key: cord-273493-xsroivzj
authors: Manalo, Iviensan F.; Smith, Molly K.; Cheeley, Justin; Jacobs, Randy
title: A Dermatologic Manifestation of COVID-19: Transient Livedo Reticularis
date: 2020-04-10
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.04.018
sha: 
doc_id: 273493
cord_uid: xsroivzj

nan

We read with great interest "COVID-19 can present with a rash and be mistaken for Dengue." To date, other described COVID-19-associated rashes include: nondescript erythematous rash, urticaria, and vesicles in Italy, 1 and dusky acrocyanosis and dry gangrene in critical intensive care unit (ICU) patients in Wuhan, China. 2 No photos were available for the first two reports. We present two cases of transient unilateral livedo reticularis (LR) in COVID-19-positive non-ICU subjects to bring awareness to a dermatologic manifestation.

A 67-year-old Caucasian male was hospitalized for COVID-19 (nasopharyngeal swab PCRconfirmed) management. His symptoms began 10 days prior with low-grade fever, nasal congestion, post-nasal drip, and cough without shortness of breath. Seven days into his symptoms, he noted a transient non-pruritic blanching unilateral livedoid patch on the right anterior thigh resembling LR ( Figure 1 ). The eruption lasted for 19 hours and resolved by the time dermatology evaluated the patient; thus no biopsy was taken. Concurrent with the lacy patches on the leg, the patient also noted gross hematuria and generalized weakness. In concert with the netlike exanthem, the hematuria resolved within 24 hours. He was eventually discharged home stable on supplemental oxygen.

A 47-year-old Caucasian female with history of Celiac disease, Hashimoto's thyroiditis, and portal vein thrombosis in 2017 with negative work-up for a hypercoagulable state (attributed to a long plane flight combined with prior oral contraceptive) tested COVID-19-positive. Symptoms began with a mild headache, sinus pressure, anosmia, and fever, with highest recorded temperature of 37.9°C. Ten days after testing positive, and with complete clinical convalescence of COVID-19 symptoms, she was sitting outside in long pants under direct sunlight for approximately 20-30 minutes. A unilateral asymptomatic rash on her right leg resembling LR was noticed incidentally immediately upon moving indoors (Figure 2 ) despite an equal amount of sun exposure on both legs. The rash lasted approximately 20 minutes and did not recur upon re-challenge with sun exposure the following day.

Livedo reticularis is caused by conditions, including disseminated intravascular coagulation (DIC), that reduce blood flow through the cutaneous microvasculature system leading to deoxygenated blood accumulation in the venous plexus. 3 We hypothesize that the microthromboses that manifest in other organs (e.g. cardiopulmonary) 4 for 20 minutes; and did not recur upon rechallenge with re-exposure to the sunlight the next day.

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Livedo reticularis: an update

Acute pulmonary embolism and COVID-19 pneumonia: a random association?

Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia