A clinicopathological description of COVID‐19‐induced chilblains (COVID‐toes) correlated with a published literature review

Abstract

Background: The abundance of publications of COVID-19-induced chilblains has resulted in a confusing situation. Methods: This is a prospective single-institution study from 15 March to 13 May 2020. Thirty-two patients received PCR nasopharyngeal swabs. Of these, 28 patients had a thoracic CT-scan, 31 patients had blood and urine examinations, 24 patients had skin biopsies including immunohistochemical and direct immunofluorescence studies, and four patients had electron microscopy. Results: COVID-19-induced chilblains are clinically and histopathologically identical to chilblains from other causes. Although intravascular thrombi are sometimes observed, no patient had a systemic coagulopathy or severe clinical course. The exhaustive clinical, radiological, and laboratory work-up in this study ruled-out other primary and secondary causes. Electron microscopy revealed rare, probable viral particles whose core and spikes measured from 120 to 133 nm within endothelium and eccrine glands in two cases. Conclusion: This study provides further clinicopathologic evidence of COVID-19-related chilblains. Negative PCR and antibody tests do not rule-out infection. Chilblains represent a good prognosis, occurring later in the disease course. No systemic coagulopathy was identified in any patient. Patients presenting with acral lesions should be isolated, and chilblains should be distinguished from thrombotic lesions (livedo racemosa, retiform purpura, or ischemic acral necrosis).

Multicenter analysis of neutrophil extracellular trap dysregulation in adult and pediatric COVID-19

“…The copyright holder for this preprint this version posted March 3, 2022. ; https://doi.org/10.1101/2022.02.24.22271475 doi: medRxiv preprint CLL has been observed in patients with mild and asymptomatic COVID-19, and post-mRNA SARS-CoV-2 vaccination, but remains controversial as many patients are PCR negative without seroconversion (Kolivras et al, 2022). Chilblains may occur in the type-1 interferonopathies and affected patients with CLL can produce increased IFN-alpha, supporting that this manifestation may be associated with rapid clearance of SARS-CoV-2 infection (Hubiche et al, 2021).…”

“…Biopsy of affected tissue may confirm the diagnosis, with superficial and deep dermal lymphocytic infiltrates surrounding eccrine glands and blood vessels (Andina et al, 2020;Hernandez and Bruckner, 2020;Kanitakis et al, 2020;Massey and Jones, 2020). CLL has been observed in patients with mild and asymptomatic COVID-19, and post-mRNA SARS-CoV-2 vaccination, but remains controversial as many patients are PCR negative without seroconversion (Kolivras et al, 2022). Chilblains may occur in the type-1 interferonopathies and affected patients with CLL can produce increased IFN-alpha, supporting that this manifestation may be associated with rapid clearance of SARS-CoV-2 infection (Hubiche et al, 2021).…”

Chronic inflammation and calciphylaxis

“…Due to the appearance of the rash, consideration of the patient’s comorbidities and initial biopsy results differential diagnosis included cutaneous manifestation of known CMV infection, cryoglobulinaemic vasculitis with history of hepatitis C, disseminated intravascular coagulopathy or atypical presentation of COVID-19 infection considering her rash occurred at the onset of the pandemic and little was known about the disease with COVID-19 vaccinations unavailable at initial presentation. There was however low suspicion for COVID-19-induced chilblains6 as she had no history of COVID-19 infection or vaccination at the time of presentation.…”

Histopathology of persistent long COVID toe: A case report

“… 6 The lymphocytic infiltrate may be deep and/or superficial, and perivascular, interstitial, and/or peri‐eccrine. 6 The lesions may also be accompanied by fibrin; however, this is not indicative of systemic coagulopathy. 7 One group examined pernio duration in COVID‐19 patients and found the mean duration was 15 and 12 days for suspected and laboratory‐confirmed COVID‐19, respectively.…”