key: cord-0868334-q245xn8k
authors: de Perosanz‐Lobo, D.; Fernandez‐Nieto, D.; Burgos‐Blasco, P.; Selda‐Enriquez, G.; Carretero, I.; Moreno, C.; Fernández‐Guarino, M.
title: Urticarial vasculitis in COVID‐19 infection: a vasculopathy‐related symptom?
date: 2020-06-08
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16713
sha: e9f4dc596ae6a2f8b5dacd97fa705c874358594d
doc_id: 868334
cord_uid: q245xn8k

The novel Coronavirus disease (COVID‐19) outbreak has been recently declared a pandemic by the World Health Organization (WHO), being Italy and Spain the worst‐hit European countries. Although the main clinical picture consists of fever and respiratory symptoms, an increasing number of studies have reported associated skin manifestations. Herein we present two patients with urticarial vasculitis arising in the context of COVID‐19 infection.

Dear Editor,

The novel Coronavirus disease (COVID-19) outbreak has been recently declared a pandemic by the World Health Organization (WHO), being Italy and Spain the worst-hit European countries. Although the main clinical picture consists of fever and respiratory symptoms, an increasing number of studies have reported associated skin manifestations. Herein we present two patients with urticarial vasculitis arising in the context of COVID-19 infection.

The first case is an elderly woman who was admitted to the hospital with bilateral pneumonia testing positive for COVID-19. She had been receiving treatment with hydroxychloroquine, lopinavir/ritonavir and azithromycin for 5 days. The Dermatology department was consulted for the appearance of painful erythematous patches on her trunk and hips, which left residual purpura when fading ( Figure 1A) . A cutaneous biopsy was performed, revealing histologic changes characteristic of small vessel vasculitis ( Figure 1B) .

A sudden worsening of her respiratory condition led to the patient's death, and therefore no treatment could be prescribed.

Our second case is a middle-aged male who presented to the Emergency department with a 2-week history of fever, cough and anosmia. Two days before consulting, he had developed

This article is protected by copyright. All rights reserved a pruritic rash on his buttocks. On examination the patient had erythematous and edematous plaques with a purpuric center ( Figure 2A) . A skin biopsy was performed,

showing evidence of small vessel damage ( Figure 2B ). Therapy with hydroxychloroquine and azithromycin was started as treatment for COVID-19. Additionally, prednisone and antihistamines were administered for his skin condition. Two weeks later the patient was asymptomatic.

Urticarial vasculitis is one of the multiple clinical expressions of leukocytoclastic vasculitis.

Drugs, viruses and autoimmune diseases, such as systemic lupus erythematosus, can be found among its most frequent causes. A type III hypersensitivity mechanism with deposit of immunocomplexes is thought to be behind this condition. Clinically, it is characterized by the appearance of urticarial lesions similar to wheals, but with individual lesions lasting more than 24 hours. Although usually asymptomatic, the lesions can be accompanied by a burning sensation, pain, or sometimes even by fever. Laboratory findings can include hypocomplementemia, especially in cases linked to connective tissue diseases.

COVID-19 has been associated with a variety of skin manifestations, including varicella-like exanthemas, dengue-like petechial rashes 1,2 or urticarial eruptions. 3 However, not only have viral rashes been related to COVID-19, but also other types of skin symptoms that are reminiscent of a vascular disease, such as acro-ischemic lesions described by Zhang et al 4 and chilblain-like lesions. 5, 6 Emerging theories claim that this novel coronavirus can produce endothelial activation, and possibly microocclusive disease, which could be the cause of acute respiratory distress 

This article is protected by copyright. All rights reserved associated with COVID-19, urticarial vasculitis has not been described in this population to date. This could be due explained by the lack of skin biopsies performed in patients with COVID-19, either because lesions are usually mild or because of fear of contagion. We are certain more cases like these could be observed, and therefore encourage dermatologists to remain alert to any possible new lesions in these patients. Much is still unknown about this new virus and its effects on the organism, and only our observation and research will allow us to increase this knowledge.

The patients in this manuscript have given written informed consent to the publication of their case details.

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