key: cord-1051631-b1ioj2n6
authors: Shehi, Elona; Chilimuri, Sridhar; Shin, Dongmin; Patel, Madanmohan; Ali, Nisha; Niazi, Masooma
title: Microthrombi on Skin Biopsy in a Patient with COVID-19
date: 2020-10-13
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2020.10.009
sha: 3e4356dd2c287bfda670d6ed609254bcac39e225
doc_id: 1051631
cord_uid: b1ioj2n6

nan

Cutaneous manifestations are an interesting presentation of COVID -19 infection, but only a few cases have described the histological findings of skin biopsy in these patients. We present the case of a COVID-19 positive patient with maculopapular rash whose skin biopsy showed the presence of fibrin microthrombi within the small vessels as the main distinctive histologic feature.

A 59 years old Hispanic male with history of hypertension and alcohol use disorder presented to the emergency department (ED) with complaints of cough and progressive shortness of breath. On examination the patient was noted to be hypoxic to 86% on room air, but otherwise the initial physical examination was unremarkable. Patient is a non-smoker, a non-drug user and he consumes alcohol daily. He is unemployed and lives in a shelter. He is allergic to Penicillin which causes him hives. He was not taking any prescribed, over the counter medications or supplements. His initial laboratory tests showed normal complete white blood cell count 6.1 k/ul, normal liver and kidney function tests, a Ddimer 212 ng/mL, lactate dehydrogenase 323 u/L , ferritin 340 ng/mL and C-reactive protein 6.9 mg/L. A cat scan of the chest without contrast showed bilateral ground-glass opacities concerning for COVID-19 infection. After the initial physical examination, laboratory and imaging findings, patient was admitted to the medical ward for suspected COVID-19 pneumonia. Two nasopharyngeal swabs for PCR for SARS-CoV 19 were performed and reported negative. A serologic testing for anti-SARS-CoV 19 antibodies was reported positive. He was treated with levofloxacin and intravenous tocilizumab 400 mg for COVID-19 pneumonia. Other medications received during the hospitalization were atorvastatin, famotidine, multivitamin, folic acid and thiamine. During the hospital stay, his oxygen requirements increased, and he was started on high flow, but he did not require mechanical ventilation and ICU care. On day three of hospitalization, a new rash was noted on physical exam. The rash initially appeared in the lower extremities, spread quickly to the trunk and neck, sparing the face, palms and soles. On exam a generalized non-blanching maculopapular eruption involving the trunk and extremities was noted, with some of the papules being urticarial (Fig 1, 2) . Patient had bilateral conjuctival injection. There was no other mucosal involvement. Repeat laboratory the day rash appeared, showed a total white blood cell count of 9.9 k/ul, elevated D dimer 13646 ng/ml, lactate dehydrogenase 233 u/l, ferritin 430 ng/mL, C reactive protein 5 mg/L, normal liver and kidney function tests. Initially, a drug eruption was suspected, and he was treated with antihistaminics and steroids with no improvement. Due to elevated D -dimer and hypoxia, pulmonary embolism was suspected, and a ct angiogram was done and showed no emboli. On day seven of the hospitalization, the rash did not improve, so a punch skin biopsy was performed. The biopsy was taken from one of the maculopapular lesions in the interscapular area. The lesion was not blanching and non-urticarial. No repeat labs were done on the day of biopsy. The hematoxilin-eosin stained tissue specimens showed post-inflammatory pigmentary alteration, a dermis with distended small vessels and capillaries filled with fibrin microthrombi (Fig 3) . Due to elevated D dimer and risk for thromboembolic events related to COVID 19 infection, Apixaban was started. Patient had no other clinical sequela of hypercoagulability. He was hospitalized for a total of eleven days and was discharge after his respiratory status and oxygen requirement improved. Approximately two months after the discharge, he had another ED visit for shortness of breath, and no rash was noted on exam.

Cutaneous manifestations are an interesting presentation of COVID-19 infection. Several cases of skin involvement like erythematous rash, urticarial lesions, vesicles resembling chicken pox ¹, petechial rash mimicking Dengue ², livedico reticularis³, acral ischemic lesions resembling chilblains , acral perniosis and erythema multiforme have been reported with COVID-19 infection. According to a review article by Muskaan Sachdeva et al that included 79 COVID-19 patients with skin lesions, the most common cutaneous manifestation of COVID-19 was maculopapular exanthem (morbilliform), presenting in 36.1% of the patients. Other findings included papulovesicular rash (34.7%), urticaria (9.7%), painful acral red purple papules (15.3%), livedo reticularis lesions (2.8%) and petechiae (1.4%). Majority of lesions were localized on the trunk (66.7%) while 19.4% of patients had lesions involving the hands and feet. In regards to the timing of the skin lesion, 12.5% of patients presented with a cutaneous lesion at diagnosis or with onset of other COVID-19 symptoms. The remaining 69.4% started having lesions after the onset of respiratory symptoms or after the diagnosis of COVID-19, with the majority of them developing cutaneous lesions within 7 days of COVID-19 symptom onset or the diagnosis of COVID-19 . Majority of the studies reported no correlation between COVID-19 severity and skin lesions. The mechanisms of skin lesions found in COVID-19 patients are not well known and not many cases of skin biopsy have been described. In our case the skin biopsy of the lesion showed microthrombi in the cutaneous microvasculature. The hypercoagulable state and thrombotic microangiopathy related to COVID-19 infection has been reported in many studies.

¹ ¹¹ ¹² ¹³ Manalo et al suggested livedo reticularis-resembling manifestation can be due to low-grade disseminated intravascular coagulation or low-grade thrombophilic state related to COVID-19 infection.³ Magro et al found pauci-inflammatory thrombogenic vasculopathy involving the cutaneous microvasculature. Their evidence suggests that the microvascular injury is thought to be mediated by activation of the complement pathways and the associated procoagulant state.¹ Reporting uncommon presentations of COVID-19 such as skin lesions can help clinicians stay aware of atypical scenarios and guide their diagnostic approach.

J o u r n a l P r e -p r o o f 

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Erythema multiforme-like eruption in patients with Covid-19 infection: clinical and histological findings

Cutaneous manifestations of COVID-19: Report of three cases and a review of literature

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