Middermal Elastolysis—A Possible End Stage of Granuloma Annulare

Abstract

samples, there were deposits of complement including C5b-9, suggesting a critical role for complement activation in the pathogenesis of the thrombotic diathesis. Coagulopathy in the context of severe inflammation (elevated D-dimer, fibrinogen, or C-reactive protein levels) has been reported in patients with COVID-19. 3 Because of the increased incidence of thrombotic events reported in severely ill patients with COVID-19 4 and recent data suggesting a survival benefit in such patients who receive anticoagulants, 5 treatment algorithms for severely ill patients with COVID-19 are including therapeutic anticoagulation at many institutions. 6 Despite initiation of prophylactic anticoagulation therapy at admission for all 4 patients, all developed cutaneous thrombosis and a clinically suspected pulmonary embolism.The limitations of this report include our inability to confirm the precise timing of rash onset owing to limited full skin examinations. In addition, we did not perform imaging for pulmonary emboli because of efforts to minimize staff exposure.The findings suggest that clinicians caring for patients with COVID-19 should be aware of livedoid and purpuric rashes as potential manifestations of an underlying hypercoagulable state. If these skin findings are identified, a skin biopsy should be considered because the result may guide anticoagulation management. Even in the absence of other thrombotic events, consultation with hematology staff, along with escalation of anticoagulation, should be considered.