key: cord-0945330-nzmej2le
authors: Chand, Sidharth; Rrapi, Renajd; Lo, Jennifer A.; Song, Sarah; Gabel, Colleen K.; Desai, Niyati; Hoang, Mai P.; Kroshinsky, Daniela
title: Purpuric Ulcers Associated with COVID-19 Infection: A Case-Series
date: 2021-02-03
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2021.01.019
sha: 211674837d83a3dbd989fb030267f37516a24fab
doc_id: 945330
cord_uid: nzmej2le

nan

Introduction: COVID-19 is an infection due to severe acute respiratory syndrome coronavirus 2 26 (SARS-CoV-2) that has resulted in a global pandemic with significant morbidity and mortality. 27

This illness has been associated with numerous dermatologic manifestations, including 28 morbilliform rash, urticaria, and retiform purpura. 1 Additionally, pressure ulcers are a concerning 29 comorbidity for patients hospitalized with COVID-19 due to impaired perfusion and reduced 30 mobility in patients with compromised respiratory function. 2 Placing patients with severe 31 respiratory disease due to COVID-19 in a prone position has improved outcomes 3 but has also 32 been associated with the development of pressure ulcers. 4 Other risk factors for developing 33 pressure ulcers include intensive care unit (ICU) stay, fever, incontinence, and poor nutrition 34 with loss of protective body mass. 5, 6 35

Purpuric lesions may represent the proposed coagulopathy and microvascular injury of COVID-36 19, and the pathophysiology is unclear. 7 This case-series reports purpuric pressure ulcers, a novel 37 cutaneous finding of pressure-related injury with secondary hemorrhage in patients with 38 COVID-19. The morphology, clinical course, and histopathological features of this cutaneous 39 manifestation of COVID-19 is described to investigate its etiology. 40

Methods: A retrospective chart review of 11 patients hospitalized with laboratory-confirmed 41 SARS-CoV-2 at a tertiary care medical institution between March and May 2020 was conducted. 42

These patients developed purpuric lesions for which dermatology was consulted for evaluation 43 lesions at pressure dependent sites, often with geometric borders and sometimes with associated 63 bullae, which typically progressed to central ulceration with eschar ( Figure 1 ). Based on the 64 morphology of these lesions, such as some with retiform appearance, the initial differential 65 diagnosis included coagulopathies, vasculitides, and pressure-induced injuries. The mean time to 66 onset of skin lesions was 10 days (standard deviation 5.4 days) from admission. These purpuric 67 pressure ulcers were observed most frequently at the buttocks (63.6%) and at other pressure- 

Case 1: A 54-year-old male with a history of hypertension, hyperlipidemia, and type II diabetes 83 mellitus presented to the emergency department (ED) with respiratory symptoms and fever for 84 eight days. Shortly after admission, his respiratory status declined prompting rapid intubation. 85

His PCR diagnostic test was positive for SARS-CoV-2 and his initial laboratory abnormalities 86 included elevated creatinine, lactate dehydrogenase (LDH), D-dimer, erythrocyte sedimentation 87 rate (ESR), c-reactive protein (CRP), and procalcitonin. 15 days after admission, he developed a 88 purpuric pressure ulcer on the bilateral buttocks that was biopsied by dermatology and 89 suggestive of pressure injury. His hospital course was complicated by septic shock and 90 pulmonary embolism. The wound improved with topical petrolatum and non-adhesive padded 91 dressing as well as increased mobility after extubation and discharge to a rehabilitation facility. 92

Case 2: A 76-year-old male with a history of hyperlipidemia presented to the ED with two weeks 94 of malaise and dyspnea. His PCR diagnostic test was positive for SARS-CoV-2, and his initial 95 laboratory abnormalities included elevated LDH, liver function tests (LFTs), and prothrombin 96 time. Three days after admission, he was intubated due to worsening respiratory function. Eight 97 days after admission, he developed a purpuric pressure ulcer on his bilateral buttocks that was 98 biopsied by dermatology and suggestive of pressure injury. His hospital course was complicated 99 by acute renal failure. The purpuric pressure ulcer persisted after discharge during his 100 rehabilitation course and was classified as a stage three wound six months after initial 101

Case 3: A 72-year-old female with a history of hypertension, hyperlipidemia, and cirrhosis 103 presented to the ED with two weeks of fever and cough. PCR diagnostic test prior to admission 104 was positive for SARS-CoV-2, and at admission the patient was intubated due to declining 105 respiratory function. Initial laboratory abnormalities showed elevated LDH, LFTs, D-dimer, and 106 ESR. 11 days after admission, she developed purpuric pressure ulcers on the bilateral buttocks 107 that were biopsied by dermatology and suggestive of pressure injury. Her hospital course was 108 complicated by pneumonia and candidemia. The purpuric pressure ulcer persisted despite daily 109 wound care and patient follow up was not available after being discharged to a long-term care 110

Discussion: This is a large case-series of dermatologist-evaluated purpuric pressure ulcers in 112 patients with COVID-19. In this cohort, these lesions were associated with obesity, impaired 113 A. Well-demarcated purpuric patches with focal areas of skin sloughing on buttocks in patient #1 recorded 6 days after lesion onset. B. Well-demarcated purpuric patch with focal full-thickness epidermal loss on buttocks of patient #2 recorded 10 days after lesion onset. C. Three areas of well-demarcated purpura with overlying bulla formation on buttocks of patient #3 recorded 6 days after lesion onset. D. Well-demarcated areas of purpura with focus of denuded skin on buttocks of patient #9 recorded 5 days after lesion onset.

HOLDER Picture file attached to submission. 

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