key: cord-0867745-tcp69kym
authors: Mahieu, Rafael; Tillard, Lila; Le Guillou‐Guillemette, Hélène; Vinatier, Emeline; Jeannin, Pascale; Croué, Anne; Le Corre, Yannick; Vandamme, Yves‐Marie
title: No antibody response in acral cutaneous manifestations associated with COVID‐19 ?
date: 2020-06-02
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16688
sha: 8331ce9926680950ec299687a15da79594ec4954
doc_id: 867745
cord_uid: tcp69kym

Skins symptoms during COVID‐19 have been recently described but their relation to SARS‐CoV‐2 is unclear while results for real‐time reverse transcriptase polymerase chain reaction (rRT‐PCR) testing were variable. Recalcati et al. reported 14 cases of patients with skin symptoms consistent with previous described COVID‐19 lesions but all the patients were tested negative. They asked for a serology to validate the hypothesis that these lesions are related to COVID‐19.

Skins symptoms during COVID-19 have been recently described but their relation to SARS-CoV-2 is unclear while results for real-time reverse transcriptase polymerase chain reaction (rRT-PCR) testing were variable. 1- 3 Recalcati et al. reported 14 cases of patients with skin symptoms consistent with previous described COVID-19 lesions but all the patients were tested negative. 2 They asked for a serology to validate the hypothesis that these lesions are related to COVID-19. 2 We identified ten patients (median age 27 years) with acral cutaneous manifestations suggestive of COVID-19 and serological assay, rRT-PCR on nasopharyngeal swab (n=10), skin biopsy (n=3) with PCR (n=4) on histological material were performed. All patients had acral chilblain-like lesions (Fig 1 d) . Two patients had non-specific symptoms (asthenia, shiver, conjunctivitis and headache) 6 to 7 days before skin lesions. The cutaneous lesions consisted in erythematoviolaceous, infiltrated papules or macules, located on the dorsum or the tips of the toes, associated with a mild swelling. They were slightly painful or pruriginous. A bullous evolution occurred in 5 patients (Fig 1 f) . The dorsal aspect of the forefoot (Fig 1 f) , the lateral sides of the feet or the heel were also frequently involved. One patient displayed similar lesions on the soles (Fig 1 a) 

This article is protected by copyright. All rights reserved While evidence of SARS-CoV-2 in the lung during the acute phase have been provided through electron microscope, immunohistochemical staining and rRT-PCR, only inflammatory lesions were found in other organs and tissues. 6 In support, none of our patients were positive for SARS-CoV-2 on rRT-PCR on skin biopsy nor had detectable anti-SARS-CoV-2 antibodies, despite an overall sensitivity of serological assay above 80%. 7 We propose that these skin lesions could be due to cytotoxic CD8 T cells, locally recruited to kill some infected keratinocytes and/or endothelial cells. Accordingly, SARS-CoV-2 proteins have been previously evidenced in a COVID-19 patient with similar cutaneous manifestations. 8 During COVID-19, lower levels of specific antibodies have been reported in patients with mild compared to severe disease 9 suggesting that T cell exhaustion and viral-associated immunosuppression may dampen the production of SARS-CoV-2 specific antibodies. 10 Inability of the host immune system during mild form of the disease to completely clear the virus may contribute to explain these delayed cutaneous lesions without detectable antibody production. 

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The patients in this short report have given written informed consent to publication of their case details.