports and newspaper publications.

RESULTS

Only 13 clinical cases met the inclusion criteria. The median age of patients described in the case reports were 38.1 years. Of them, 3 children were less than 5 years old. Twelve patients were male. In 7 of 13 cases of immunoglobulin A vasculitis, renal involvement was found.

DISCUSSION

The analysis of published clinical cases showed that COVID-19-associated immunoglobulin A vasculitis affected mostly adults and was characterized by a more severe course because of renal involvement. COVID-19 may be a possible trigger for immunoglobulin A-related disorders. More research is needed to better understand the relationship between immunoglobulin A vasculitis and COVID-19.

Cutaneous manifestations of COVID-19 among healthcare workers: A Case report and literature review

Common clinical features of COVID-19 are increasingly known but cutaneous manifestations are rarely described among healthcare workers. A review of cutaneous manifestations of COVID-19 especially among healthcare workers (HCW) is thus required. The aim of our current study was to provide a comprehensive review of cutaneous manifestations of COVID-19 among HCW through six case reports and a literature review. We conducted a literature search for cases reports, original and review articles using PubMed and the Google search engines. We included the written English studies that mentioned cutaneous symptoms during COVID-19 infection. In addition to the review, 6 cases were collected among the HCW working at the Charles Nicolle Hospital of Tunis from September 2020 to January 2021. In our review, we included 17 articles in addition to our six cases. The type of papers was case series and case reports in respectively 8 and 9 studies. Skin manifestations were reported in two studies including two HCW, in addition to our series of six HCW. Skin manifestations were chilblain-like lesions (44.5%), a generalized macular or maculopapular exanthem (32.1%), a papulovesicular rash and chicken pox-like vesicles (11.5%), painful acral red-purple papules (4.6%), urticaria (2.8%), purpuric or petechial lesions (2.3%), and livedo reticularis lesions (0.45%). Of the 218 cases, 203 cases have reported the location of lesions. The very great majority of lesions were found on the trunk, hands, and feet. Fifty-one patients (23.4%) experienced lesions on the trunk. The time of onset of cutaneous lesions was variable. At the diagnosis or the onset of COVID-19 symptoms, 8.3% (18/218) of patients presented with cutaneous lesions. After the onset of respiratory symptoms or COVID-19 diagnosis, 36.7% (80/218) of patients presented with cutaneous lesions. Of the 197 cases with reported healing times, healing times were up to 24 days. COVID-19 has been associated with different cutaneous manifestations, likely of varying pathophysiology and severity, some preceding COVID-19 symptomatology and others occurring during active disease or later in the course. Thus, heightened awareness and timely recognition of cutaneous manifestations in COVID-19 are important for occupational physicians treating HCW with COVID-19.

Population-Based Incidence of Guillain-Barré Syndrome During Mass Immunization With Viral Vaccines: A Pooled Analysis

Misunderstanding temporal coincidence of adverse events during mass vaccination and invalid assessment of possible safety concerns have negative effects on immunization programs, leading to low immunization coverage. We conducted this systematic review and meta-analysis to identify the incidence rates of GBS that are temporally associated with viral vaccine administration but might not be attributable to the vaccines. By literature search in Embase and PubMed, we included 48 publications and 2,110,441,600 participants. The pooled incidence rate of GBS was 3.09 per million persons (95% confidence interval [CI]: 2.67 to 3.51) within six weeks of vaccination, equally 2.47 per 100,000 person-year (95%CI: 2.14 to 2.81). Subgroup analyses illustrated that the pooled rates were 2.77 per million persons (95%CI: 2.47 to 3.07) for individuals who received the influenza vaccine and 2.44 per million persons (95%CI: 0.97 to 3.91) for human papillomavirus (HPV) vaccines, respectively. Our findings evidence the GBS-associated safety of virus vaccines. We present a reference for the evaluation of post-vaccination GBS rates in mass immunization campaigns, including the SARS-CoV-2 vaccine.

Mucocutaneous lesions associated with SARS‑CoV‑2 infection (Review)

The ongoing COVID-19 pandemic, declared by the World Health Organisation in March 2020, with the emergence of new, possibly more contagious and more virulent strains, remains a research subject, with the complex systemic involvement better described and understood, but also with a variety of skin and mucosal lesions described in the literature. Mucocutaneous lesions associated with SARS-CoV-2 infection are still under investigation, due to their polymorphic clinical aspect and incompletely understood pathogenic mechanism. The cutaneous inflammatory, exanthematous and purpuric rashes, erythemato-purpuric enanthems, oral ulcers, lichenoid oral lesions, conjunctivitis, conjunctival pseudomembranes, or corneal lesions have been described in patients with COVID-19. Several classifications have been proposed based on the clinical pattern, histological findings, and possible pathogenic mechanisms. The pathogenic mechanism, the diagnostic criteria, the prognostic importance of these lesions are still being debated. The diverse clinical aspects of dermatological manifestations render the diagnosis difficult. However, several clinical patterns strongly associated with COVID-19, such as chilblains, papulovesicular exanthems, and febrile rash require increased awareness and changes to the investigation protocols for these conditions, to include testing for SARS-CoV-2. In the present review, the mucocutaneous findings associated with the novel coronavirus infection, reported thus far in the literature, was provided.

CUTANEOUS MANIFESTATIONS OF COVID-19 IN A TERTIARY COVID REFERRAL HOSPITAL IN THE PHILIPPINES

Background

Reports on COVID-19 skin manifestations and associated clinical outcomes are limited. Like viral diseases, cutaneous findings may be present and can help in confirmation and prognostication among those suspected or diagnosed with COVID-19.

Objective

To determine COVID-19 cutaneous manifestations and their association with disease severity and course.

Methods

This study was conducted in a designated COVID-19 referral hospital from January 1 to March 31, 2021. Skin manifestations recorded from January 1 to February 17 were retrospectively gathered. Reports from February 18 to March 31 were prospectively collected using a dermatologic checklist which was incorporated into all official medical records.

Results

A total of 507 confirmed patients with COVID-19 were included. COVID-19 skin signs were detected in 39 patients (7.7%). Morbilliform lesions were most common. Skin signs were significantly associated with severe or critical cases (odds ratio, 3.4; 95% CI, 1.3-8.7) and mortality (relative risk, 2.9; 95% CI, 2.0-4.2).

Limitations

Underestimation of prevalence of COVID-19 skin signs due to exclusion of outpatient and discharged patients and the subjective assessment in the retrospective part.

Conclusion

Cutaneous signs were significantly associated with severe/critical COVID-19 as well as death among 507 hospitalized patients in a Philippine COVID-19 referral hospital.

Dermatological Manifestations of COVID-19 in Patients Reporting to a Tertiary Care Hospital in Rawalpindi, Pakistan

Introduction The clinicopathological description of dermatological manifestations of COVID-19 leaves much to be desired. There is a need to determine their association with disease severity, outcome, and other clinical variables. Objectives The objectives of this study are to record and histopathologically examine the cutaneous manifestations of COVID-19 and correlate these to age, disease severity, and mortality. Methods All confirmed COVID-19 patients admitted to a single tertiary healthcare hospital in Rawalpindi, Pakistan, were included. Their diseases were classified as mild, moderate, severe, and critical. The recent onset skin eruptions in these patients were recorded via photographs along with relevant clinical data. The photographs were independently reviewed by a group of three dermatologists without knowledge of the clinical information. The skin manifestations were divided into disease-specific and nonspecific categories using an already defined algorithm. Histopathological examination of skin manifestations was conducted. Results A total of 23% (n=47) had "new" skin manifestations. Specific skin findings were seen in 21.6% (n=44), which consisted of ecchymosis/purpura in 50% (n=22), maculopapular exanthem in 18% (n=8), livedo reticularis in 16.2% (n=7), ischemia/gangrene in 16.2% (n=7), perniosis in 15.9 % (n=7), vesiculo-bullous rash in 9% (n=4) and urticaria in 4% (n=1). Non-specific findings were seen in 6% (n=13) and included bedsores, dermatitis passivata, dryness, herpes labialis, oral ulcerations, and nasogastric tube-induced ulcerations. There was a significant association (p=0.03) between disease severity and specific skin lesions. Ischemia/gangrene was significantly associated with COVID-19 disease severity and mortality. Vesiculobullous lesions were associated with higher mortality, though not with disease severity. Livedo reticularis had a higher-than-expected count in critical disease, albeit statistically insignificant. The association of maculopapular exanthem and ecchymosis/purpura with severe/critical disease was statistically insignificant. Urticaria was significantly associated with low disease severity. Mean age with specific manifestations was 56.86 ± 15.81 and with nonspecific/without any manifestations was 42.58 ± 16.96, a highly significant difference, with p-value < 0.001. Old age (>60 years) was significantly associated with ecchymosis (p=0.038), maculopapular exanthem (p=0.021), and vesiculo-bullous rash (p=0.029). Histopathology varied according to the type of skin lesion. Conclusions Dermatological manifestations coexist in many patients and tend to appear more in severe cases of COVID-19 among the older age group and only minimally in mild/moderate cases. Their presence could help set prognostic criteria of COVID-19 disease in the future.

Cutaneous Pathology of COVID-19 as a Window into Immunologic Mechanisms of Disease

Many skin manifestations of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection reflect activation of cutaneous and systemic immune responses involving effector pathways of both the innate and adaptive arms of the immune system. This article reviews evidence from the recent clinical and scientific literature that informs the current understanding of the consequences of coronavirus disease 2019 (COVID-19)-induced immune cell activation, as relevant to dermatology. Topics include the clinical consequences of autoantibody production in patients with COVID-19, immunologic evidence for chilblains as a manifestation of SARS-CoV-2 infection, and the relationship between type I interferons and COVID-19 disease severity.

COVID-19-specific skin changes related to SARS-CoV-2: Visualizing a monumental public health challenge

The novel coronavirus SARS-CoV-2 has caused coronavirus disease-2019, known as COVID-19, now a pandemic stressing millions of individuals worldwide. COVID-19 is a systemic respiratory infection that may have dermatologic signs and systemic sequelae, a devastating public health challenge with parallels to the two great influenza pandemics of the last century. Skin lesions linked with COVID-19 have been grouped into six categories, with three distinct indicative patterns: vesicular (varicella-like), vasculopathic, and chilblains-like (including “COVID toes” and “COVID fingers”) plus the following three less suggestive patterns: dermatitic, maculopapular, and urticarial morphologies. Vasculopathic changes are the most concerning, in some patients, reflecting a devastating blood clotting dysfunction. We discuss the ways to detect, prevent, and treat COVID-19, keeping in mind the context of possible cutaneous markers of COVID-19 to enhance detection.

Cutaneous Manifestations of COVID-19: A Brief Review of a Possible Diagnostic Tool

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A comprehensive review on clinical and mechanistic pathophysiological aspects of COVID-19 Malady: How far have we come?

Since its outbreak in 2019, the coronavirus disease (COVID-19) has become a pandemic, affecting more than 52 million people and causing more than 1 million mortalities globally till date. Current research reveals a wide array of disease manifestations and behaviors encompassing multiple organ systems in body and immense systemic inflammation, which have been summarized in this review. Data from a number of scientific reviews, research articles, case series, observational studies, and case reports were retrieved by utilizing online search engines such as Cochrane, PubMed, and Scopus from December 2019 to November 2020. The data for prevalence of signs and symptoms, underlying disease mechanisms and comorbidities were analyzed using SPSS version 25. This review will discuss a wide range of COVID-19 clinical presentations recorded till date, and the current understanding of both the underlying general as well as system specific pathophysiologic, and pathogenetic pathways. These include direct viral penetration into host cells through ACE2 receptors, induction of inflammosomes and immune response through viral proteins, and the initiation of system-wide inflammation and cytokine production. Moreover, peripheral organ damage and underlying comorbid diseases which can lead to short term and long term, reversible and irreversible damage to the body have also been studied. We concluded that underlying comorbidities and their pathological effects on the body contributed immensely and determine the resultant disease severity and mortality of the patients. Presently there is no drug approved for treatment of COVID-19, however multiple vaccines are now in use and research for more is underway.

Skin disorders associated with the COVID-19 pandemic: A review

Introduction

In December 2019, a new coronavirus has emerged out of China, the SARS‐CoV‐2 virus, causing a disease known as COVID‐19, which steadily has progressed into a pandemic. This coronavirus affects many organs, including the skin, whose manifestations are a consequence of the disease itself, as well as the preventative measures taken to avoid the infection. This paper reviews the cutaneous manifestations which currently have been encountered during this pandemic.

Methods

A search was conducted on PubMed, and all relevant articles were included.

Results

The results show the occurrence of many cutaneous findings, ranging from those related to the infection itself and to various dermatitides related to the use of personal protective equipment (PPE) utilized by healthcare workers while attending to infected patients.

Discussion

Recognizing these findings is important for the accurate diagnosis of those infected with COVID‐19 as well as the prompt treatment of the side effects caused by PPE that might further impair the effectiveness of healthcare workers.

Bilateral Chilblain-like Lesions of the Toes Characterized by Microvascular Remodeling in Adolescents During the COVID-19 Pandemic

IMPORTANCE

Chilblain-like lesions have been one of the most frequently described cutaneous manifestations during the COVID-19 pandemic. Their etiopathogenesis, including the role of SARS-CoV-2, remains elusive.

OBJECTIVE

To examine the association of chilblain-like lesions with SARS-CoV-2 infection.

DESIGN, SETTING, AND PARTICIPANTS

This prospective case series enrolled 17 adolescents who presented with chilblain-like lesions from April 1 to June 30, 2020, at a tertiary referral academic hospital in Italy.

MAIN OUTCOMES AND MEASURES

Macroscopic (clinical and dermoscopic) and microscopic (histopathologic) analysis contributed to a thorough understanding of the lesions. Nasopharyngeal swab, serologic testing, and in situ hybridization of the skin biopsy specimens were performed to test for SARS-CoV-2 infection. Laboratory tests explored signs of systemic inflammation or thrombophilia. Structural changes in peripheral microcirculation were investigated by capillaroscopy.

RESULTS

Of the 17 adolescents (9 [52.9%] male; median [interquartile range] age, 13.2 [12.5-14.3] years) enrolled during the first wave of the COVID-19 pandemic, 16 (94.1%) had bilaterally localized distal erythematous or cyanotic lesions. A triad of red dots (16 [100%]), white rosettes (11 [68.8%]), and white streaks (10 [62.5%]) characterized the dermoscopic picture. Histologic analysis revealed a remodeling of the dermal blood vessels with a lobular arrangement, wall thickening, and a mild perivascular lymphocytic infiltrate. SARS-CoV-2 infection was excluded by molecular and serologic testing. In situ hybridization did not highlight the viral genome in the lesions.

CONCLUSIONS AND RELEVANCE

This study delineated the clinical, histologic, and laboratory features of chilblain-like lesions that emerged during the COVID-19 pandemic, and its findings do not support their association with SARS-CoV-2 infection. The lesions occurred in otherwise healthy adolescents, had a long but benign course to self-resolution, and were characterized by a microvascular remodeling with perivascular lymphocytic infiltrate but no other signs of vasculitis. These results suggest that chilblain-like lesions do not imply a concomitant SARS-CoV-2 infection. Ongoing studies will help clarify the etiopathogenic mechanisms.

Skin manifestations in COVID-19 patients, state of the art. A systematic review

INTRODUCTION

Since COVID-19 has become a pandemic, extensive literature has been produced. The commonest symptoms of COVID-19 disease are fever, cough, anosmia, and lymphocytopenia. However, other apparently less common clinical symptoms have been described, including skin lesions. We conducted a systematic review to evaluate skin involvement in COVID-19.

METHODS

The authors performed a systematic review of literature, in accordance with the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA). The search was reiterated until May 06, 2020.

RESULTS

Overall, 1593 patients (M/F ratio: 1 : 9) with suspect of COVID-19 were examined. The mean age was 37.8 (range 0-91) years. Among the analyzed patients, 84 (5.3%) were pediatrics (<18 years). Chilblains are very common among skin lesions and represent almost half of all skin lesions reported (46%); in 75% of patients with cutaneous manifestation, the latter presented before other typical clinical manifestation of COVID-19. Vasculitis or thrombosis was identified in almost 70% of patients who suffered from skin manifestations.

CONCLUSION

The present study highlights the importance of skin involvement in COVID-19. Limbs should be examined to eventually foresee the onset of further typical symptoms. Chilblains can be considered typical features. Studies with higher scientific evidence are required.

Cutaneous manifestations and dermatological sequelae of Covid-19 infection compared to those from other viruses

In the last few months, there have been numerous reports describing a variety of cutaneous signs associated with COVID-19. Clinicians from Italy were the first to describe the cutaneous manifestations of COVID-19, which were later observed in other parts of the globe. In some cases, cutaneous signs were the only manifestation of COVID-19 rather than the typical syndrome of fever and upper respiratory tract symptoms. However, there is considerable heterogeneity amongst the cutaneous signs described so far, which has been published extensively. Our aim is to summarise the latest studies that have reported the early and late cutaneous signs of COVID-19 and compare them to the most common established viral exanthems.

COVID-19-associated leukocytoclastic vasculitis leading to gangrene and amputation

A 41-year-old male with type 2 diabetes mellitus (T2DM) presented with complaints of recent onset limb weakness, diffuse body rash and fever. Computerized Tomography (CT) scan of the brain did not reveal a stroke but laboratory investigations of the patient portrayed multi-systemic involvement. Naso-pharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was taken which resulted as positive. Soon after, a biopsy of the skin lesions revealed histo-pathological features of leukocytoclastic vasculitis. The patient was further investigated for connective tissue disease and vasculitis only to yield a negative result for all relevant antibodies, with the exception of the anti-phospholipid antibody which was positive. The patient suffered through a complex and prolonged hospital stay that required the input of multiple sub-speciality teams. Although initially presenting with a normal chest X-ray the patient went on to have severe bilateral pneumonia and a progression of initial skin rash leading to severe necrosis of the left foot with dry gangrene of the left big toe. Due to these issues, coronavirus-disease-2019 (COVID-19) aimed therapy was started along with multiple skin debridements, antibiotics and eventual amputation of the patient's affected large toe. The following case-study details all the before-mentioned events with discussion of the possible reasons behind the patient's presentation and eventual outcome.

Chilblain-Like Lesions (CLL) Associated With COVID-19 ("COVID Toes"): A Systematic Review

Reports of chilblain-like lesions (CLL) coinciding with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been described in the literature, but this phenomenon has not been critically summarized. The aim of this paper is to summarize reports of CLL coinciding with SARS-CoV-2 infection to clarify the prevalence, clinical relevance, and prognostic value of these lesions. A literature search was conducted using the Embase, Pubmed, and Scopus databases from December 2019 to June 16, 2020 using the search terms ("COVID-19" OR "coronavirus" OR "2019-nCoV" OR "SARS-CoV-2") AND ("chilblain-like" OR "COVID toes" OR "acral"). Papers that described skin changes in patients with suspected or confirmed COVID-19 were included. A total of 31 papers were summarized, representing 813 cases of CLL. Available data suggests an equal gender distribution, mean age of 21 years, and median age of 14 years. Mild extracutaneous symptoms were reported in 53% of cases and 47% were asymptomatic. CLL occurred an average of 16 days after extracutaneous symptoms. Patients with CLL were positive for SARS-CoV-2 in 15% of cases. Lesions were mainly described as asymptomatic and/or pruritic erythematous to violaceous acral macules and plaques. Partial or complete resolution occurred in 85% of cases in a mean of 13 days. The most common histologic findings were perivascular and perieccrine superficial and deep lymphocytic infiltrates. Although a causal relationship between CLL and SARS-CoV-2 has not been confirmed, the temporal association and 15% positive SARS-CoV-2 rate in affected individuals should not be ignored.

Coronavirus disease-19: The multi-level, multi-faceted vasculopathy

BACKGROUND AND AIMS

The new coronavirus disease (COVID-19) is a systemic disease. Mounting evidence depict signs and symptoms involving multiple organs, most of which supported by pathological data. A plausible link to these manifestations is vascular and endothelial dysfunction/damage. However, much of the current knowledge relies on opinion and incipient evidence. We aim to objectively appraise current evidence on the association between COVID-19 and vascular disease, specifically endotheliitis and vasculitis.

METHODS

Two researchers independently entered the search terms COVID-19 OR SARS-CoV-2 AND vasculitis, endotheliitis OR endothelium in the following online platforms: MedRxiv and LitCovid (PubMed). The search period was set from November 1, 2019 to August 28, 2020. Manuscripts with unavailable full texts, not in English, mainly on pre-clinical data, presenting only study designs or not directly related to the topics of this review were excluded. Retrospective and prospective studies, especially longitudinal ones, were given priority to the purpose of this review. Since there was paucity of prospective controlled evidence, case reports/series were also considered.

RESULTS

A total of 318 manuscripts were initially found. Sixty-seven (21%) were excluded: 59 (18.5%) met exclusion criteria and 8 (2.5%) were duplicates. One hundred and forty-two manuscripts (44,6%) did not provide original data and were also excluded: 35 (11%) were comments, 108 (33.9%) reviews; 1 (0.3%) position paper. One hundred and seven (33.6%) studies were considered for the present scoping review: 81 (25,5%) case reports/series; 18 (5.7%) prospective; 8 (2.5%) retrospective. Viral inclusions in endothelial cells, mononuclear cell infiltrates in the intima of small vessels and markers of endothelial cell apoptosis were demonstrated. Specificities of COVID-19 may lead to diverse vascular manifestations in different levels of the vascular bed.

CONCLUSIONS

Evidence indicates that COVID-19 targets vasculature and endothelium. However, high quality data is still lacking and studies with prospective designs and appropriately matched controls are needed.

Cutaneous Manifestations in Patients With COVID-19: Clinical Characteristics and Possible Pathophysiologic Mechanisms

The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections soon led to a pandemic with serious health, economic, political, and cultural repercussions across the globe. The disease caused by SARS-CoV-2, coronavirus disease 2019 (COVID-19), is a multisystemic disease that requires a multidisciplinary approach involving specialists from all fields and levels of care. In this article, we review the literature on the diverse cutaneous manifestations associated with COVID-19. We also describe the pathophysiologic mechanisms proposed to date and their possible association with these manifestations. Finally, we propose a system for classifying the cutaneous manifestations of COVID-19 according to their underlying pathophysiologic mechanisms and prognosis.

Skin manifestations of COVID-19 in children: Part 1

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discuss one of the first and most widespread cutaneous manifestation of COVID-19, chilblain-like lesions. In Part 2, we review other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome, while in Part 3, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children, for both COVID-19 and any other pre-existing conditions.

Diagnostic value of cutaneous manifestation of SARS-CoV-2 infection

Background

One of the challenging aspects of SARS‐CoV‐2 infection is its diverse multisystemic disease presentation.

Objectives

To evaluate the diagnostic value of cutaneous manifestations of SARS‐CoV‐2 infection and investigate their duration and timing in relation to other COVID‐19 symptoms.

Methods

We used data from 336 847 UK users of the COVID Symptom Study app to assess the diagnostic value of body rash or an acral rash in SARS‐CoV‐2 infection, and data from an independent online survey of 11 544 respondents to investigate skin‐specific symptoms and collect their photographs.

Results

Using data from the app, we show significant association between skin rashes and a positive swab test result (odds ratio 1·67, 95% confidence interval 1·42–1·97). Strikingly, among the respondents of the independent online survey, we found that 17% of SARS‐CoV‐2‐positive cases reported skin rashes as the first presentation, and 21% as the only clinical sign of COVID‐19. Together with the British Association of Dermatologists, we have compiled a catalogue of images of the most common skin manifestations of COVID‐19 from 400 individuals (https://covidskinsigns.com), which we have made publicly available to assist clinicians in recognition of this early clinical feature of COVID‐19.

Conclusions

Skin rashes cluster with other COVID‐19 symptoms, are predictive of a positive swab test, and occur in a significant number of cases, either alone or before other classical symptoms. Recognizing rashes is important in identifying new and earlier cases of COVID‐19.

What is already known about this topic?

Several studies conducted in hospital settings reported that patients with COVID‐19 presented with unusual skin rashes, including urticarial rashes, vesicular lesions and, less frequently, chilblains in fingers or toes.

What does this study add?

We confirmed, in a community‐based setting that also includes milder forms of the disease, that the presence of a skin rash is predictive of SARS‐CoV‐2 infection.

We provide a website with photos of skin manifestations to help healthcare professionals in diagnosing COVID‐19.

Skin rashes should be taken into account to provide a quick COVID‐19 diagnosis to curb the spread of the disease.

Linked Comment: Naldi. Br J Dermatol 2021; 184:793–794.

Skin manifestations of COVID-19: A worldwide review

OBJECTIVE

Because of the increasing emergence of skin manifestations of COVID-19 worldwide, we investigated the published reports of these lesions.

METHODS

We conducted a literature search for original and review articles published from November 11, 2019 to September 30, 2020.

RESULTS

We identified 5 skin lesions common in patients with COVID-19: pseudo-chilblains, rashes containing macules and papules, and urticarial, vesicular, and vaso-occlusive lesions. These lesions manifested at various times in relation to the COVID-19 symptoms, which may indicate whether the lesions are virus-induced or are delayed immunological responses to the infection. Skin lesions were more prevalent among Europeans and United States residents than among Asians, as was pseudo-chilblain, and the morphology of the skin lesions varied among continents. Pseudo-chilblains were the most common COVID-19 skin manifestation in Europe and the United States, but there was only 1 reported case from Asian populations. Additionally, patients with vaso-occlusive lesions were more likely than those with pseudo-chilblains to be admitted to the intensive care unit and to die.

CONCLUSION

Different cutaneous manifestations in patients with COVID-19 could reflect a wide spectrum of viral interactions with the skin, though reporting bias may play a role as well.

Skin Manifestations in COVID-19 Patients: Are They Indicators for Disease Severity? A Systematic Review

Introduction: Until now, there are several reports on cutaneous manifestations in COVID-19 patients. However, the link between skin manifestations and the severity of the disease remains debatable. We conducted a systematic review to evaluate the temporal relationship between different types of skin lesions and the severity of COVID-19. Methods: A systematic search was conducted for relevant studies published between January and July 2020 using Pubmed/Medline, Embase, and Web of knowledge. The following keywords were used: "SARS-CoV-2" or "COVID-19" or "new coronavirus" or "Wuhan Coronavirus" or "coronavirus disease 2019" and "skin disease" or "skin manifestation" or "cutaneous manifestation." Results: Out of 381 articles, 47 meet the inclusion criteria and a total of 1,847 patients with confirmed COVID-19 were examined. The overall frequency of cutaneous manifestations in COVID-19 patients was 5.95%. The maculopapular rash was the main reported skin involvement (37.3%) commonly occurred in middle-aged females with intermediate severity of the disease. Forty-eight percentage of the patients had a mild, 32% a moderate, and 20% a severe COVID-19 disease. The mild disease was mainly correlated with chilblain-like and urticaria-like lesions and patients with vascular lesions experienced a more severe disease. Seventy-two percentage of patients with chilblain-like lesions improved without any medication. The overall mortality rate was 4.5%. Patients with vascular lesions had the highest mortality rate (18.2%) and patients with urticaria-like lesions had the lowest mortality rate (2.2%). Conclusion: The mere occurrence of skin manifestations in COVID-19 patients is not an indicator for the disease severity, and it highly depends on the type of skin lesions. Chilblain-like and vascular lesions are the ends of a spectrum in which from chilblain-like to vascular lesions, the severity of the disease increases, and the patient's prognosis worsens. Those with vascular lesions should also be considered as high-priority patients for further medical care.

The JANUS of chronic inflammatory and autoimmune diseases onset during COVID-19 - A systematic review of the literature

The diverse clinical manifestations of COVID-19 is emerging as a hallmark of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. While the initial target of SARS-CoV-2 is the respiratory tract, it is becoming increasingly clear that there is a complex interaction between the virus and the immune system ranging from mild to controlling responses to exuberant and dysfunctional multi-tissue directed autoimmune responses. The immune system plays a dual role in COVID-19, being implicated in both the anti-viral response and in the acute progression of the disease, with a dysregulated response represented by the marked cytokine release syndrome, macrophage activation, and systemic hyperinflammation. It has been speculated that these immunological changes may induce the loss of tolerance and/or trigger chronic inflammation. In particular, molecular mimicry, bystander activation and epitope spreading are well-established proposed mechanisms to explain this correlation with the likely contribution of HLA alleles. We performed a systematic literature review to evaluate the COVID-19-related autoimmune/rheumatic disorders reported between January and September 2020. In particular, we investigated the cases of incident hematological autoimmune manifestations, connective tissue diseases, antiphospholipid syndrome/antibodies, vasculitis, Kawasaki-like syndromes, acute arthritis, autoimmune-like skin lesions, and neurologic autoimmune conditions such as Guillain-Barré syndrome. We screened 6263 articles and report herein the findings of 382 select reports which allow us to conclude that there are 2 faces of the immune response against SARS-CoV-2, that include a benign virus controlling immune response and a many faceted range of dysregulated multi-tissue and organ directed autoimmune responses that provides a major challenge in the management of this viral disease. The number of cases for each disease varied significantly while there were no reported cases of adult onset Still disease, systemic sclerosis, or inflammatory myositis.

Cutaneous Manifestations in Patients With COVID-19: Clinical Characteristics and Possible Pathophysiologic Mechanisms

The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections soon led to a pandemic with serious health, economic, political, and cultural repercussions across the globe. The disease caused by SARS-CoV-2, coronavirus disease 2019 (COVID-19), is a multisystemic disease that requires a multidisciplinary approach involving specialists from all fields and levels of care. In this article, we review the literature on the diverse cutaneous manifestations associated with COVID-19. We also describe the pathophysiologic mechanisms proposed to date and their possible association with these manifestations. Finally, we propose a system for classifying the cutaneous manifestations of COVID-19 according to their underlying pathophysiologic mechanisms and prognosis.

Review on 3D printing: Fight against COVID-19

The outbreak of coronavirus disease in 2019 (COVID-19) caused by the SARS-CoV-2 virus and its pandemic effects have created a demand for essential medical equipment. To date, there are no specific, clinically significant licensed drugs and vaccines available for COVID-19. Hence, mapping out COVID-19 problems and preventing the spread with relevant technology are very urgent. This study is a review of the work done till October, 2020 on solving COVID-19 with 3D printing. Many patients who need to be hospitalized because of COVID-19 can only survive on bio-macromolecules antiviral respiratory assistance and other medical devices. A bio-cellular face shield with relative comfortability made of bio-macromolecules polymerized polyvinyl chloride (BPVC) and other biomaterials are produced with 3D printers. Summarily, it was evident from this review study that additive manufacturing (AM) is a proffered technology for efficient production of an improved bio-macromolecules capable of significant COVID-19 test and personal protective equipment (PPE) to reduce the effect of COVID-19 on the world economy. Innovative AM applications can play an essential role to combat invisible killers (COVID-19) and its hydra-headed pandemic effects on humans, economics and society.

Inflammation and Vascular Injury as the Basis of COVID-19 Skin Changes: Preliminary Analysis of 23 Patients from the Literature

Background

COVID-19 can affect various organ systems including the skin. Cutaneous manifestations of COVID-19 in infected patients are poorly characterized.

Objective

To summarize retrospectively the skin features of COVID-19 infection and to analyze the skin rash incidence rate, clinical onset time, cutaneous manifestations, pathological characteristics and relationship with the novel coronavirus pneumonia severity.

Methods

The literature up to Sep 20, 2020, were searched and analyzed. Information on clinical features including skin manifestations, disease severity, stage and onset day, and cutaneous pathological characteristics was extracted. Data were analyzed using descriptive non-parametric statistics. For categorical data, the number and percentage of patients are presented. A Spearman correlation test was used to analyze the associations between rash type, rash onset and severity of COVID-19. All statistical analysis was performed with IBM SPSS software (version 20) using two-tailed tests. P values <0.05 were considered statistically significant.

Results

Twenty-three cases of COVID-19 patients with cutaneous manifestations from seven reports were collected. Inflammatory dermatosis, skin vasculitis and vascular dermatosis were the main lesion types of COVID-19 patients. Microvascular and endothelial cell injury, perivascular lymphocytic infiltrate, thrombosis, extremely dilated vessels and prominent deposits of C5b-9 were the main dermatologic pathological changes. The onset day analysis showed that out of 19 patients, 63.2% of cutaneous manifestations were within 10 days, 21.1% in 10–20 days and 15.8% were 20 days after the time the patient presented with COVID-19 main symptoms. Spearman rho analysis found no correlation between skin rash type, onset day and COVID-19 severity.

Conclusion

COVID-19 induced skin changes are one of the manifestations of immune responses to the novel coronavirus. Clinical and pathological characteristics were identified as dermal inflammatory reactions and/or skin vascular injury. External or systematic use of anti-inflammatories, protection of blood vessels and circulation-improving medicines should be considered in the skin treatments for novel coronavirus pneumonia patients.

COVID-19 and dermatology

Background/aim

Sars-CoV-2 virus infection (COVID-19) was observed in China in the last months of 2019. In the period following, this infection spread all over the world. In March 2020 the World Health Organization announced the existence of a pandemic. The aim of this manuscript is to investigate skin diseases associated with COVID-19 under three main headings: skin problems related to personal protective equipment and personal hygiene measures, skin findings observed in SARS-CoV-2 virus infections, and skin findings due to COVID-19 treatment agents.

Materials and methods

In PubMed, Google Scholar databases, skin lesions related to personal protective equipment and personal hygiene measures, skin findings observed in SARS-CoV-2 virus infections and skin findings due to COVID-19 treatment agents subjects are searched in detail.

Results

Pressure injury, contact dermatitis, itching, pressure urticaria, exacerbation of preexisting skin diseases, and new skin lesion occurrence/new skin disease occurrence may be due to personal protective equipment. Skin problems related to personal hygiene measures could include itching, dryness, and contact dermatitis. Skin findings may also be observed in SARS-CoV-2 virus infections. The incidence of skin lesions due to COVID-19 was reported to be between 0.2% and 29%. Many skin lesions including maculopapular, urticarial, vesicular, chilblain-like, thrombotic/ischemic, etc. are observed in COVID-19 patients. Some authors have stated that there is an absence of SARS-CoV-2 virus infection-specific skin findings. However, in asymptomatic or presymptomatic COVID-19 patients in particular, skin lesions can lead to the diagnosis of COVID-19. In addition, skin lesions may occur due to COVID-19 treatment agents.

Conclusion

Many skin lesions may appear as a result of COVID-19. Even in the absence of a COVID-19 diagnosis, skin findings should be evaluated carefully in this pandemic period.

Cutaneous Manifestations in Confirmed COVID-19 Patients: A Systematic Review

There have been increasing reports of skin manifestations in COVID-19 patients. We conducted a systematic review and included manuscripts describing patients with positive RT-PCR coronavirus testing from nasopharyngeal swabs who also developed cutaneous manifestations. A total of 655 patients were selected, with different types of skin rashes: Erythematous maculopapular (n = 250), vascular (n = 146), vesicular (n = 99), urticarial (n = 98), erythema multiforme/generalized pustular figurate erythema/Stevens-Johnson syndrome (n = 22), ocular/periocular (n = 14), polymorphic pattern (n = 9), generalized pruritus (n = 8), Kawasaki disease (n = 5), atypical erythema nodosum (n = 3), and atypical Sweet syndrome (n = 1). Chilblain-like lesions were more frequent in the younger population and were linked to a milder disease course, while fixed livedo racemosa and retiform purpura appeared in older patients and seemed to predict a more severe prognosis. For vesicular rashes, PCR determined the presence of herpesviruses in the vesicle fluid, which raised the possibility of herpesvirus co-infections. The erythema-multiforme-like pattern, generalized pustular figurate erythema and Stevens-Johnson syndrome were most frequently linked to hydroxychloroquine intake. A positive PCR determination of SARS-COV-2 from conjunctival swabs suggest that eye discharge can also be contagious. These cutaneous manifestations may aid in identifying otherwise asymptomatic COVID-19 carriers in some cases or predict a more severe evolution in others.

Guidance for the Management of Patients with Vascular Disease or Cardiovascular Risk Factors and COVID-19: Position Paper from VAS-European Independent Foundation in Angiology/Vascular Medicine

COVID-19 is also manifested with hypercoagulability, pulmonary intravascular coagulation, microangiopathy, and venous thromboembolism (VTE) or arterial thrombosis. Predisposing risk factors to severe COVID-19 are male sex, underlying cardiovascular disease, or cardiovascular risk factors including noncontrolled diabetes mellitus or arterial hypertension, obesity, and advanced age. The VAS-European Independent Foundation in Angiology/Vascular Medicine draws attention to patients with vascular disease (VD) and presents an integral strategy for the management of patients with VD or cardiovascular risk factors (VD-CVR) and COVID-19. VAS recommends (1) a COVID-19-oriented primary health care network for patients with VD-CVR for identification of patients with VD-CVR in the community and patients' education for disease symptoms, use of eHealth technology, adherence to the antithrombotic and vascular regulating treatments, and (2) close medical follow-up for efficacious control of VD progression and prompt application of physical and social distancing measures in case of new epidemic waves. For patients with VD-CVR who receive home treatment for COVID-19, VAS recommends assessment for (1) disease worsening risk and prioritized hospitalization of those at high risk and (2) VTE risk assessment and thromboprophylaxis with rivaroxaban, betrixaban, or low-molecular-weight heparin (LMWH) for those at high risk. For hospitalized patients with VD-CVR and COVID-19, VAS recommends (1) routine thromboprophylaxis with weight-adjusted intermediate doses of LMWH (unless contraindication); (2) LMWH as the drug of choice over unfractionated heparin or direct oral anticoagulants for the treatment of VTE or hypercoagulability; (3) careful evaluation of the risk for disease worsening and prompt application of targeted antiviral or convalescence treatments; (4) monitoring of D-dimer for optimization of the antithrombotic treatment; and (5) evaluation of the risk of VTE before hospital discharge using the IMPROVE-D-dimer score and prolonged post-discharge thromboprophylaxis with rivaroxaban, betrixaban, or LMWH.

Skin Manifestations Associated with COVID-19: Current Knowledge and Future Perspectives

Background

Coronavirus disease-19 (COVID-19) is an ongoing global pandemic caused by the “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2), which was isolated for the first time in Wuhan (China) in December 2019. Common symptoms include fever, cough, fatigue, dyspnea and hypogeusia/hyposmia. Among extrapulmonary signs associated with COVID-19, dermatological manifestations have been increasingly reported in the last few months.

Summary

The polymorphic nature of COVID-19-associated cutaneous manifestations led our group to propose a classification, which distinguishes the following six main clinical patterns: (i) urticarial rash, (ii) confluent erythematous/maculopapular/morbilliform rash, (iii) papulovesicular exanthem, (iv) chilblain-like acral pattern, (v) livedo reticularis/racemosa-like pattern, (vi) purpuric “vasculitic” pattern. This review summarizes the current knowledge on COVID-19-associated cutaneous manifestations, focusing on clinical features and therapeutic management of each category and attempting to give an overview of the hypothesized pathophysiological mechanisms of these conditions.

Dermatological aspects of SARS-CoV-2 infection: mechanisms and manifestations

The human infection caused by the novel SARS-CoV-2 is a public health emergency of international concern. Although the disease associated to this virus, named COVID-19, mainly affects the lungs, the infection can spread to extrapulmonary tissues, causing multiorgan involvement in severely ill patients. The broad infective capacity of SARS-CoV-2 is related to the pattern of expression of the viral entry factors ACE2 and TMPRSS2 in human tissues. As such, the respiratory and gastrointestinal tracts are at high risk for SARS-CoV-2 infection due to their high expression of ACE2 and TMPRSS2, which explains the clinical phenotype described in the vast majority of infected patients that includes pneumonia and diarrhea. Recently, preoccupation about the potential of the virus to infect the skin has been raised by dermatologists due to the increasing observations of cutaneous manifestations in patients with SARS-CoV-2 infection. Although there is little evidence of the expression of ACE2 and TMPRSS2 in the normal skin, the dermatological findings observed among COVID-19 patients warrants further investigation to delineate the mechanisms of skin affection after SARS-CoV-2 infection. Here, we provide a summary of the dermatological findings observed among patients with laboratory-confirmed SARS-CoV-2 infection based on recent reports. In addition, we analyze possible mechanisms of skin injury in COVID-19 patients and discuss about the risk of individuals with chronic skin conditions for SARS-CoV-2 infection. The present review constitutes a useful informative tool to improve our understanding of the pathophysiological mechanisms of COVID-19 and the possible implications of the current pandemic in dermatology.

Dermatologic manifestations of COVID-19: a comprehensive systematic review

Recent reports have suggested that there may be dermatologic manifestations of COVID-19. We searched 12 databases for peer-reviewed or pre-print published studies until July 15, 2020, for this PRISMA-compliant review (CRD42020182050). We used the Oxford Center for Evidence-Based Medicine Levels of Evidence to facilitate data synthesis. From 86 retrieved studies, we collated data on 2,560 patients with dermatologic manifestations of COVID-19. The most common findings were chilblains/pernio-like lesion (51.5%), erythematous maculopapular rashes (13.3%), and viral exanthem (7.7%). Average pediatric age was 12.9 years (SD 3.6) and adult was 34.2 years (SD 21.8). Average latency from time of upper respiratory illness symptoms to cutaneous findings was 1.5 days (SD 2.9) in children and 7.9 days (SD 10.7) in adults, ranging from -3 to 38 days. Roughly one-tenth in both populations were otherwise asymptomatic or presented with only skin findings for the entirety of the disease course; 13.3% (pediatrics) and 5.3% (adults) presented with skin issues first. Dermatologic findings may play an important role in identifying cases early and serve as an important proxy to manage spread. Further prospective data collection with international prospective registries is needed.

Covid-19 pandemic and the skin

In the beginning of the COVID-19 outbreak, skin manifestations, if present, were not paid enough attention. Then, the focus moved toward the impact of the prolonged use of personal protective measures in both healthcare workers and patients. In the meantime, attention is increasingly paid to dermatology as a result of the concern for certain groups of dermatologic patients, including those whose condition may worsen by the thorough disinfection measures and those treated with immunosuppressants or immunomodulators. Following patients with psoriasis on biological therapy, as well as other inflammatory and autoimmune cutaneous disorders such as atopic dermatitis, pemphigus, pemphigoid diseases, and skin cancer provoked the interest of dermatologists. Finally, an intriguing question to the dermatologic society was whether skin changes during COVID-19 infection exist and what could be their diagnostic or prognostic value. Here, we summarize skin conditions during the COVID-19 pandemic, patient information, and expert recommendations and give an overview about the registries launched to document skin changes during COVID-19, as well as details about certain patient groups infected with SARS-CoV-2, for example, psoriasis, atopic dermatitis, and autoimmune bullous diseases.

Multisystem Imaging Manifestations of COVID-19, Part 2: From Cardiac Complications to Pediatric Manifestations

Infection with severe acute respiratory syndrome coronavirus 2 results in coronavirus disease 2019 (COVID-19), which was declared an official pandemic by the World Health Organization on March 11, 2020. COVID-19 has been reported in most countries, and as of August 15, 2020, there have been over 21 million cases of COVID-19 reported worldwide, with over 800 000 COVID-19-associated deaths. Although COVID-19 predominantly affects the respiratory system, it has become apparent that many other organ systems can also be involved. Imaging plays an essential role in the diagnosis of all manifestations of the disease and its related complications, and proper utilization and interpretation of imaging examinations is crucial. A comprehensive understanding of the diagnostic imaging hallmarks, imaging features, multisystem involvement, and evolution of imaging findings is essential for effective patient management and treatment. In part 1 of this article, the authors described the viral pathogenesis, diagnostic imaging hallmarks, and manifestations of the pulmonary and peripheral and central vascular systems of COVID-19. In part 2 of this article, the authors focus on the key imaging features of the varied pathologic manifestations of COVID-19, involving the cardiac, neurologic, abdominal, dermatologic and ocular, and musculoskeletal systems, as well as the pediatric and pregnancy-related manifestations of the virus. Online supplemental material is available for this article. ©RSNA, 2020.

Cutaneous Manifestations in the Context of SARS-CoV-2 Infection (COVID-19)

The coronavirus 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus2 (SARS-CoV-2), has had enormous health, economic, and social consequences. The clinical spectrum of cutaneous manifestations observed in patients with COVID-19 is both heterogeneous and complex. To date, reports have identified 5main categories: acral lesions, vesicular rashes, urticarial rashes, maculopapular rashes, and livedoid and necrotic lesions. However, these will probably be modified as new information comes to light. Cutaneous manifestations associated with COVID-19 probably reflect the activation of pathogenic pathways by the virus or a response to inflammatory processes, vascular or systemic complications, or even treatments. Familiarity with the cutaneous manifestations of COVID-19 may enable early diagnosis or help guide prognosis.

Patients with specific skin disorders who are affected by COVID-19: What do experiences say about management strategies? A systematic review

In patients with specific dermatologic disorders who are affected by new corona virus, we know little about disease course (underlying disease and new onset infection), and the most proper management strategies include both issues that are what this systematic review targets. Databases of PubMed, Scopus, Google Scholar, Medscape, and Centre of Evidence-Based Dermatology, coronavirus dermatology resource of Nottingham University searched completely up to May 15, 2020, and initial 237 articles were selected to further review and finally 9 articles (including 12 patients) entered to this study. From 12 patients with chronic underlying dermatologic disease treated with systemic therapies, only 1 patient required Intensive Care Unit admission, the others have been treated for mild-moderate symptoms with conventional therapies. The biologic or immunosuppressive/immunomodulator agents have been ceased during the course of disease. The course of coronovirus diseases 2019 (COVID-19) and its management was as similar as normal populations. Their underlying dermatologic disease were exacerbating from mild to moderate. Their treatment has been continued as before, after the symptoms improved. Exacerbation of patients underlying dermatologic disease was mild to moderate. Discontinuing the treatment in the acute period of COVID and the restart after recovery may prevent severe recurrence and disturbing cytokine storms in these patients.

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

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.

Skin manifestations in patients hospitalized with confirmed COVID-19 disease: a cross-sectional study in a tertiary hospital

BACKGROUND

COVID-19 cutaneous manifestations have been recently described and classified in five different clinical patterns, including acral erythema-edema (pseudo-chilblain), maculopapular exanthemas, vesicular eruptions, urticarial lesions, and livedo or necrosis.

OBJECTIVES

The objective of this study was to examine the skin of hospitalized patients with a confirmed diagnosis of COVID-19 disease and describe the real prevalence of skin manifestations.

METHODS

A cross-sectional study, which included hospitalized patients in Cruces University Hospital from April 14-30, 2020, with a laboratory-confirmed diagnosis of COVID-19 (with polymerase chain reaction and/or serology tests), was conducted. Entire body surface examination was performed by experienced dermatologists to search for cutaneous manifestations related to COVID-19 disease.

RESULTS

From a sample of 75 patients, 14 (18.7%) developed cutaneous manifestations possibly related to COVID-19. We found six patients with acral erythema-edema (pseudo-chilblain) (42.8%), four patients with maculopapular exanthemas (28.6%), two patients with urticarial lesions (14.3%), one patient with livedo reticularis-like lesions (7.15%), and one patient with vesicular eruption (7.15%).

CONCLUSIONS

Our study provides a more plausible relationship between the main cutaneous patterns and COVID-19 in hospitalized patients as all of them had a confirmatory laboratory test. Skin manifestations are frequent but mild with spontaneous resolution. These findings are nonspecific and can be similar to other viral infections and adverse drug reactions in hospitalized patients.

COVID-19 and Skin Manifestations: An Overview of Case Reports/Case Series and Meta-Analysis of Prevalence Studies

Background and Aim: Since the onset of the 2019-nCoV disease (COVID-19), many skin manifestations have been reported in COVID-19 patients. This study aims to provide a systematic review and meta-analysis of various skin manifestations among patients with COVID-19 through case reports/case series and prevalence studies. Methods: A systematic literature search strategy was conducted by reviewing original research articles published in Medline, Web of Science, and Embase databases in 2020. Statistical analysis was performed using STATA software, version 14.0 (Stata Corporation, College Station, Texas, USA) to report the global prevalence of skin manifestations among patients with COVID-19. Results: Forty-three studies (35 articles were case reports/case series, and 8 articles were prevalence studies) were included in our study. A meta-analysis of prevalence studies showed that skin manifestations among patients with COVID-19 were reported in four countries (China, Thailand, France, and Italy), with an overall prevalence of 1.0% [(95% CI) 0.1-1.9] among 2,621 patients. Evaluation of the results of the case reports/case series revealed that, out of 54 patients with COVID-19, 48 patients (88.8%) showed skin manifestations. Erythematous rash (59.1%) and urticaria (14.8%) were the most common skin manifestation reported in studied patients. Conclusion: Infection with 2019-nCoV may lead to skin manifestations with various clinical symptoms. These clinical features combined with clinical symptoms of COVID-19 may aid in the timely diagnosis of patients with COVID-19.

Rheumatic manifestations of COVID-19: a systematic review and meta-analysis

BACKGROUND

Different proportions of musculoskeletal or autoimmune manifestations associated with COVID-19 have been reported in literature. We performed a systematic review and meta-analysis with the aim of assessing the prevalence of rheumatic manifestations in patients affected by COVID-19, as initial symptom or during disease course.

METHODS

A database search was run on May 18th, 2020, using two distinct strategies. We were interested in the percentage of symptoms of potential rheumatologic interest observed in large population studies of COVID-19 cases, and in identifying uncommon autoimmune disorders described in patients with COVID-19. For manifestations individually reported, a meta-analysis was performed taking into consideration the proportion of COVID-19 patients presenting the symptom.

RESULTS

Eighty eight original articles were included in the systematic review and 51 in the meta-analysis. We found pooled estimates of 19% for muscle pain and 32% for fatigue as initial symptom of COVID-19 presentation and, respectively, of 16 and 36% during the disease course. Only one article discussed arthralgia as unique symptom. Additionally, we found that vasculitis, chilblains, presence of autoantibodies commonly found in patients with rheumatic diseases, or autoimmune haematological and neurological disorders have all been reported in patients with COVID-19.

CONCLUSIONS

In conclusion, our review and meta-analysis emphasises that symptoms potentially leading to rheumatologic referral are common in patients with COVID-19. Therefore, COVID-19 is a new differential diagnosis to bear in mind when evaluating patients with musculoskeletal symptoms and rheumatologists might play a crucial role in identifying COVID-19 cases in early phases of the illness.

COVID-19: An overview for dermatologists

Numerous unexplained pneumonia cases were reported to the World Health Organization (WHO) by Wuhan, China, in December 2020. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a zoonotic pathogen, came into sight, spreading coronavirus disease 2019 (COVID-19) all over the globe. Association of cutaneous signs and symptoms with COVID-19 is being studied worldwide, principally, to determine if these dermatoses can help in early recognition of SARS-CoV-2 infection. These dermatological manifestations can range from erythematous rash, urticaria to livedo reticularis, and acrocyanosis in patients of all age groups. Correspondingly, dermatologists treating COVID-19 patients, suffering from inflammatory dermatoses, with biologics or immunomodulators should exert caution and use specific protocols to adjust the doses of these medications. Prevention of person-to-person transmission of COVID-19 is being promoted universally, with the use of personal protective equipment (PPE), hand washes, and hand sanitizers around the clock. However, an array of cutaneous adverse effects such as contact dermatitis, irritant contact dermatitis, friction blisters, contact urticaria, acne, and infections are associated with the use of PPE. Extra-pulmonary manifestations of COVID-19 are still emerging in the community, and physicians and researchers are working together globally to strengthen the clinical management of these patients. Cases of COVID-19 continue to rise across the world, and an unprecedented approach has been taken to develop effective vaccines and therapeutic strategies against existing and forthcoming mutagenic strains of SARS-CoV-2.

Cutaneous Manifestations in the Context of SARS-CoV-2 Infection (COVID-19)

The coronavirus 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has had enormous health, economic, and social consequences. The clinical spectrum of cutaneous manifestations observed in patients with COVID-19 is both heterogeneous and complex. To date, reports have identified 5 main categories: acral lesions, vesicular rashes, urticarial rashes, maculopapular rashes, and livedoid and necrotic lesions. However, these will probably be modified as new information comes to light. Cutaneous manifestations associated with COVID-19 probably reflect the activation of pathogenic pathways by the virus or a response to inflammatory processes, vascular or systemic complications, or even treatments. Familiarity with the cutaneous manifestations of COVID-19 may enable early diagnosis or help guide prognosis.