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Case Reports

Abstract

We present a case of prolonged acrocyanosis in a 19-year-old male, with overlapping clinical and histological features suggestive of both cold agglutinin disease and prolonged cutaneous manifestations of COVID-19 infection, persisting for 48 months post-suspected infection. The patient presented with a 3-year history of dependent rubor, non-tender acrocyanosis, and blistering and scabbing of the toes following a severe upper respiratory tract infection in February 2020. Associated symptoms included non-specific stomach pain, brain fog, fatigue, and generalized malaise. Notably, lab work revealed a positive cold agglutinin test.  Skin biopsy of the left toe showed dilation and fibrinoid necrosis of the superficial and mid-dermal vessels without active vasculitis. In the superficial dermis, there was deposition of fibrinoid material, mild dermal edema, sclerosis, and minimal inflammation. In the deep dermis, perivascular lymphocytic inflammation was seen. Histological features did not align with typical cold agglutinin disease, as it classically demonstrates vascular proliferation with intravascular thrombi. A similar clinical presentation to perniosis is seen in “COVID toes”; however, the symptoms are typically confined to a two-week period surrounding the infection. To our knowledge, the longest previously described prolonged perniosis-like symptoms associated with COVID-19 were reported up to 22 months post-infection. The timing of presentation for our case is outside of the reported duration for “COVID toes”, however, histopathologic features are suggestive of this entity. Despite atypical findings, this case emphasizes the overlap between cold agglutinin disease and prolonged COVID-19 dermatological manifestations, underlining the importance of accurate diagnosis and clinicopathological correlation.