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,
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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. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 23 | 9 | 32 |
| 2024 Outubro | 129 | 69 | 198 |
| 2024 Setembro | 176 | 87 | 263 |
| 2024 Agosto | 172 | 115 | 287 |
| 2024 Julho | 154 | 104 | 258 |
| 2024 Junho | 149 | 88 | 237 |
| 2024 Maio | 134 | 73 | 207 |
| 2024 Abril | 151 | 93 | 244 |
| 2024 Março | 130 | 85 | 215 |
| 2024 Fevereiro | 134 | 74 | 208 |
| 2024 Janeiro | 110 | 52 | 162 |
| 2023 Dezembro | 82 | 56 | 138 |
| 2023 Novembro | 110 | 92 | 202 |
| 2023 Outubro | 73 | 72 | 145 |
| 2023 Setembro | 105 | 79 | 184 |
| 2023 Agosto | 68 | 31 | 99 |
| 2023 Julho | 83 | 51 | 134 |
| 2023 Junho | 66 | 38 | 104 |
| 2023 Maio | 75 | 22 | 97 |
| 2023 Abril | 49 | 12 | 61 |
| 2023 Março | 66 | 42 | 108 |
| 2023 Fevereiro | 49 | 22 | 71 |
| 2023 Janeiro | 51 | 48 | 99 |
| 2022 Dezembro | 74 | 43 | 117 |
| 2022 Novembro | 87 | 59 | 146 |
| 2022 Outubro | 106 | 55 | 161 |
| 2022 Setembro | 61 | 78 | 139 |
| 2022 Agosto | 49 | 57 | 106 |
| 2022 Julho | 64 | 64 | 128 |
| 2022 Junho | 63 | 60 | 123 |
| 2022 Maio | 59 | 58 | 117 |
| 2022 Abril | 63 | 59 | 122 |
| 2022 Março | 65 | 91 | 156 |
| 2022 Fevereiro | 54 | 47 | 101 |
| 2022 Janeiro | 90 | 66 | 156 |
| 2021 Dezembro | 64 | 65 | 129 |
| 2021 Novembro | 51 | 69 | 120 |
| 2021 Outubro | 50 | 89 | 139 |
| 2021 Setembro | 54 | 68 | 122 |
| 2021 Agosto | 55 | 53 | 108 |
| 2021 Julho | 38 | 47 | 85 |
| 2021 Junho | 38 | 49 | 87 |
| 2021 Maio | 82 | 91 | 173 |
| 2021 Abril | 154 | 264 | 418 |
| 2021 Março | 159 | 92 | 251 |
| 2021 Fevereiro | 53 | 24 | 77 |
| 2021 Janeiro | 38 | 18 | 56 |
| 2020 Dezembro | 13 | 12 | 25 |
| 2020 Novembro | 2 | 3 | 5 |
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