1
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COBANOGLU B, CEBECI F, SIMSEK M, OZKANLI S. Clinicopathological Features of Cutaneous Findings of SARS-CoV-2 Infection. Medeni Med J 2022; 37:270-276. [PMID: 36128840 PMCID: PMC9500323 DOI: 10.4274/mmj.galenos.2022.05046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective In December 2019, severe acute respiratory syndrome coronavirus-2, which emerged in Wuhan, China, spread rapidly and created a pandemic. Coronavirus disease-2019 (COVID-19) can affect different organ systems, including the skin. Recently, COVID-19 cases with skin lesions of different clinicopathological features have been published. This study aimed to present the histopathological features of 19 COVID-19 cases with cutaneous findings and discuss them in light of the literature. Methods Skin biopsy specimens of 19 patients with skin rashes associated with COVID-19 were evaluated histopathologically and clinically. Results Clinical manifestations of rashes developed in eight female, seven male, and four pediatric patients with COVID-19. Urticaria/urticarial vasculitis (n=7), maculopapular eruption (n=7), panniculitis (n=2), purpuric eruptions (n=2), and livedoid-like lesions were noted. Histopathologically, besides the inflammatory findings, the most striking feature was that the vessels were more or less affected in almost all cases. Conclusions Cutaneous lesions associated with COVID-19 are increasingly being reported. We believe that every data presented about this disease, which has many unknowns, will shed light on future research. Every case can lead us a new way.
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Affiliation(s)
- Bengu COBANOGLU
- Istanbul Medeniyet University Faculty of Medicine, Department of Pathology, Istanbul, Turkey,* Address for Correspondence: Istanbul Medeniyet University Faculty of Medicine, Department of Pathology, Istanbul, Turkey E-mail:
| | - Filiz CEBECI
- Istanbul Medeniyet University Faculty of Medicine, Department of Dermatology, Istanbul, Turkey
| | - Mustafa SIMSEK
- University of Health Sciences Turkey, Istanbul Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Clinic of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Seyma OZKANLI
- Istanbul Medeniyet University Faculty of Medicine, Department of Pathology, Istanbul, Turkey
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2
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Quintero-Bustos G, Aguilar-Leon D, Saeb-Lima M. Histopathological and Immunohistochemical Characterization of Skin Biopsies From 41 SARS-CoV-2 (+) Patients: Experience in a Mexican Concentration Institute: A Case Series and Literature Review. Am J Dermatopathol 2022; 44:327-337. [PMID: 35170469 DOI: 10.1097/dad.0000000000002151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
ABSTRACT The SARS-CoV-2 pandemic brought countless clinical and pathophysiological questions. Although mucocutaneous infections are the most visible, they are among the least studied. This article provides relevant information to characterize morphologically and immunohistochemically the dermatoses from patients with COVID-19, during the first year of the pandemic. Immunohistochemistry reactions against the spike protein were performed in 48 skin biopsies, and the positive cases were classified according to their histomorphology; at the end, 41 biopsies led us to identify 12 morphological patterns that mimic other skin pathologies, among which pityriasiform patterns predominate. For the literature review, we selected cases of SARS-CoV-2 dermatoses that included complete histopathological information and that were published during the same interval of time; after careful evaluation, 205 biopsies were selected and then classified into 8 groups according to previously published proposals. Dermatoses associated with SARS-CoV-2 are as diverse in their clinical expression as in their histopathology, mimicking entities totally unrelated to COVID-19. Furthermore, some of these groups are characteristically associated with an aggressive course of the disease. Undoubtedly, it is necessary to delve into the possibility that these findings are translatable into prognostic and therapeutic factors.
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Affiliation(s)
- Gabriel Quintero-Bustos
- Pathology Department, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
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3
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Sadeghzadeh‐Bazargan A, Rezai M, Najar Nobari N, Mozafarpoor S, Goodarzi A. Skin manifestations as potential symptoms of diffuse vascular injury in critical COVID-19 patients. J Cutan Pathol 2021; 48:1266-1276. [PMID: 33978234 PMCID: PMC8239514 DOI: 10.1111/cup.14059] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 01/08/2023]
Abstract
As a respiratory viral infection caused by a novel coronavirus, COVID-19 became rapidly pandemic within a few months. Despite the wide range of manifestations and organ involvement in COVID-19 patients, the exact pathogenesis of severe and fatal types of COVID-19 and causes involved with the individual base of the disease is not yet understood. Several studies have reported clinical, laboratory, and histopathological data in favor of vascular injury in multiple organs of critically ill patients with COVID-19 as a result of hyperactive immune response, inflammation, and cytokine storm. Also, both clinical and histopathological evidence points to such vascular involvements in the skin. Given the ease of clinical examinations and skin biopsy and the lower risks of transmission of COVID-19 to healthcare workers, the present review article was conducted to investigate the vascular skin manifestations of COVID-19 patients clinically and/or histopathologically as helpful clues for better understanding the pathogenesis and predicting the prognosis of the disease, especially in severe cases.
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Affiliation(s)
| | - Mahdi Rezai
- Department of Emergency Medicine Management Research Center, Rasool Akram Medical ComplexIran University of Medical Sciences (IUMS)TehranIran
| | - Niloufar Najar Nobari
- Department of Dermatology, Rasool Akram Medical ComplexIran University of Medical Sciences (IUMS)TehranIran
| | - Samaneh Mozafarpoor
- Dermatologist, Skin Disease and Leishmaniasis Research Center, Department of DermatologyIsfahan University of Medical SciencesIsfahanIran
| | - Azadeh Goodarzi
- Department of Dermatology, Rasool Akram Medical ComplexIran University of Medical Sciences (IUMS)TehranIran
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4
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Ramos SG, Rattis BADC, Ottaviani G, Celes MRN, Dias EP. ACE2 Down-Regulation May Act as a Transient Molecular Disease Causing RAAS Dysregulation and Tissue Damage in the Microcirculatory Environment Among COVID-19 Patients. THE AMERICAN JOURNAL OF PATHOLOGY 2021; 191:1154-1164. [PMID: 33964216 PMCID: PMC8099789 DOI: 10.1016/j.ajpath.2021.04.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/05/2021] [Accepted: 04/22/2021] [Indexed: 02/06/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2, the etiologic agent of coronavirus disease 2019 (COVID-19) and the cause of the current pandemic, produces multiform manifestations throughout the body, causing indiscriminate damage to multiple organ systems, particularly the lungs, heart, brain, kidney, and vasculature. The aim of this review is to provide a new assessment of the data already available for COVID-19, exploring it as a transient molecular disease that causes negative regulation of angiotensin-converting enzyme 2, and consequently, deregulates the renin-angiotensin-aldosterone system, promoting important changes in the microcirculatory environment. Another goal of the article is to show how these microcirculatory changes may be responsible for the wide variety of injury mechanisms observed in different organs in this disease. The new concept of COVID-19 provides a unifying pathophysiological picture of this infection and offers fresh insights for a rational treatment strategy to combat this ongoing pandemic.
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Affiliation(s)
- Simone Gusmão Ramos
- Department of Pathology and Forensic Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
| | - Bruna Amanda da Cruz Rattis
- Department of Pathology and Forensic Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Giulia Ottaviani
- Centro di Ricerca Lino Rossi, Anatomic Pathology MED-08, Università degli Studi di Milano, Milan, Italy
| | - Mara Rubia Nunes Celes
- Department of Pathology and Forensic Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil,Department of Bioscience and Technology, Institute of Tropical Pathology and Public Health, Federal University of Goias, Goiania, Goias, Brazil
| | - Eliane Pedra Dias
- Department of Pathology, Faculty of Medicine, Fluminense Federal University, Niteroi, Rio de Janeiro, Brazil
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5
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Akl J, El-Kehdy J, Salloum A, Benedetto A, Karam P. Skin disorders associated with the COVID-19 pandemic: A review. J Cosmet Dermatol 2021; 20:3105-3115. [PMID: 34077629 PMCID: PMC8242622 DOI: 10.1111/jocd.14266] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Jennifer Akl
- Department of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon.,Faculty of Medicine, University of Balamand, Beirut, Lebanon
| | - Jessica El-Kehdy
- Department of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon.,Faculty of Medicine, University of Balamand, Beirut, Lebanon
| | - Antoine Salloum
- Department of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon.,Faculty of Medicine, University of Balamand, Beirut, Lebanon.,Dermatologic SurgiCenter, Philadelphia, PA, USA
| | - Anthony Benedetto
- Dermatologic SurgiCenter, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paula Karam
- Department of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon.,Faculty of Medicine, University of Balamand, Beirut, Lebanon
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6
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Sharma S, Raby E, Prasad Kumarasinghe S. Cutaneous manifestations and dermatological sequelae of Covid-19 infection compared to those from other viruses. Australas J Dermatol 2021; 62:141-150. [PMID: 33595840 PMCID: PMC8014733 DOI: 10.1111/ajd.13561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/21/2020] [Accepted: 01/02/2021] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Surabhi Sharma
- Willetton Medical CentreWillettonWestern AustraliaAustralia
| | - Edward Raby
- Fiona Stanley HospitalMurdochWestern AustraliaAustralia
| | - Sujith Prasad Kumarasinghe
- Fiona Stanley HospitalMurdochWestern AustraliaAustralia,Faculty of Health and Medical SciencesSchool of MedicineUniversity of Western AustraliaPerthWestern AustraliaAustralia
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7
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Tomsitz D, Biedermann T, Brockow K. Im Zusammenhang mit COVID‐19‐Infektionen beschriebene Hautmanifestationen. J Dtsch Dermatol Ges 2021; 19:530-535. [PMID: 33861006 PMCID: PMC8250391 DOI: 10.1111/ddg.14353_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/20/2020] [Indexed: 01/08/2023]
Abstract
Die Prävalenz aller kutanen Manifestationen, die direkt mit einer COVID‐19‐Infektion assoziiert sind, ist unbekannt. Allerdings steigt die Anzahl der entsprechenden Berichte schnell an und unser vorläufiges Wissen entwickelt sich rasch weiter. Die gemeldeten Hautmanifestationen lassen sich in zwei Gruppen einteilen: (1) Hautveränderungen, die unspezifisch auf eine mögliche infektiöse Erkrankung hinweisen, speziell makulopapulöses Exanthem, Urtikaria und Erythema multiforme, und (2) Hautveränderungen, die spezifischer auf eine COVID‐19‐Infektion hindeuten, insbesondere windpockenartige Läsionen, Livedo reticularis oder Frostbeulen‐artige Läsionen. Letztere scheinen mit thromboembolischen Ereignissen und vaskulären Veränderungen in Zusammenhang zu stehen.
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Affiliation(s)
- Dirk Tomsitz
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Fakultät für Medizin, Technische Universität München
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Fakultät für Medizin, Technische Universität München
| | - Knut Brockow
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Fakultät für Medizin, Technische Universität München
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8
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Cappel MA, Cappel JA, Wetter DA. Pernio (Chilblains), SARS-CoV-2, and COVID Toes Unified Through Cutaneous and Systemic Mechanisms. Mayo Clin Proc 2021; 96:989-1005. [PMID: 33714595 PMCID: PMC7826004 DOI: 10.1016/j.mayocp.2021.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 01/05/2021] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
Pernio or chilblains is characterized by erythema and swelling at acral sites (eg, toes and fingers), typically triggered by cold exposure. Clinical and histopathologic features of pernio are well described, but the pathogenesis is not entirely understood; vasospasm and a type I interferon (IFN-I) immune response are likely involved. During the coronavirus disease 2019 (COVID-19) pandemic, dermatologists have observed an increase in pernio-like acral eruptions. Direct causality of pernio due to COVID-19 has not been established in many cases because of inconsistent testing methods (often negative results) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, a form of COVID-19‒associated pernio (also called COVID toes) is probable because of increased occurrence, frequently in young patients with no cold exposure or a history of pernio, and reports of skin biopsies with positive SARS-CoV-2 immunohistochemistry. PubMed was searched between January 1, 2020, and December 31, 2020 for publications using the following keywords: pernio, chilblain, and acral COVID-19. On the basis of our review of the published literature, we speculate that several unifying cutaneous and systemic mechanisms may explain COVID-19‒associated pernio: (1) SARS-CoV-2 cell infection occurs through the cellular receptor angiotensin-converting enzyme 2 mediated by transmembrane protease serine 2, subsequently affecting the renin-angiotensin-aldosterone system with an increase in the vasoconstricting, pro-inflammatory, and prothrombotic angiotensin II pathway. (2) Severe acute respiratory syndrome coronavirus 2 cell infection triggers an immune response with robust IFN-I release in patients predisposed to COVID-19‒associated pernio. (3) Age and sex discrepancies correlated with COVID-19 severity and manifestations, including pernio as a sign of mild disease, are likely explained by age-related immune and vascular differences influenced by sex hormones and genetics, which affect susceptibility to viral cellular infection, the renin-angiotensin-aldosterone system balance, and the IFN-I response.
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Key Words
- ace2, angiotensin-converting enzyme 2
- adam17, a disintegrin and metalloproteinase 17
- ang, angiotensin
- ang1-7, angiotensin-(1-7)
- angii, angiotensin ii
- at1r, angiotensin type 1 receptor
- at2r, angiotensin type 2 receptor
- covid-19, coronavirus disease 2019
- hif-1α, hypoxia-inducible factor 1α
- ifn, interferon
- ifn-i, type i interferon
- ifn-α, interferon α
- il, interleukin
- mxa, myxovirus resistance protein a
- no, nitric oxide
- nsp, nonstructural protein
- pcr, polymerase chain reaction
- pdc, plasmacytoid dendritic cell
- raas, renin-angiotensin-aldosterone system
- s1, spike protein 1
- s2, spike protein 2
- sars-cov, severe acute respiratory syndrome coronavirus
- sars-cov-2, severe acute respiratory syndrome coronavirus 2
- th17, helper t cell 17
- tlr7, toll-like receptor 7
- tmprss2, transmembrane protease serine 2
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Affiliation(s)
- Mark A Cappel
- Gulf Coast Dermatopathology Laboratory, Dermatology Associates of Tampa Bay, Tampa, FL
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9
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Multisystem inflammatory syndrome in a neonate, temporally associated with prenatal exposure to SARS-CoV-2: a case report. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:304-308. [PMID: 33675696 PMCID: PMC7929789 DOI: 10.1016/s2352-4642(21)00055-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023]
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10
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Jakhar D, Grover C. Challenges in Performing Nail-Fold Capillaroscopy during COVID-19. Skin Appendage Disord 2021; 7:246-247. [PMID: 34046435 PMCID: PMC8018213 DOI: 10.1159/000511742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/20/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Deepak Jakhar
- Department of Dermatology, North Delhi Municipal Corporation Medical College & Hindu Rao Hospital, New Delhi, India
| | - Chander Grover
- Department of Dermatology & STD, University College of Medical Sciences & GTB Hospital, New Delhi, India
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11
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Putko RM, Bedrin MD, Clark DM, Piscoya AS, Dunn JC, Nesti LJ. SARS-CoV-2 and limb ischemia: A systematic review. J Clin Orthop Trauma 2021; 12:194-199. [PMID: 33281415 PMCID: PMC7700725 DOI: 10.1016/j.jcot.2020.11.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Recent spread of severe acute respiratory coronavirus syndrome-2 (SARS-CoV-2) has led to the coronavirus disease (COVID-19) pandemic, resulting in new challenges across all medical specialties. Limb and digit ischemia have been associated with COVID-19 infection. This systematic review includes primary studies of COVID-19 limb ischemia to identify risk factors, comorbidities, case characteristics, and treatment strategies to better understand the nature of this disease and its effects on the extremities. METHODS A literature search for studies detailing COVID-19 infected patients with limb or digit ischemia was performed, identifying 157 articles, 12 of which met inclusion criteria, accounting for 47 patients. Inclusion criteria were (1) primary studies, (2) positive disease diagnosis (3) limb ischemia, (4) reported treatment. Demographic data, case characteristics, treatments, outcomes and mortality were collected and pooled. RESULTS The average patient age was 67.6 years, predominantly male (79.6%). Of the 44 cases discussing treatment, 13 (30%) patients underwent medical treatment alone, while 23 (52.3%) patients underwent medical plus surgical treatment. Four patients (9.1%) were treated with observation. In 10 of the 12 studies, lab findings, thrombosis, or conclusions supporting a hypercoagulable state as a cause of limb/digit ischemia were cited. Five patients (10.6%) were on vasopressors and 8 patients (17.0%) were on a ventilator. Of those treated with observation alone, there was 100% resolution of symptoms. Of those treated medically without surgical intervention (17 patients), 6 patients (35.3%) were reported to have revascularization, 6 patients (35.3%) died, and the remaining outcomes were not reported. Medical and surgical treatment resulted in one limb amputation (4.4%) and altogether 74% of patients achieved revascularization of the affected limb/digit. Mortality rate was 45%. CONCLUSIONS COVID-19 infection may be associated with increased risk of limb or digital ischemia, although the quality of evidence supporting this theory is limited. Evidence of inflammatory-mediated thrombosis and endothelial injury are possible explanations which would support the use of immunotherapy in addition to anticoagulation for treatment or prevention of thromboembolic events. Current outcomes and treatment strategies are variable. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Robert M. Putko
- Department of Orthopaedic Surgery, Uniformed Services University - Walter Reed National Military Medical Center Surgery, Bethesda, MD, 20889, USA
- Corresponding author. Department of Orthopaedic Surgery, Uniformed Services University - Walter Reed National Military Medical Center Surgery, 8901 Wisconsin Ave, America Building (19), 2nd Floor, Bethesda, MD, 20889, USA.
| | - Michael D. Bedrin
- Department of Orthopaedic Surgery, Uniformed Services University - Walter Reed National Military Medical Center Surgery, Bethesda, MD, 20889, USA
| | - DesRaj M. Clark
- Department of Orthopaedic Surgery, Uniformed Services University - Walter Reed National Military Medical Center Surgery, Bethesda, MD, 20889, USA
| | - Andres S. Piscoya
- Department of Orthopaedic Surgery, Uniformed Services University - Walter Reed National Military Medical Center Surgery, Bethesda, MD, 20889, USA
| | - John C. Dunn
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, 79920, USA
| | - Leon J. Nesti
- Department of Orthopaedic Surgery, Uniformed Services University - Walter Reed National Military Medical Center Surgery, Bethesda, MD, 20889, USA
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12
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Tomsitz D, Biedermann T, Brockow K. Skin manifestations reported in association with COVID-19 infection. J Dtsch Dermatol Ges 2020; 19:530-534. [PMID: 33377313 DOI: 10.1111/ddg.14353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/20/2020] [Indexed: 01/08/2023]
Abstract
The prevalence of all cutaneous manifestations directly associated with COVID-19 infection is unknown, but the number of reports is rapidly increasing and provisional knowledge is rapidly evolving. Skin manifestations reported can be classified into (1) manifestations unspecifically indicating possible infectious diseases, i.e. maculopapular exanthem, urticaria and erythema multiforme, and (2) manifestations more specifically indicating COVID-19 infection, i.e. varicella-like, livedo reticularis or chilblain-like eruptions. The latter appear to be associated with thrombovascular events and vascular pathologies.
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Affiliation(s)
- Dirk Tomsitz
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
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13
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Novelli L, Motta F, De Santis M, Ansari AA, Gershwin ME, Selmi C. The JANUS of chronic inflammatory and autoimmune diseases onset during COVID-19 - A systematic review of the literature. J Autoimmun 2020; 117:102592. [PMID: 33401171 PMCID: PMC7833462 DOI: 10.1016/j.jaut.2020.102592] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 12/15/2022]
Abstract
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. The immune system plays a major role in the acute progression of COVID-19. SARS-CoV-2 infection shares features with autoimmune diseases. SARS-CoV-2 can induce Guillain-Barré syndrome, arthritis, chilblain-like lesions.
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Affiliation(s)
- Lucia Novelli
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center- IRCCS, Rozzano, MI, Italy
| | - Francesca Motta
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center- IRCCS, Rozzano, MI, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, MI, Italy
| | - Maria De Santis
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center- IRCCS, Rozzano, MI, Italy
| | - Aftab A Ansari
- Division of Rheumatology, Department of Medicine, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, USA
| | - M Eric Gershwin
- Division of Rheumatology, Department of Medicine, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, USA
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center- IRCCS, Rozzano, MI, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, MI, Italy.
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14
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Mirza FN, Malik AA, Omer SB, Sethi A. Dermatologic manifestations of COVID-19: a comprehensive systematic review. Int J Dermatol 2020; 60:418-450. [PMID: 33141443 DOI: 10.1111/ijd.15168] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Fatima N Mirza
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Amyn A Malik
- Department of Internal Medicine (Infectious Disease), Yale School of Medicine, Yale University, New Haven, CT, USA.,Yale Institute for Global Health, Yale University, New Haven, CT, USA
| | - Saad B Omer
- Department of Internal Medicine (Infectious Disease), Yale School of Medicine, Yale University, New Haven, CT, USA.,Yale Institute for Global Health, Yale University, New Haven, CT, USA.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, CT, USA.,Yale School of Nursing, Yale University, Orange, CT, USA
| | - Aisha Sethi
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, CT, USA
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Kaya G, Kaya A, Saurat JH. Clinical and Histopathological Features and Potential Pathological Mechanisms of Skin Lesions in COVID-19: Review of the Literature. Dermatopathology (Basel) 2020; 7:3-16. [PMID: 32608380 PMCID: PMC7583593 DOI: 10.3390/dermatopathology7010002] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023] Open
Abstract
In recent weeks, several reports have emerged of skin lesions with different clinical presentations in COVID-19 cases. All dermatologists should be aware of these cutaneous lesions, which may be early clinical symptoms of infection. We reviewed the literature on cutaneous manifestations in the PubMed database from December 2019 and June 2020. From the cases described as case reports or series in 57 recent articles, it appears that skin lesions (i) are highly varied, (ii) may not be related to the severity of the condition and (iii) resolve spontaneously in a few days. The frequency of these lesions in COVID-19 patients varies between 1.8% and 20.4%. The major clinical forms described were maculopapular eruptions, acral areas of erythema with vesicles or pustules (pseudochilblain), urticarial lesions, other vesicular eruptions and livedo or necrosis. The lesions were mainly localized in the trunk and extremities. The majority of patients were male, aged between 4.5 and 89 years. A minority of the patients were children presenting with acral, chilblain-like lesions, papulo-vesicular eruptions or Kawasaki disease-like pediatric inflammatory multisystem syndrome. The mean duration of the lesions was a few days, but some lasting as little as 20 min and others as long as four weeks have been reported. The mean latency time in the majority of cases was between 1 and 14 days; however, in some patients, lesions appeared 2 to 5 days before the onset of COVID-19 symptoms. The histopathological features of these lesions also vary, corresponding to the diversity of clinical manifestations. These features underline the nature of epidermal and dermal vascular lesions-and in severe cases, microvascular injury and thrombosis-associated with COVID-19, and provide important clues to their pathological mechanisms.
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Affiliation(s)
- Gürkan Kaya
- Departments of Dermatology and Clinical Pathology, University Hospital of Geneva, 1205 Geneva, Switzerland
| | - Aysin Kaya
- Department of Clinical Pharmacology and Toxicology, University of Geneva, 1205 Geneva, Switzerland; (A.K.); (J.-H.S.)
| | - Jean-Hilaire Saurat
- Department of Clinical Pharmacology and Toxicology, University of Geneva, 1205 Geneva, Switzerland; (A.K.); (J.-H.S.)
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