Two cases of COVID-19 presenting with a clinical picture resembling chilblains: first report from the Middle East.

Linked Article:Torres‐Navarro

The clinical characteristics of COVID‐19 disease were identified in a cohort study involving 1099 patients from China, and it was found that COVID‐19 most commonly presented with fever, cough, fatigue and congestion. Of the 1099 patients, 2 were reported to have skin rash, but the time of onset and clinical description of rash were missing. Another study focused primarily on cutaneous manifestations associated with COVID‐19, and evaluated 88 patients from Italy; of these, 18 patients developed cutaneous manifestations, but only 8 developed skin lesions at disease onset. The majority of these eight cases had an erythematous rash, while three patients had widespread urticaria and one patient developed chicken‐pox like vesicles. Since then, more cases of COVID‐19 presenting with cutaneous lesions have been reported. Hunt and Koziatek reported a case of COVID‐19 presenting with fever and morbilliform rash as the primary presenting symptoms, while Joob and Wiwanitkit reported a case of COVID‐19 presenting initially with a petechial skin rash.

We report two further cases of COVID‐19 presenting with cutaneous lesions, specifically, chilblain‐like lesions, which have not been reported previously, to our knowledge.

Both patients were women (Patient 1 was 27 and Patient 2 was 35 years old) and were previously healthy. They presented to the Dermatology clinic in Qattar with the chief complaint of a skin rash.

Physical examination revealed red–purple papules on the dorsal aspect of the fingers on both hands. Additionally, Patient 2 had diffused erythema in the subungual area of her right thumb (Fig. 1). The medical and drug history for both patients were unremarkable. Both patients reported recent travel to the UK, necessitating screening for COVID‐19. Reverse transcriptase (RT)‐PCR confirmed COVID‐19 in both patients. Full blood count and complete metabolic profile were normal. Chest radiographs were clear of clinically detectable pathology. Skin biopsy was not performed.

Figure 1

Red–purple papules on the dorsal aspect of fingers bilaterally. In addition to diffused erythema in the subungual area of the right thumb.

We diagnosed the patients as having COVID‐19‐related lesions, with ischaemia considered to be the underlying process (Fig. 2).

Figure 2

Red–purple papules on the dorsum of the right ring finger.

The pathological characteristics of COVID‐19 were evaluated in lung, blood vessel, skin and other organs by Yao et al., using minimally invasive autopsies. Degeneration and necrosis of parenchymal cells and formation of hyaline thrombi in small vessels were observed in lung and other organs. This could be the underlying pathology in our cases and could explain the clustering of cases of acral ischaemia reported in patients with COVID‐19 in Italy. Mazzotta and Troccoli reported a few dozen cases, initially presenting with red–purple papules on the feet and hands, which either evolved into haemorrhagic bullae or developed a blackish crust; however, laboratory tests of the reported cases were only available for two cases, both of which were confirmed by RT‐PCR to be infected with COVID‐19.

In conclusion, we report the occurrences of red–purple papules on acral areas in two asymptomatic patients who were both confirmed by RT‐PCR to be infected with COVID‐19. Both these cases and the earlier cases reported from Italy could be similar, but unfortunately not all the cases in the earlier study were tested for COVID‐19. Acral ischaemic lesions may be a rare presentation of a symptomatic COVID‐19, and this possibility should be kept in mind by dermatologists receiving referrals of such cases.