key: cord-1034559-272999um
authors: Calvão, J; Relvas, M; Pinho, A; Brinca, A; Cardoso, J.C.
title: Acro‐ischemia and COVID‐19 infection: clinical and histopathological features
date: 2020-06-02
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16687
sha: 90b85dc385ad870e3f3994bf26b74c2a52ab7ac5
doc_id: 1034559
cord_uid: 272999um

With the COVID‐19 pandemic we are facing a changing world. This new coronavirus (SARS‐CoV‐2) poses new challenges to dermatologists too. Some of us are in the field, others are describing skin aspects related to this infection, either directly or indirectly caused (e.g: dermatoses resulting from prolonged contact with personal protective equipment and excessive personal hygiene). Still, cutaneous manifestations are uncommonly reported and the majority has no clinical or histological pictures.

This article is protected by copyright. All rights reserved Chilblain-like lesions are also being described, especially in young patients with mild infections. [6] [7] [8] 

This article is protected by copyright. All rights reserved We describe the case of an 81-year-old male admitted for bilateral pneumonia, with a negative initial swab for COVID-19. Blood tests showed an elevated C-reactive protein (26.97mg/dL) and procalcitonin (2.09ng/mL), leucocytosis (12.8x10 9 /L) with neutrophilia (11.45x10 9 /L) and lymphopenia (0.74x10 9 /L), and elevated D-dimers (4708ng/mL). Platelet count and coagulation tests were normal, and the patient didn't take antiaggregants or anticoagulants. He started empiric antibiotherapy, and blood cultures were negative. One week later he developed petechial lesions confined to fingers and toes, that progressed in a few days to haemorrhagic bullae and necrotic plaques on the hands and feet (Figure 1 ) Although there is much to discover about SARS-CoV-2 and its manifestations, abnormal coagulation results, especially elevated D-dimers and fibrin degradation products have been associated with poor prognosis, and disseminated intravascular coagulation (DIC) is common in critically ill COVID-19 patients. 9 Manalo et al. 4 

hypothesized that the microthromboses that manifest in other organs and as DIC in critically ill COVID-19 patients were the most plausible aetiology for LR, and that manifestations could vary from transient LR in milder cases to acrocyanosis in critically ill patients. Findings from minimally invasive autopsies showed degeneration and necrosis of parenchymal cells as well as formation of hyaline thrombi in small vessels in lung and other organs. 8, 10 In our case, however, we did not find evidence of vascular occlusion but instead a predominantly neutrophilic smallvessel vasculitis, suggesting that the pathogenesis of the lesions may be different.

To our knowledge, this is the first clinical and histopathological report of COVID-19 infectioninduced acro-ischemic lesions. Similar to other reports 5 , our case also suggests that these acute and Accepted Article

Covid-19 pandemic and the skin -What should dermatologists know? Clin Dermatol

Cutaneous manifestations in COVID-19: a first perspective

COVID-19 can present with a rash and be mistaken for Dengue

A Dermatologic Manifestation of COVID-19: Transient Livedo Reticularis

COVID-19) infection-induced chilblains: a case report with histopathological findings. JAAD Case Reports

A new vasculitis at the time of COVID-19

A case of COVID-19 presenting in clinical picture resembling chilblains disease. First report from the Middle East

Abnormal coagulation parameters are associated with poor

This article is protected by copyright. All rights reserved ischemic acral lesions may predict a poor prognosis, in contrast to chilblain lesions that are mostly seen in young and asymptomatic or milder symptomatic patients 6, 8 .