key: cord-278710-2fiyzl5u
authors: Kalner, Samantha; Vergilis, Irene J.
title: Periorbital Erythema as a Presenting Sign of Covid-19
date: 2020-05-11
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2020.05.001
sha: 
doc_id: 278710
cord_uid: 2fiyzl5u

nan

Reports in literature of the presence of cutaneous findings in patients who have tested positive for SARS-CoV2 which causes the coronavirus disease 2019 (COVID-19), have ranged from 20.4% 1 to 0.2% of the cases 2 . Reported cutaneous manifestations span from nonpruritic to pruritic erythematous morbilliform eruptions involving the trunk, to localized or widespread urticaria, to chickenpox-like vesicles 1 . Petechial rash has also been described at the initial presentation of the COVID-19 disease 3 , along with confluent erythematous-yellowish papules on heels bilaterally that presented 13 days after the onset of COVID-19 and which progressed to pruritic, hard, erythematous plaques 4 . The timing of the reported cutaneous manifestations observed has also varied, with some patients presenting with cutaneous findings at the onset of the COVID-19 symptoms, while other patients develop cutaneous involvement after infection has progressed and they have been hospitalized 1 . Herein, we present a novel cutaneous finding, a dusky red, non-pruritic, non-blanching periorbital dyschromia that we have observed in several patients who have been diagnosed with COVID-19. This rash appeared prior to the development of any of the systemic symptoms of COVID-19 and we believe that it can potentially serve as an early sign of patients developing COVID-19.

Patient 1, an otherwise heathy 43-year-old female, presented with dusky red, non-pruritic, nonblanching periorbital dyschromia ( Figure 1 ). There was no conjunctivitis, other ocular symptoms or any systemic findings of COVID-19 reported at the time that periorbital dyschromia appeared. 2 days after the appearance of the rash, Patient 1 reported that she had developed fever, cough, sore throat, muscle weakness, myalgias, and shortness of breath. Patient 1 was prescribed alclometasone dipropionate 0.05% ointment. She was followed via telemedicine encounters and reported that she subsequently tested positive for the SARS-CoV2. Patient 1 reported that she was using prescribed ointment twice a day and her rash completely has been comprised to date. Some of the cutaneous manifestations of COVID-19 that have been described in the literature have ranged from erythematous eruptions involving the trunk, to widespread erythema and chickenpox-like vesicles 1 , to skin rash with petechia 3 , to confluent erythematous-yellowish papules on heels bilaterally which progressed to hard, erythematous plaques 4 . Furthermore, COVID-19 patients seem to be prone to coagulation dysfunction with signs of small blood vessel occlusion, as is evident by systemic, as well as cutaneous findings of ischemia in the limbs. These cutaneous manifestations of microcirculation disorder that patients with COVID-19 may be developing can clinically present as findings ranging from petechiae or tiny bruises, to nonpruritic blanching livedoid vascular eruptions on extremities, to plantar plaques, plantar vesicles, dry gangrene, or just bruising in the fingers and toes 5 . Perhaps the periocular dyschromia that we have noticed is a part of the coagulation dysfunction affecting the periocular vasculature. Although much more research is needed in order to evaluate the cutaneous manifestations which accompany COVID-19, herein we present our findings of periorbital dyschromia which presents a few days prior to the onset of systemic manifestations of COVID-19 and does not have any ocular findings unlike in other reported studies 6 . We believe that appearance of periorbital dyschromia may potentially serve as an early cutaneous manifestation of COVID-19 and as a precursor of the systemic symptoms which seem to follow this presentation. 

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