key: cord-266475-t04pukea
authors: Balestri, R.; Termine, S.; Rech, G.; Girardelli, C.R.
title: Late onset of acral necrosis after SARS‐CoV‐2 infection resolution
date: 2020-05-26
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16668
sha: 
doc_id: 266475
cord_uid: t04pukea

SARS‐CoV‐2 has been hypothesized as the aetiologic agent of CLL, on the basis of the temporal correlation between the “burst” of skin manifestations and the viral pandemic, even though we have scarce evidence of swab‐confirmed infections. Authors have therefore suggested some pathogenetic mechanisms such as a delayed immune‐mediated reaction to the virus in genetically‐predisposed patients(1) or an early IFN‐I response in young patients, muting early viral replication but also inducing microangiopathic changes.

the presence of a worldwide outbreak of chilblain-like lesions (CLL) contemporarily to COVID-19 pandemic has been largely reported, not only on social media, but also in the literature. [1] [2] [3] [4] SARS-CoV-2 has been hypothesized as the aetiologic agent of CLL, on the basis of the temporal correlation between the "burst" of skin manifestations and the viral pandemic, even though we have scarce evidence of swab-confirmed infections. Authors have therefore suggested some pathogenetic mechanisms such as a delayed immunemediated reaction to the virus in genetically-predisposed patients 1 or an early IFN-I response in young patients, muting early viral replication but also inducing microangiopathic changes. 2 The dermatologic community is currently focusing on the pediatric population, 1 having observed acute acral areas of erythema-oedema in asymptomatic or mildly symptomatic young patients 4 and is speculating on clinical implications. On the contrary acral, true ischemic lesions have been described in COVID-19 as a consequence of clotting disorders, but only in severely affected patients, hospitalized in intensive care units. [4] [5] [6] We would like to report a case of SARS-CoV-2-related acro-ischemia, peculiar for several reasons: i) the patient presented real acral ischemia that progressed toward necrosis; ii) she was otherwise completely asymptomatic; iii) she was on regular medication with warfarin for atrial fibrillation.

A 74-year-old female was referred to our emergency service because of the presence of livedoid macules that had initially appeared on her hands 6 days before. She reported only pain, while she had no complaint referable to currently known Covid-19 symptomatology.

Her medical history included chronic venous leg ulcers, atrial fibrillation on regular medication with warfarin, and a recent hospitalization due to congestive heart failure one month before. During this hospitalization, in accordance with the directives of the Regional Health Service, she was tested for SARS-CoV-2 even though she was completely asymptomatic, and resulted positive. She was later discharged and was tested twice at home, resulting negative both times; the last test was 20 days before our evaluation.

This article is protected by copyright. All rights reserved On examination we observed blanching of fingers, dusky red macules, digital infarcts and an ischemic necrosis of the left third fingertip (Fig.1) .

We requested power Doppler ultrasound examination and vascular surgery assessment, but the patient opted for discharge against medical advice. We contacted her by phone 6 days later, but she refused any further visits, claiming improvement.

The present case, to the best of our knowledge, is the first case of true acral necrosis in an asymptomatic SARS-COV-2 infected. This observation raises several questions and considerations.

Firstly, it would be important to determine the pathogenesis of vascular damage to understand why the patient developed acral necrosis 20 days after her second test had resulted negative (i.e. the patient could be considered healed). Our case seems to support the theory of a delayed immune-mediated reaction to the virus. 1 Moreover, until now we have been used to observing benign acral lesions that progress toward complete recovery, therefore it is important to determine whether the necrotic outcome is related to any risk factor such as the advanced age of the patient, a genetic predisposition or whether it could be related to her well-established venous impairment, the latter being less likely as we did not observe a worsening of the leg ulcers.

We would like to draw clinicians' attention to the possibility that acral lesions may also be observed in the elderly and that these could have a necrotic outcome.

Finally, we underline that, whilst necrosis is considered a primary lesion of COVID-19, 4, 5 it can also present with a late onset, suggesting that a longer period of follow-up is needed also in the healed population to detect late complications.

Chilblain-like lesions during COVID-19 epidemic: a preliminary study on 63 patients

COVID-19) infection-induced chilblains: A case report with histopathologic findings. JAAD Case Rep

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

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

Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19

The authors have no conflict of interest to disclose All authors have agreed to the contents of the manuscript in its submitted form

Acknowledgment: "The patient in this manuscript has given written informed consent to publication of her case details."

This article is protected by copyright. All rights reserved