key: cord-258757-vwfey8of
authors: Torres‐Navarro, I.; Abril‐Pérez, C.; Roca‐Ginés, J.; Sánchez‐Arráez, J.; Botella‐Estrada, R.; Évole‐Buselli, M.
title: Comment on ‘Two cases of COVID‐19 presenting with a clinical picture resembling chilblains: first report from the Middle East’: pernio unrelated to COVID‐19
date: 2020-05-24
journal: Clin Exp Dermatol
DOI: 10.1111/ced.14255
sha: 
doc_id: 258757
cord_uid: vwfey8of

Dear editor, we have read with interest Dr´s Alramthan and Aldaraji contribution to the spectrum of COVID-19 clinical manifestations.1 Since COVID-19 outbreak begin, new symptoms have been described.2 Some of them, were not initially highlighted and could be a distinguishing feature of COVID-19 infection, like anosmia or ageusia.3 Therefore, it is believed that a newly reported one, so-called acute acro-ischemia is another novel clinical manifestation of COVID-19 infection.4.

We read with interest the recent paper by Alramthan and Aldaraji in Clinical and Experimental Dermatology, contributing to the spectrum of COVID-19 clinical manifestations. 1 Since the COVID-19 outbreak began, a number of new symptoms have been described. 2 Some of these were not initially highlighted but could be a distinguishing feature of COVID-19 infection, such as anosmia or ageusia. 3 Therefore, it is believed that a newly reported symptom, termed acute acro-ischaemia, is another novel clinical manifestation of COVID-19 infection. 4 Alramthan and Aldaraji described two previously healthy women presenting with red-purple papules on the dorsal aspect of the fingers bilaterally. 1 One of the patents also had diffused subungual erythema in the right thumb. Both patients presented to a clinic in Kuwait, but as they had recently travelled from the UK, a reverse transcription-PCR test for SARS-CoV-2 infection was performed, which gave a positive result. 1 The authors suggested that such skin lesions might be a new clinical manifestation of COVID-19 infection in otherwise asymptomatic individuals.

We report two patients with similar clinical manifestation, but a different diagnosis.

Two patients presented with similar lesions on the fingers also suspected to be induced by COVID-19. Patient 1 was a 16-year-old girl, who presented with a 1-week history of violaceous erythema over the distal joints (Fig. 1) . Patient 2 was a 16-year-old boy, who presented with a 3-week history of acral erythema (Fig. 2a,b) and red papules with an orange hue (Fig. 2c) .

Laboratory investigations including complete blood count; erythrocyte sedimentation rate; routine urine tests; serum biochemical tests; assays for antinuclear antibodies; serum complement components C3 and C4, anticardiolipin antibodies, antiphospholipid and beta-2-gycoprotein-I, cryoglobulins and cold agglutinins; serological tests for enterovirus, Epstein-Barr virus, herpesvirus 6, parvovirus B19, mycoplasma, rubella and measles; levels of IgG, IgM and IgA; and PCR (nasopharyngeal swab) for SARS-CoV-2 were performed, all of which gave normal or negative results. Skin biopsy was not taken. In consequence, a clinical diagnosis of pernio (chilblains) was made. 5 After 1 week of follow-up, the cutaneous lesions had notably improved.

Thus, we hypothesize that the increasing number of clinical cutaneous manifestations being reported are not caused directly by COVID-19, but are related to the globally imposed strict stay-at-home rules. In our opinion, this acral manifestation should be better classified as simple pernio. The lockdown was declared in Spain on March 14, and since then, children have not been allowed to go outdoors. It is possible this immobility has directed children to not move as frequently as normal, and cold temperatures could also have contributed to the appearance of this outbreak of pernio. The two patients reported by Alramthan and Aldaraji had recently been on a trip to the UK, a colder country than Kuwait, and cold is associated with pernio. Thence, the concurrent positivity for COVID-19 may be a coincidence, as the virus is widely spread and young people tend to have no or mild symptoms. 

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

Clinical characteristics of coronavirus disease 2019 in China

Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study

Acute acro-ischemia in the child at the time of COVID-19. Dermatologia Pediatr

Epidemiological patterns of perniosis, and its association with systemic disorder

Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 24 April 2020