key: cord-0721163-jiuyzvhn
authors: Tusheva, Ivana; Damevska, Katerina; Dimitrovska, Irena; Markovska, Zorica; Malinovska-Nikolovska, Liljana
title: Unilateral livedo reticularis in COVID-19 patient: Case with fatal outcome
date: 2020-11-05
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2020.10.033
sha: b6de35c4545e77d328f45190f203c00ef3eb23b5
doc_id: 721163
cord_uid: jiuyzvhn

nan

Dear Editor, Recently Strom et al. (1) described a patient whose initial sign of coronavirus disease 2019 (COVID-19) infection was a reticular skin eruption. Other reports also indicate that livedoid eruptions in COVID-19 patients are associated with more severe disease and that these skin findings may be a clinical clue to an underlying thrombotic state (2) (3) (4) . In contrast, Manalo et al. (5) described transient unilateral livedo reticularis (LR) in two patients with mild-to-moderate disease and favorable outcome. The authors speculated such manifestations may be associated with a low-grade disseminated intravascular coagulation (DIC) as a possible cause. However, the small number of reported cases and lack of coagulation studies make it difficult to draw definitive conclusions at this time. We report a case of unilateral LR in a patient with fatal outcome, presenting initial and follow-up patient clinical and laboratory findings. A previously healthy 59-year-old female presented with an eight-day history of dry cough, mild dyspnea, and a low-grade fever. Тhe physical examination revealed body temperature of 37.6°C, blood pressure of 110/70 mmHg, pulse rate of 75 beats per minute and oxygen saturation (SpO2) of 70% on room air. A chest radiograph demonstrated patchy bilateral lung opacities. COVID-19 was confirmed by polymerase chain reaction. Her skin examination revealed non-blanching, nontender, and red-to-purple reticular discoloration over her right lower limb that persisted for 8 hours (Figure) . The patient denied sun or heat exposition before the onset of the cutaneous lesions. Within 24 hours after admission, her skin lesions gradually faded. On the second day after admission oxygen saturation decreased and the patient was transferred to the Intensive Care Unit ICU for full ventilatory and inotropic support. Despite intensive treatment, the patient died 12 days after admission. Clinical and laboratory parameters are summarized in the Table. A variety of cutaneous manifestations in patients with COVID-19 has been described. At present, a potential association between morphological subtypes with different COVID-19-associated syndromes and/or outcomes remains unclear (3) . A reticulated vascular pattern indicates partial or intermittent cutaneous blood flow disturbance. LR is characterized with non-fixed, dusky patches forming complete rings, while livedo racemosa, which is representative of a more significant reduction of blood flow, presents with broken rings that are persistent but rarely necrotic or ulcerative (6) . Coagulation disorders in COVID-19 infected patients range from thrombocytopenia, elevated D-dimers, and prolonged prothrombin time, to episodes of macro-and microvascular thrombosis (7) . Several mechanisms have been proposed to explain these observations, including (i) DIC, (ii) properties of the virus itself, (iii) antiphospholipid syndrome, (iv) activation of the complement cascade, (v) endothelial dysfunction (7) , and (vi) drug interactions (8, 9) . Similarly as in the case described by Strom at al., the only parameters that were evident in our patient when LR persisted were the low oxygen saturation and increased lactates, and coagulopathy happened a few days later (Table) . Therefore, close monitoring is required in patients with COVID-19 and LR to ensure the early detection of disease progression, even in initially asymptomatic or mild to moderate cases.

Reticular skin eruption as the initial sign of coronavirus disease 2019 infection

Livedoid and Purpuric Skin Eruptions Associated With Coagulopathy in Severe COVID-19

Cutaneous manifestations in patients with COVID-19: a preliminary review of an emerging issue. The British journal of dermatology

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

A dermatologic manifestation of COVID-19: Transient livedo reticularis

Retiform purpura: A diagnostic approach

Coagulation disorders in coronavirus infected patients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past

The Role of Anticoagulation in COVID-19-Induced Hypercoagulability

Direct oral anticoagulant plasma levels' striking increase in severe COVID-19 respiratory syndrome patients treated with antiviral agents: The Cremona experience

The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management

Reticular skin eruption as the initial sign of coronavirus disease 2019 infection

Figure legend Unilateral livedo reticularis in a PCR confirmed COVID-19 patient

J o u r n a l P r e -p r o o f