Transverse orange nail lesions following SARS‐CoV ‐2 infection

Abstract

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

Nail Manifestations in COVID-19: Insight into a Systemic Viral Disease

“…Orange discolorations at the end of the fingernail beds were noted in an elderly, female patient 16 weeks after the onset of COVID-19 symptoms [ 8 ]. Physical exam revealed orange discoloration of the distal nail plate with a demarcation separating them from the healthy-appearing nail bed areas (Fig.…”

“…Physical exam revealed orange discoloration of the distal nail plate with a demarcation separating them from the healthy-appearing nail bed areas (Fig. 2 ) [ 8 ]. The shape of the proximal border of the discoloration followed the shape of the nail lunula which is consistent with a systemic cause of this finding [ 8 ].…”

“…2 ) [ 8 ]. The shape of the proximal border of the discoloration followed the shape of the nail lunula which is consistent with a systemic cause of this finding [ 8 ]. A positive PCR diagnosis and IgG against SARS-CoV-2 confirmed the diagnosis.…”

“…A positive PCR diagnosis and IgG against SARS-CoV-2 confirmed the diagnosis. The nail findings were unchanged 1 month later [ 8 ]. The patient also had ferropenic anemia [ 8 ].…”

Nails and COVID ‐19 – A comprehensive review of clinical findings and treatment

“…Distal orange discolorations of the nail plates have been reported as a delayed response several weeks after COVID‐19 disease in elderly patients who developed later sarcopenia and anemia. 33 …”