COVID-19 and nail manifestation: be on the lookout for the red half-moon nail sign Dear Editor, Multiple cutaneous dermatologic manifestations have been reported in patients infected with SARS-CoV-2, especially pernio-like lesions. 1 Interestingly, nail apparatus manifestations of SARS-CoV-2 have been scarcely reported, with only one published report in the literature to date. 2 We report the case of a 37-year-old woman who presented with anosmia, dry cough, persistent fever, and relatively normal oxygen saturation (>92%). A positive nasal swab polymerase chain reaction for SARS-CoV-2 confirmed the infection. Two days after the symptoms began, the patient noticed changes in the nail bed characterized by a red-violet band, above the nail lunule. These changes were asymptomatic and lasted for 1 week before gradually returning to normal (Fig. 1). The patient was managed at home and did not require supplemental oxygen. Cutaneous manifestations, such as erythematous rash, rash with petechiae, vesicular rash, acral ischemia, livedo reticularis, and widespread urticaria, can present in up to 20% of patients with SARS-CoV-2 infection. 1 The chilblain-like lesions in patients with SARS-CoV-2 infection range from mild to severe acral ischemia lesions. Recently Neri et al., reported a case of "transversal red bands of the nail" also referred to as the "red half-moon nail sign". 2 We believe that our case confirms this finding. The pathophysiology of this nail manifestation remains to be elusive; however, similar to Neri et al., we hypothesized that this transient phenomenon could be secondary to vascular inflammation. 2 We did not perform a biopsy because of its morbidity and possible permanent cosmetic results. Therefore, the associated histological findings of the red half-moon nail sign associated with SARS-CoV-2 infection remain uncertain. In summary, it is important to emphasize a complete and detailed dermatological review, in search of these nail changes in all patients with SARS-CoV-2 infection.

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Post-herpetic abdominal pseudohernia is a neurologic complication of herpes zoster resulting from paresis of the abdominal wall muscles ipsilateral to the eruption. This poorly known condition may raise suspicion for true abdominal wall hernia or other concerning etiologies, resulting in extensive work-up and imaging. Post-herpetic abdominal pseudohernia is a relatively benign condition, which resolves spontaneously in the majority of cases. Therefore, it is important for the clinician to be aware of this complication in order to avoid unnecessary imaging or excessive management, which may increase the cost of care and burden to the patient.

Tumor mutational burden (TMB) has recently been identified as a biomarker of response to immune checkpoint inhibitors in many cancers, including melanoma. Co-assessment of TMB with inflammatory markers and genetic mutations may better predict disease outcomes. The goal of this study was to evaluate the potential for TMB and somatic mutations in combination to predict the recurrence of disease in advanced melanoma. A retrospective review of 85 patients with stage III or IV melanoma whose tumors were analyzed by next-generation sequencing was conducted. Fisher’s exact test was used to assess differences in TMB category by somatic mutation status as well as recurrence locations. Kaplan–Meier estimates and Cox-proportional regression model were used for survival analyses. The most frequently detected mutations were TERT (32.9%), CDKN2A (28.2%), KMT2 (25.9%), BRAF V600E (24.7%), and NRAS (24.7%). Patients with TMB-L + BRAFWT status were more likely to have a recurrence [hazard ratio (HR), 3.43; confidence interval (CI), 1.29–9.15; P = 0.01] compared to TMB-H + BRAF WT. Patients with TMB-L + NRASmut were more likely to have a recurrence (HR, 5.29; 95% CI, 1.44–19.45; P = 0.01) compared to TMB-H + NRAS WT. TMB-L tumors were associated with local (P = 0.029) and in-transit (P = 0.004) recurrences. Analysis of TMB alone may be insufficient in understanding the relationship between melanoma’s molecular profile and the body’s immune system. Classification into BRAFmut, NRASmut, and tumor mutational load groups may aid in identifying patients who are more likely to have disease recurrence in advanced melanoma.