, unexplained pneumonia cases were initially reported in Wuhan, China. The pathogen, a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was isolated from lower respiratory tract samples of infected patients, and the resultant disease was termed as Coronavirus Disease 2019 (COVID-19). 1 By February 15, COVID-19 has rapidly spread throughout China and across the world, until a pandemic condition was announced by March 11. 2 Italy was one of the most involved country, and extraordinary restricted measures were performed. Nonetheless, many health workers were affected, and due to this condition, a strong effort was asked to every physicians and nurses. Dermatologists were involved in first line as well, especially in the triage stations and in the medical wards with positive cases, because of the lack of medical doctors. Suspect of COVID-19 is mainly made on clinical signs (fever, fatigue, dry cough, anorexia, dyspnoea, rhinorrhoea, ageusia, anosmia), on vital parameters (temperature, pulse oximetry saturation) and on radiological settings (X-ray, chest CT scan). 3 Laboratory findings could often demonstrate lymphopenia and elevated LDH. Nasopharyngeal and oropharyngeal swab, allowing the virus isolation, confirm the diagnosis. There are no data in the literature so far about skin manifestations in COVID-19. As dermatologists, we tried to analyse the cutaneous involvement in COVID-19 patients hospitalized in the Lecco Hospital, Lombardy, Italy. We visited directly or indirectly (because of the high risk of contagion and the lack of protective masks) 148 positive patients and we tried, where it was possible, to record medical history. No clinical images were performed because of the high risk to infect other patients, introducing a photographic device in a restricted room. Analysing history of recent drug intake, we excluded 60 patients that had used any new medicine in the 15 previous days. From the collected data (88 patients), 18 patients (20.4%) developed cutaneous manifestations. Eight patients developed

Dear Editor, Coronavirus disease 2019 (COVID-19) has become a pandemic condition, yet little is known about its dermatologic manifestations. 1,2 We report here on peculiar (perniosis-like) skin lesions, unreported in the previous years, observed in young outpatients visited in our dermatologic unit in the last 4 weeks of COVID-19 pandemic (March-April 2020). Similar cases were referred to us in the same period by paediatricians and dermatologists from Italy and European countries. We directly observed 14 cases including 11 children (average age 14.4 years, range 13-18) and three young adults (average age 29 years, range 23-39). In this series, three couples were siblings and the ratio female-male was 8 : 6. The cutaneous manifestations consisted of an acral eruption of erythemato-violaceous papules and macules, with possible bullous evolution, or digital swelling (Fig. 1a-c). Lesions were localized on the feet in eight cases, on the hands in four cases and on both sites in 2. Two

The novel coronavirus SARS-CoV-2/COVID-19 is rapidly and dramatically spreading throughout the world. We describe the clinical and histopathological features of 3 Italian patients with different cutaneous presentations of COVID-19 infection, observed and followed at the University of Milan. CASE REPORTSCase 1. A 59-year-old woman was admitted to the intensive care unit (ICU) at the University of Milan with bilateral interstitial pneumonia. Three days after admission, she developed widespread erythematous macules on arms, trunk and lower limbs (Fig. 1 A-C) that spontaneously improved within 5 days. C-reactive protein was 12 mg/l. Reverse transcriptase (RT)-PCR for COVID-19 virus was positive. Treatment was started with lopinavir-ritonavir, heparin and levofloxacin. She is currently recovering. Case 2. An 89-year-old woman was suffering from fever and cough of one-week duration. An exanthem on the trunk and arms was observed on admission at ICU (Fig. 1 D,E). Laboratory tests revealed mild increase in fibrinogen and transaminases. RT-PCR was positive for COVID-19 virus. Ceftriaxone and azithromycin were started. The exanthem improved spontaneously 8 days later. Case 3. A 57-year-old man in good general health acutely developed a widespread pruritic eruption of erythematous macules and papules (Fig. 1 F,G), followed two days later by fever, headache, cough and arthralgias. RT-PCR for COVID-19 virus was positive. Treatment with levofloxacin and hydroxychloroquine was started.

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: Skin manifestations of COVID-19 infections are diverse and are new to the dermatology community. We had the opportunity to examine the clinical and histopathological features of several patients who were divided into 3 groups. The first group included 8 COVID-19–positive patients who were hospitalized and quarantined at home. The second group included children and young adults who presented with chilblain erythema, erythema multiforme, and urticaria-like lesions. This group of patients was negative for the COVID-19 gene sequences by polymerase chain reaction but had a high risk of COVID-19 infection. The third group included clinically heterogeneous and challenging lesions. These patients were not subject to either polymerase chain reaction tests or serological analyses because they sought dermatological attention only for a dermatosis. The histopathological analysis of these cases showed a wide spectrum of histopathological patterns. What appears to be constant in all skin biopsies was the presence of prominent dilated blood vessels with a swollen endothelial layer, vessels engulfed with red blood cells, and perivascular infiltrates, consisting mainly of cytotoxic CD8+ lymphocytes and eosinophils. In 2 cases, there was diffuse coagulopathy in the cutaneous vascular plexus. In the early phases of the disease, there were numerous collections of Langerhans cells in the epidermis after being activated by the virus. The presence of urticarial lesions, chilblains, targetoid lesions (erythema multiforme–like lesions), exanthema, maculohemorrhagic rash, or chickenpox-like lesions associated with the histopathological features mentioned previously should cause clinical dermatologists to suspect the possibility of COVID-19 infection, especially in patients with fever and cough.

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Extranodal natural killer/T-cell (ENK/T) lymphoma is a rare neoplasm, subcategorized into ENK/T-nasal (ENK/T-N) and ENK/ T-nasal type (ENK/T-NT) lymphomas. ENK/ T-NT lymphoma with initial presentation