<p>Incidence, Characteristics, Laboratory Findings and Outcomes in Acro-Ischemia in COVID-19 Patients</p>

Abstract

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/EQDtTCBSFOI Aim: In addition to its respiratory impact of SARS-CoV2, skin lesions of probable vascular origin have been described. This study intends to quantify the incidence of acro-ischemic lesions in COVID-19 infected adult subjects in our population, describing clinical patterns and associated findings. Methods: All adult confirmed cases of COVID-19 infection who presented with acroischemic lesions and received care in our institution were prospectively enrolled up to May 15th, 2020. The variables included demographics, comorbidities, analytical parameters, clinical presentations and COVID-19 treatment. Results: We enrolled 24 patients. The overall rate of acro-ischemic findings in COVID-19 patients was 1.2% [0.6% for outpatients and 2.9% for hospitalized (ICU and non-ICU patients)], but the observed incidence for acro-ischemia in ICU patients was remarkably higher (23.0%, p<0.001). We have described four different clinical patterns of acroischemia: atypical Raynaud´s phenomenon (ARP), (4); pseudo-pernio (PP), (5); severe microcirculatory ischemia with preserved pulse (SMI), (6); and dry gangrene with arteriosclerosis obliterans (AO), (9). Kendall´s τ correlation with lung disease severity was 0.877 (95% CI, 0.756 to 0.968); p<0.01). ARP individuals were predominantly female, while SMI appeared lately in elderly hospitalized subjects with better prognosis. AO occurred in patients with more comorbidity and younger than those with SMI. We observed other associated lesions of suggestive ischemic nature in other organs in all groups (15 patients of total sample). Plasma procalcitonin was significantly higher in patients who developed SMI (median and interquartile range: 9.99 (4.2, 12.3) mg/mL vs 0.26 (0.11, 0.89) mg/mL; p<0.001), and D-dimer level at hospital admission was significantly higher in AO patients (median and interquartile range: 1166 (1050, 2111) mg/L vs 502 (448, 777) mg/L; p<0.001). Conclusion: The observed risk for acroischemia in COVID-19 is high in ICU patients (23%). We have described four different clinical patterns of acroischemia (ARP, PP, SMI and AO) associated with lung disease severity. Authors have communicated various lesions of suggestive ischemic nature in other organs. Raynaud-like pattern is reported as a "novelty".

Acute limb ischemia among patients with COVID-19 infection

“… 61 Cutaneous ischemic lesions are frequent in such patients even in absence of major vessel thrombosis. 62 In particular, severe endothelial injury, widespread thrombosis with microangiopathy, alveolar‐capillary microthrombi and new vessel growth have been detected in infected cases. 63 Vascular pathological changes in such patients include partial vascular endothelial shedding, vascular intimal inflammation and thrombosis.…”

Isolated “puffy hands” following COVID-19: clue to a long-term capillary leakage syndrome?

“…Capillary dysfunction and microvascular damage have been shown in acute COVID-19 patients [3], with increased permeability and subsequent leakage [4]. Further, acro-ischaemic lesions were found to be common during the course of SARS-CoV-2 infection [5], and signs of endothelial activation have been histologically described in acral lesions obtained from COVID-19 patients [6]. Therefore, on the basis of this background, we feel that a long-term endothelial impairment resulting in acral capillary leakage may explain the clinical presentation observed in the two described cases, suggesting that the development of manifestations mimicking the puffy hands seen in early systemic sclerosis may be expected even weeks after COVID-19.…”

Dermatological manifestations associated with COVID‐19: A comprehensive review of the current knowledge

“… 36 Several other lesions have been reported for COVID‐19, some of which cannot be categorized into one of the mentioned groups. Examples include pityriasis rosea‐like rash, 37 Grover's disease‐like eruptions, 23 , 38 acro‐ischemia, 39 malar erythema, and facial edema, 40 palmar erythema, 41 symmetrical drug‐related intertriginous and flexural exanthema (SDRIFE)‐like eruptions, 42 hand‐foot‐mouth‐like diseases, 24 “COVID toes” or pernio‐like eruptions, 43 Dengue‐like rashes, 33 diffuse melanoderma, 44 gangrene, 45 paronychia, 46 sacral and buttocks ulcerations, 47 mottling, 48 lichenoid eruptions, 49 drug reaction with eosinophilia and systemic symptom (DRESS), 50 acute generalized exanthematous pustulosis (AGEP), 51 Raynaud's phenomenon, 52 eruptive cherry angioma, 1 violaceous macules with “porcelain‐like” appearance, 53 IgA vasculitis, 54 leukocytoclastic vasculitis, 55 retiform purpura, eosinophilic panniculitis, 56 and periorbital dyschromia. 57 …”