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Acrofacial purpura and necrotic ulcerations in COVID‐19: a case series from New York City

2020; Wiley; Volume: 59; Issue: 11 Linguagem: Inglês

10.1111/ijd.15181

1365-4632

Theodora K. Karagounis, Katharina S. Shaw, Avrom S. Caplan, Kristen Lo Sicco, Alisa N. Femia,

Parvovirus B19 Infection Studies

Dear Editor, As COVID-19 continues to spread worldwide, the prognostic significance of its cutaneous manifestations has been increasingly scrutinized, including that of retiform purpura. Additionally, an increased incidence of thromboembolism has been seen in COVID-19,1 and histopathologic evaluation of retiform purpura in COVID-19 patients demonstrated thrombotic vasculopathy suggestive of a hypercoagulable state.2 To better characterize purpura and necrotic ulcerations in hospitalized COVID-19 patients and examine incidence of systemic coagulopathy in this population, we performed a retrospective review of patients seen within a tertiary care center during peak incidence of COVID-19 in New York City. After IRB approval, we reviewed patient charts for whom dermatology and wound care were consulted at NYU Tisch and Bellevue Hospital from March 1 to May 1, 2020. Over 3,800 patients were hospitalized for COVID-19 during this time. Inclusion criteria consisted of positive SARS-CoV-2 PCR (severe acute respiratory syndrome coronavirus polymerase chain reaction) and presence of purpura and/or necrotic ulceration. Salient laboratory values and clinical outcomes were documented (Table 1). In an attempt to exclude typical hospital-acquired sacral pressure ulcers, patients solely with sacral purpura/necrosis were excluded. Yes, for elevated D-dimer Yes, for elevated D-dimer Yes, for elevated D-dimer Yes, for elevated D-dimer Yes, for elevated D-dimer Yes, for elevated D-dimer Yes, for elevated D-dimer We identified 21 PCR-positive COVID-19 patients with purpuric and/or necrotic ulcerations on the ears, face, distal extremities, and/or genitalia (Fig. 1). Fourteen of 21 patients had multiple sites of involvement including eight patients who also had sacral ulcers. In 17/21 patients, sites in direct contact with medical devices including nasal cannula, endotracheal tube, urinary catheter, or pulse oximeter were involved; devices were in place for a range of 2–30 days (median 11 days) at the time of dermatologic evaluation, and time between hospitalization and first identification of skin manifestations ranged from 2 to 33 days (median 19 days). Case age varied greatly and was younger overall (25–88 years, median age 56) than in prior reports of retiform purpura in COVID-19.3 Only 3/21 patients were female. Most patients were critically ill; 19/21 required invasive mechanical ventilation and 18/21 required vasopressors within 2 weeks of lesion onset. All patients were intermittently proned. In terms of systemic hypercoaguability, five patients developed deep vein thromboses and one experienced myocardial infarction. Sixteen developed acute kidney injury, possibly related to renal microthrombosis.4 Therapeutic anticoagulation was initiated in 16/21 (76%) for a thrombotic event or elevated D-dimer: 13 prior to the recognition of cutaneous findings, while the remainder were transitioned from prophylactic to therapeutic doses of anticoagulation after cutaneous eruptions were noted. Recent reports document a high incidence of coagulopathic events in COVID-19.1 While the exact pathomechanism remains unclear, direct invasion of endothelial cells by SARS-CoV-2 virus and complement-mediated endothelial injury may promote2 a microthrombotic syndrome with potential for cutaneous involvement. In our review of 21 patients, we demonstrate a propensity for acrofacial purpura and necrotic ulceration in COVID-19, often associated with minor pressure (including intermittent proning or contact with medical devices) and occurring on nonsacral sites. Moreover, we identify a 29% rate of detectable thromboembolic events, 76% incidence of acute renal injury possibly related to microthrombosis4, and 90% incidence of severe COVID-19 pneumonia in this cohort, despite a younger median age than previously reported.3 The majority of patients were men, likely reflective of increased COVID-19 disease severity as described in men compared with women.5 While sacral ulcerations are frequently seen in critically ill patients, acrofacial purpura and necrosis are less common. We posit that a microthrombotic syndrome associated with COVID-19 may result in acrofacial cutaneous purpura/necrosis and that pressure-associated tissue hypoxemia is an inciting factor in areas not typically prone to pressure-induced injury. We highlight these cases to suggest increased vigilance for pressure-related cutaneous injury in severely ill COVID-19 patients. Further, observation of necrotic ulcerations may warrant heightened clinical suspicion for a procoagulant state and/or signs of other end-organ damage. These cutaneous findings may have implications regarding appropriate therapeutic anticoagulation targets, although additional prospective studies are needed.