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COVID-19 presents with a wide range of clinical neurological manifestations. It has been recognized that SARS-CoV-2 infection affects both the central and peripheral nervous system, leading to smell and taste disturbances; acute ischemic and hemorrhagic cerebrovascular disease; encephalopathies and seizures; and causes most surviving patients to have long lasting neurological symptoms. Despite this, typical neuropathological features associated with the infection have still not been identified. Studies of post-mortem examinations of the cerebral cortex are obtained with difficulty due to laboratory safety concerns. In addition, they represent cases with different neurological symptoms, age or comorbidities, thus a larger number of brain autoptic data from multiple institutions would be crucial. Histopathological findings described here are aimed to increase the current knowledge on neuropathology of COVID-19 patients. We report post-mortem neuropathological findings of ten COVID-19 patients. A wide range of neuropathological lesions were seen. The cerebral cortex of all patients showed vascular changes, hyperemia of the meninges and perivascular inflammation in the cerebral parenchyma with hypoxic neuronal injury. Perivascular lymphocytic inflammation of predominantly CD8-positive T cells mixed with CD68-positive macrophages, targeting the disrupted vascular wall in the cerebral cortex, cerebellum and pons were seen. Our findings support recent reports highlighting a role of microvascular injury in COVID-19 neurological manifestations.

Dear Editor,Recent articles have drawn the attention to the different types of cutaneous manifestations associated to COVID-19. 1 Notwithstanding, there is a dearth of works focusing on signs involving the nails, whose inspection should be a fundamental component of an adequate dermatological examination.We report the case of an 89-year-old woman in a nursing home who amid an outbreak of coronavirus disease 2019 (COVID-19) presented cough and asthenia. A diagnosis of COVID-19 was made after PCR of a nasopharyngeal swab specimen tested negative to SARS-CoV-2 infection. After 16 weeks from the event, she developed orange discolorations at the end of the nail beds of her fingers (Figure 1). When the ungual lesions were brought to medical attention, a blood test highlighted the presence of IgG against SARS-CoV-2 and ferropenic anemia. The patient also developed sarcopenia, as part of a post-COVID-19 syndrome. Notably, the lesions remained unaltered and had the same features at follow-up a month later.Nails, like the skin, can provide important information regarding the presence and nature of systemic diseases. As a matter of fact, compelling evidence indicates that nails may presumptively be affected by or give clues about COVID-19 as much as the rest of the body. 2,3 In our patient, the shape of the proximal border of discoloration followed the shape of the lunula, indicating a systemic cause.Neri et al 2 reported the case of a COVID-19 patient who developed the "red half-moon" sign, which consists in "distally convex halfmoon-shaped red bands surrounding the distal margin of the lunula".Interestingly, this novel finding has been corroborated by a recent article by Méndes-Flores et al 3 Of note, both case reports involved patients of female sex. However, unlike the evidence that we found in the literature, the nail lesions of our patient were located distally in the nails. Interestingly, similar findings have been documented in patients affected by Kawasaki disease, a disease with a vascular etiology. 4 Recently, transverse leukonychia has been described in a COVID-19 patient. 5

patients who had COVID-19 and got vaccinated against the SARS-CoV-2 infection is still evolving.Further studies to elucidate the mild to moderate cutaneous reactions to vaccines are warranted.

In general, the use of reflectance confocal microscopy in diseases of the dermis is hampered because of the laser depth penetration limits (~250 µm). 5 In our case, it allowed the detection in the upper dermis of bright structures of different sizes corresponding to the dense lymphohistiocytic infiltrate: the small pinpoint particles likely correlate with lymphocytes, whereas the larger pleomorphic cells with epithelioid histiocytes. Although the dermal infiltrate of epithelioid histiocytes is not specific of CGPD, it is highly suggestive of a granulomatous disease. In conclusion, we have reported the dermoscopy and reflectance confocal microscopy features of CGPD. These techniques, combined with the clinical features, may be useful to narrow down the differential diagnosis, possibly limiting, in selected cases, the need for skin biopsy. Childhood granulomatous periorificial dermatitis is a benign and self-limiting condition, and a prompt diagnosis is important to avoid overtreatment.

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