Abstract:

A wide variety of skin manifestations secondary to COVID-19 infection have been described. One particularly notable skin lesion has been coronavirus disease toes, or COVID toes, also known as SARS-CoV-2 induced pernio/chilblains. COVID toes has been hypothesized to manifest as pernio-like lesions or secondary to subcutaneous vessel thrombi. Here, we report a case of COVID fingers. A 31-year-old male presents for recurrent violaceous to erythematous discrete papules scattered on his fingers with associated pain and swelling following COVID infection one year ago. The episodes were often triggered by cold and last for 1-2 weeks. The patient had not sought prior treatment. Punch biopsy was obtained from a lesion on the patients right second finger. Histopathologic examination revealed a dense deep perivascular and perieccrine lymphocytic infiltrate. A few microthrombi were identified in deep dermal vessels, with surrounding lymphocytes and extravasated erythrocytes. The dermal mucin did not appear to be increased. The histopathologic differential included pernio-like skin lesions associated with COVID-19 or perniosis. Because this patients lesions started after COVID-19 infection, and classic features of perniosis such as papillary dermal edema and superficial perivascular lymphocytic inflammation were not seen in the biopsy, perniosis was deemed less likely. In our present case, given the clinical and histopathologic findings, our patients skin lesions were attributed to a hypercoagulability-induced etiology rather than pernio. It has been hypothesized that COVID-19 infection induces hypercoagulability via a complement-mediated mechanism of thrombosis. Lesions such as those found in our case should be carefully noted, as they may provide indication of hypercoagulability, despite this patients lack of COVID-19 respiratory symptoms. Our case further contributes to the rapidly evolving literature on COVID-19 skin manifestations.

Financial Disclosure:
No current or relevant financial relationships exist.

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Caroline Zhu, BS