key: cord-0688721-2b3yeoej
authors: Tammaro, Antonella; Magri, Francesca; Adebanjo, Ganiyat A. R.; Parisella, Francesca R.; Chello, Camilla; Rello, Jordi; Ramirez‐Estrada, Sergio
title: Bullous dermatosis on the hands following SARS‐CoV‐2 infection
date: 2021-06-21
journal: Int J Dermatol
DOI: 10.1111/ijd.15746
sha: 1de7e7aeca35755e7e6fa3d452b826982b87796c
doc_id: 688721
cord_uid: 2b3yeoej

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personal history was positive for hypertension and atrial fibrillation. The patient was treated with dexamethasone 6 mg/day for 10 days and enoxaparin 1 mg/kg/day. On day 10 from the admission, the patient was intubated and mechanical ventilation was administrated. Furthermore, continuous renal replacement therapy was started. On the 22nd day of admission, a skin eruption abruptly occurred bilaterally at the hands of our patient.

On physical examination, bilateral and confluent purplish and violaceous macular and papular lesions were evident at the dorsal region of both hands. In addition, multiple tense and prominent bullae were observed in both hands, strained from 0. 1 The reported occurrence of vascular lesions supports the hypothesis that endothelial dysfunction plays a key role in organ injury. 2 Many hypotheses have been advanced to explain the onset of endothelial damage in COVID-19 patients:

It has been considered as an immunological reaction to viral antigens deposition; also, immune activation, especially high level of IL-6, and the stimulation of the coagulation system due to viral load have been proposed as possible triggers. 3 In case of prominent vascular damage, conspicuous bullous lesions may appear; however, only few cases of extended bullous vasculitis following the novel coronavirus infections have been reported so far. 3, 4 Importantly, the published evidence described bullous lesions which were primarily localized on the lower extremities. 3, 4 Compellingly, the concept that a virus may induce a blistering dermatosis has been previously hypothesized: both herpes simplex virus and Chikungunya virus have been linked to the development of prominent blistering lesions. 5,6 Thus, we may conjecture that SARS-CoV-2 may somehow lead to the appearance of bullous manifestations. Notwithstanding, further studies are warranted to substantiate this statement. Because a biopsy of the skin lesions could not be performed, the presence of bullous pemphigoid could not be verified. Moreover, there is published evidence describing numerous drugs, with enoxaparin being one of them, and renal replacement therapy as agents that are able to induce drug-induced bullous pemphigoid. [7] [8] [9] We report this case to add a new dimension of knowledge to the understanding of the dermatologic manifestations of COVID-19.

Necrotic acral lesions and lung failure in a fatal case of COVID-19

Cutaneous endothelial dysfunction and complement deposition in COVID-19

Exuberant bullous vasculitis associated with SARS-CoV-2 infection

Chilblain-like lesions with prominent bullae in a patient with COVID-19

Herpes simplex virus infection mimicking bullous disease in an immunocompromised patient

Severe bullous skin lesions associated with Chikungunya virus infection in small infants

A systematic review of druginduced pemphigoid

Development of bullous pemphigoid during the haemodialysis of a young man: case report and literature survey

Development of generalized bullous lesions after hemodialysis with polysulfone membrane dialyzer

Figure 2 Bullous dermatosis on the left hand of the patient. Multiple grayish bullae containing hemorrhagic and necrotic material on top of maculopapular skin changes are evident