key: cord-260218-add4i1c9
authors: Bosch‐Amate, X; Giavedoni, P; Podlipnik, S; Andreu‐Febrer, C; Sanz‐Beltran, J; Garcia‐Herrera, A; Alós, L; Mascaró, JM
title: Retiform purpura as a dermatological sign of covid‐19 coagulopathy
date: 2020-06-03
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16689
sha: 
doc_id: 260218
cord_uid: add4i1c9

Since December 2019, coronavirus disease 2019 (COVID‐19) has spread worldwide to become a pandemic. Multiple skin manifestations related to the infection have been described progressively. Recalcati(1) asserted that 20.4% of infected patients developed cutaneous manifestations and Galván‐Casas et al(2) have recently proposed 5 clinical patterns (pseudo‐chilblain, vesicular, urticarial, maculopapular and livedo/necrosis). We report a case of COVID‐19 with retiform purpura and its histopathological correlation.

This article is protected by copyright. All rights reserved patients. 6 Purpura, Raynaud's phenomenon, chilblain-like and erythema multiforme-like lesions in young asymptomatic patients have also been observed with this infection, although the connection with coagulopathy is unknown. 7, 8 Our patient presented with retiform purpura as a cutaneous manifestation of COVID-19 coagulopathy. Galván-Casas et al linked the livedoid/necrotic lesions to older patients and severe disease (10% mortality) but no biopsies were performed. 2 In the present case, histology showed thrombi in small cutaneous vessels, with complement pathway activation as demonstrated by C3 and C9 deposition. Heparin was changed to fondaparinux after suspecting heparin-induced thrombocytopenia, but Fan et al described mild thrombocytopenia (100-150 x10 9 /L) in 20% of COVID-19 patients. 9 Our case highlights the concomitant presentation of cutaneous microthrombi presenting as retiform purpura and macrothrombi presenting as pulmonary thromboembolism in the setting of COVID-19 coagulopathy. To our knowledge, there have been no histologically proven cases describing this phenomenon. We hope that in the coming months, pathophysiology of skin manifestations secondary to coagulation alterations will be better understood. From now on, we will have to include COVID-19 infection in the differential diagnosis of retiform purpura. 10 

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Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases

Changes in Blood Coagulation in Patients with Severe Coronavirus Disease 2019 (COVID-19): a Meta-Analysis

Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases

Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acro-ischemia

Vascular skin symptoms in COVID-19: a french observational study

Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak

Hematologic parameters in patients with COVID-19 infection

The patient in this manuscript has given written informed consent to publication of their case details.

This article is protected by copyright. All rights reserved