key: cord-0712705-k58ytmul
authors: Ciccarese, Giulia; Drago, Francesco; Boatti, Martina; Porro, Alice; Muzic, Shaun Ivan; Parodi, Aurora
title: Oral erosions and petechiae during SARS‐CoV‐2 infection
date: 2020-07-06
journal: J Med Virol
DOI: 10.1002/jmv.26221
sha: 37f552dcbd0ffa18595f8f6a10f26d3d8fe20600
doc_id: 712705
cord_uid: k58ytmul

An increasing number of reports have been written regarding the cutaneous manifestations during the coronavirus disease-2019 (COVID-19), though knowledge of the possible oral manifestations is still poor. This may be due to a lack of intraoral examinations, which may be caused by a limited availability of the recommended protective measures and the use of telemedical consultations for SARS-CoV-2 infections. This article is protected by copyright. All rights reserved.

(400 mg per day) 3 days earlier. She also reported a sudden onset of fatigue, hyposmia, and asymptomatic cutaneous and oropharyngeal lesions that started 2 days before admission. On admission, she was afebrile and her vital signs (blood pressure, beats/minute, oxygen saturation) were normal. Physical examination revealed erythematous macules, papules and petechiae on the lower extremities ( Figure 1A) ; erosions, ulcerations, and blood crusts on the inner surface of the lips ( Figure 1B ) and palatal and gingival petechiae. Chest radiograph and pulmonary ultrasound were normal. A complete blood cell count revealed increased white cells (12 000/mm 3 , 60% of lymphocytes), aspartate aminotransferase (200 U/L), alanine aminotransferase (140 U/L), lactic dehydrogenase (LDH) (300 mU/mL) and severe thrombocytopenia (platelet count 2000/mm 3 ). Hemoglobin and C-reactive protein levels were normal. Real-time reverse transcriptase-polymerase chain reaction (PCR) from a nasopharyngeal swab was positive for SARS-CoV-2. Antibiotic therapy was discontinued and intravenous immune globulins (400 mg/kg) and methylprednisolone (1 mg/kg) was administered for 5 days.

On day 5, the systemic symptoms regressed, though some maculopapular lesions were still present on the legs; the platelet count had increased to 98 000/mm 3, and aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase returned to normal ranges. On day 10, the complete blood count was normal (white cells 9000/mm 3 with 40% of lymphocytes; platelet count 152,000/mm 3 ) and skin and mucosal lesions disappeared.

In the literature, the prevalence of cutaneous findings in SARS-CoV-2 patients ranges from 0,2% 1 to 20,4%. 2 Skin lesions are heterogeneous and divided into acral erythematous-edematous chilblain-like lesions, maculopapular, vesicular and urticarial eruptions. 3 Petechial eruptions are sporadically reported, 4 while oropharyngeal lesions have been described in only seven patients to date (Table 1) . [5] [6] [7] [8] They were all adult patients (mean age 57 years), often affected by diabetes and hypertension, presenting with painful oropharyngeal lesions in the form of ulcers (5 cases), 5,6,8 blisters and gingivitis (1 case), 5 palatal petechiae, erythema and pustules (1 case). 7 Histological analysis, performed in three cases revealed inflammatory infiltrates and focal necrosis-hemorrhages in the lamina propria, and in one case, small vessel obliteration with thrombi. In these three cases, infections with herpes simplex virus (HSV)1/2 were excluded through in-situ hybridization and PCR on the lesion tissue. 6, 8 Compared to the previously reported cases, 5-8 our patient was younger and without comorbidities. Notably, the oral lesions in our patient were painless, heterogeneous in morphology, and associated 

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