Case Letter
Petechial lesions in a patient with COVID-19
Luciana Botinelly Mendonça Fujimotoa, Silvana de Albuquerque Damasceno Ferreirab, Fabiane Braga dos Santosc, Carolina Talharib,d,
Corresponding author
a Department of Pathology and Legal Medicine, Universidade Federal do Amazonas, Manaus, AM, Brazil
b Department of Dermatopathology, Fundação Alfredo da Matta de Dermatologia e Venereologia, Manaus, AM, Brazil
c Private Clinic, Manaus, AM, Brazil
d Department of Dermatology, Universidade do Estado do Amazonas, Manaus, AM, Brazil
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"referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Pathology and Legal Medicine, Universidade Federal do Amazonas, Manaus, AM, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Dermatopathology, Fundação Alfredo da Matta de Dermatologia e Venereologia, Manaus, AM, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Private Clinic, Manaus, AM, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Dermatology, Universidade do Estado do Amazonas, Manaus, AM, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 652 "Ancho" => 750 "Tamanyo" => 39364 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Erythematous macula on the dorsal surface of the fifth finger of the left hand.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Rash, urticaria, and varicelliform presentations have already been associated with SARS-CoV-2.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Pernio-like lesions, classically associated with lupus erythematosus, have also been reported.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 39-year-old female patient presented fever, dry cough, and odynophagia two weeks prior. After a presumptive diagnosis of COVID-19, she was treated with azithromycin, acetylcysteine, vitamin C, and zinc. On the tenth day, she presented anosmia, worsening of the cough, and painless, non-pruritic lesions on the fingers.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient reported hepatic steatosis and systemic arterial hypertension (she used losartan, atenolol, hydrochlorothiazide, and amlodipine, daily).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The physical examination revealed erythematous macules on the third, fourth, and fifth left fingers (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Skin biopsy of the lesion of the fourth finger and swab (the same as that used to collect oro- and nasopharynx fluids) of the collected skin tissue were performed. After this procedure, the swab was placed in a tube with saline for reverse transcription polymerase chain reaction (RT-PCR).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Histopathological examination revealed a discrete focus of spongiosis in the epidermis, with slightly increased volume of keratinocytes, cytoplasmic vacuolization, and elongated and hyperchromatic nuclei. Apparently, there was pale intranuclear inclusion. In the dermis adjacent to these focal areas, there was a slight interface change with lymphohistiocytic permeation of the basal layer, perivascular inflammatory infiltrate, and vessels with intermingled nuclear debris (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The SARS-CoV-2 virus was not identified by RT-PCR in the samples collected from the nasopharynx and skin. The anti-SARS-CoV-2 IgM antibody in peripheral blood was reactive and the IgG was non-reactive. Serological tests for dengue fever (DENV), Zika (ZIKV), and chikungunya (CHKV) virus were negative.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was treated with topical corticosteroids, three times a day, for five days, with disappearance of the cutaneous lesions.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In Italy, the majority of SARS-CoV-2 patients developed pernio-like lesions on the tenth day of illness, similar to the present case.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, more localized acral edema, pain, and/or itching was observed in more than 70% of cases.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> There are reports of pernio-like lesions associated with COVID-19, with vacuolar changes in the basal layer with apoptotic keratinocytes and lichenoid inflammatory infiltrate in the papillary and reticular dermis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> There is no description of a viral cytopathic effect, as in the case reported here.</p><p id="par0045" class="elsevierStylePara elsevierViewall">There is still no gold standard technique for the identification of SARS-CoV-2 in the skin. In the autopsy of patients with COVID-19, a swab was introduced directly into the lung tissue. In that study, a sample collected was positive, by RT-PCR, for SARS-CoV-2.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> From this observation, a similar methodology was adopted for the present case.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In patients with skin rash, from tropical countries, several viruses should be investigated; DENV, ZIKV, and CHIKV are among the main ones. In the present case, there was also the possibility of a drug eruption, since in addition to antihypertensive drugs, the patient also used azithromycin and acetylcysteine before the onset of the skin condition. This hypothesis was ruled out by the histopathological examination. The IgM antibody reagent for SARS-CoV-2, negative serologies for DENV, ZIKV, CHIKV, and histopathological findings suggest that the lesions presented here are associated with COVID-19.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with a clinical and/or laboratory picture of COVID-19 with cutaneous manifestations should be clinically and histopathologically evaluated by dermatologists, for the correct diagnosis and therapeutic conduct.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Ethical aspects</span><p id="par0085" class="elsevierStylePara elsevierViewall">This case report was submitted and approved by the Research Ethics Committee of Fundação Alfredo da Matta de Dermatologia (CAAE: 32573520.7.0000.0002). The patient signed an informed consent.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">Luciana Botinelly Mendonça Fujimoto: Approval of the final version of the manuscript; design and planning of the study; analysis and interpretation of data; critical review of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Silvana de Albuquerque Damasceno Ferreira: Approval of the final version of the manuscript; analysis and interpretation of data; critical review of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Fabiane Braga dos Santos: Approval of the final version of the manuscript; design and planning of the study; analysis and interpretation of data; critical review of the manuscript.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Carolina Talhari: Approval of the final version of the manuscript; design and planning of the study; analysis and interpretation of data; editing of the manuscript; critical review of the manuscript.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Ethical aspects" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contributions" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-28" "fechaAceptado" => "2020-08-13" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Fujimoto LBM, Damasceno Ferreira AS, Santos FB, Talhari C. Petechial lesions in a patient with COVID-19. An Bras Dermatol. 2021;96:111–3.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the "Dermatologia Talhari" Clinic, Manaus, AM, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 701 "Ancho" => 750 "Tamanyo" => 54278 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous macules on the digital pulps of the third, fourth, and fifth fingers of the left hand.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 652 "Ancho" => 750 "Tamanyo" => 39364 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Erythematous macula on the dorsal surface of the fifth finger of the left hand.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 845 "Ancho" => 1500 "Tamanyo" => 200329 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pale nuclear inclusion (arrow) in epidermal cell amid spongiosis. Adjacent interface change with lymphocyte permeation and slight extravasation of red blood cells in the dermis (Hematoxylin & eosin, ×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Huang" 1 => "Y. Wang" 2 => "X. Li" 3 => "L. Ren" 4 => "J. Zhao" 5 => "Y. Hu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Lancet." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 23 | 9 | 32 |
| 2024 October | 129 | 69 | 198 |
| 2024 September | 176 | 87 | 263 |
| 2024 August | 172 | 115 | 287 |
| 2024 July | 154 | 104 | 258 |
| 2024 June | 149 | 88 | 237 |
| 2024 May | 134 | 73 | 207 |
| 2024 April | 151 | 93 | 244 |
| 2024 March | 130 | 85 | 215 |
| 2024 February | 134 | 74 | 208 |
| 2024 January | 110 | 52 | 162 |
| 2023 December | 82 | 56 | 138 |
| 2023 November | 110 | 92 | 202 |
| 2023 October | 73 | 72 | 145 |
| 2023 September | 105 | 79 | 184 |
| 2023 August | 68 | 31 | 99 |
| 2023 July | 83 | 51 | 134 |
| 2023 June | 66 | 38 | 104 |
| 2023 May | 75 | 22 | 97 |
| 2023 April | 49 | 12 | 61 |
| 2023 March | 66 | 42 | 108 |
| 2023 February | 49 | 22 | 71 |
| 2023 January | 51 | 48 | 99 |
| 2022 December | 74 | 43 | 117 |
| 2022 November | 87 | 59 | 146 |
| 2022 October | 106 | 55 | 161 |
| 2022 September | 61 | 78 | 139 |
| 2022 August | 49 | 57 | 106 |
| 2022 July | 64 | 64 | 128 |
| 2022 June | 63 | 60 | 123 |
| 2022 May | 59 | 58 | 117 |
| 2022 April | 63 | 59 | 122 |
| 2022 March | 65 | 91 | 156 |
| 2022 February | 54 | 47 | 101 |
| 2022 January | 90 | 66 | 156 |
| 2021 December | 64 | 65 | 129 |
| 2021 November | 51 | 69 | 120 |
| 2021 October | 50 | 89 | 139 |
| 2021 September | 54 | 68 | 122 |
| 2021 August | 55 | 53 | 108 |
| 2021 July | 38 | 47 | 85 |
| 2021 June | 38 | 49 | 87 |
| 2021 May | 82 | 91 | 173 |
| 2021 April | 154 | 264 | 418 |
| 2021 March | 159 | 92 | 251 |
| 2021 February | 53 | 24 | 77 |
| 2021 January | 38 | 18 | 56 |
| 2020 December | 13 | 12 | 25 |
| 2020 November | 2 | 3 | 5 |
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