Livedo reticularis y COVID-19

April 15, 2020

Cases of transient unilateral livedo reticularis in patients with COVID-19

According to a case study published in the Journal of the American Academy of Dermatology, clinicians should be aware of dermatologic manifestations in patients with coronavirus disease 2019 (COVID-19).

"We present 2 cases of transient unilateral livedo reticularis in COVID-19-positive non-ICU subjects to bring awareness to a dermatologic manifestation," wrote Iviensan F. Manalo, MD, Emory University School of Medicine, Atlanta, Georgia, and colleagues.

The first case was a male aged 67 years hospitalised for COVID-19. 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 livedo reticularis. The eruption lasted for 19 hours and resolved by the time dermatology evaluated the patient; therefore, no biopsy was taken. In addition to the patches on his leg, the patient also noted gross haematuria and generalised weakness, which resolved in 24 hours. He was eventually discharged home stable on supplemental oxygen.

The second case was a female aged 47 years with a 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). Her symptoms began with a mild headache, sinus pressure, anosmia, and fever. 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 to 30 minutes. When she moved indoors, she noticed a unilateral asymptomatic rash resembling livedo reticularis on her right leg 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.

"We hypothesise that the microthromboses that manifest in other organs (ie, cardiopulmonary) and as disseminated intravascular coagulation (DIC) in critically ill patients with COVID-19 are the most plausible etiology to our patients' livedo reticularis presentations," the authors wrote. "We postulate that manifestations can vary from transient livedo reticularis in mild-moderate cases to acrocyanosis in critically ill patients."

"In the future, histopathology of active exanthema may be helpful in elucidating the underlying pathology of the cutaneous and perhaps systemic manifestations of COVID-19 infection," the authors concluded. "Additionally, platelet count, coagulation studies, and fibrin degradation products assessments in these patients would be enlightening."

Reference: https://www.jaad.org/article/S0190-9622(20)30558-2/pdf

SOURCE: Journal of the American Academy of Dermatology