Chilblains Covid

1. Suspected Covid-19 -Related Reticulated
Purpura Of The Soles In An Infant
Journal Reading
DERMATOVENEREOLOGY DEPARTMENT
HASANUDDIN UNIVERSITY FACULTY OF MEDICINE
DR WAHIDIN SUDIROHUSODO HOSPITAL MAKASSAR
2022
David Andina, MD,a Isabel Colmenero, MD,b Carlos Santonja, MD,c Irenen Munoz de Leon, MD,a Lucero
Noguera-Morel,MD,d, Angela Hernandez-Martin, MD,d and
Antonio Torrelo, MD,d
Read By :
Andi Amalia Nefyanti
Advisor:
Dr. dr. Nurelly Waspodo, Sp.KK, FINSDV, FAADV
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2. INTRODUCTION
A variety of skin lesions are being reported in children during
the outbreak of COVID-19 pandemic.
chilblains (“COVID toes”) and erythema multiforme 
strongly link with SARS-CoV-2
This article reported a not previously recognized manifestation of
COVID-19 in a young infant, in whom IHC for SARS-CoV-2 was positive
in the endothelia of dermal blood vessels.
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3. CASE REPORT
A 1-month, 29-day-old female
⦁ Presented with a 5-days history of a skin lesions on her soles
⦁ History of other disease, trauma, or drug or heat
exposure (-)
The baby had been
suffering mild nasal
congestion, and her mom
had also had mild nasal
congestion 1 week earlier
than the baby.
3 weeks earlier • On examination , reticulated
purpura was seen on both soles,
more pronounced on her left
foot.
• No induration or edema was
present.
Reticulated purpura on the soles,
more prominent on the left foot
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4. • Slight thrombocytosis (473 × 103/μL; normal: 150-400 ×
103/μL). Coagulation studies were normal, D-dimer levels
were mildly elevated (790 ng/mL; normal < 500 ng/mL). C-
reactive protein was 0.04 mg/dL (normal: 0.01-1 mg/dL)
• PCR in oropharyngeal and nasopharyngeal swabs for SARS-
CoV-2 was negative
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5. A skin biopsy --> HE
sections showed
dilated superficial
dermal vessels lined
by swollen endothelial
cells. Significant red
cell extravasation was
noted around them .
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The antibody was
previously optimized using
autopsy lungs from
patients with confirmed
COVID-19 as positive
controls and different non-
COVID-19 tissues as
negative controls.
SARS-CoV-2
immunohistochemistry
- Cytoplasmic granular
positivity for SARS-CoV/SARS-
CoV-2 spike protein was
detected in the cytoplasm of
endothelial cells and
epithelial cells of eccrine
glands.
- minimal perivascular
lymphocytic infiltrate, mostly
composed by CD3 + mature T
cell was noted
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6. 6
FIGURE 2 A. Low-power view of the sole lesion (H&E stain;
4×). B, C. Vascular ectasia, swollen endothelium and
perivascular erythrocyte extravasation (H&E stain; B, 40×; C,
100×). D, Positive granular stain for SARS-CoV/SARS-CoV-2 spike
protein in the endothelial cells by IHC (400×)

7. TREATMENT
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ii. On telephone follow-up, her mother reported that the lesions gradually
faded and eventually resolved two weeks after the diagnosis.
i. No treatment was recommended because the patient was in good health.
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8. DISCUSSION
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• Our Patient
– Reticulated purpuric lesions on the soles characterized
histologically by purpura and dilated blood vessels
– IHC for SARS-CoV-2 was considered positive in the cytoplasm of
endothelial cells of dermal vessels and in the eccrine glands
Previously found IHC positivity for SARS-CoV-2 in two skin
biopsies of COVID-19-related erythema multiforme and in
seven cases of COVID-19 chilblains in children

9. DISCUSSION
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• Our Patient
– Negative result for PCR obtained in the vast majority of cases of
acral ischemic lesions identical to chilblains, which have been
reported associated with COVID-19
Strongly suspected that these skin lesions are secondary to COVID-19
• Transient presence of the virus in the pharynx is followed by subsequent spread
to distant locations

10. DISCUSSION
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• COVID-19-related chilblains
– histologic features of prominent perivascular lymphocytic
inflammation and lymphocytic vasculitis with endothelial damage
Our case
• The toes were not involved and the lesions did not resemble chilblains, neither
clinically nor on histology
• Clinicopathological condition related to acro-ischemic chilblains of children
and teenagers, but with a milder vascular involvement and less inflammation

11. Conclusion
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• COVID-19 chilblains appear to be extremely rare in infants.
• The young age can thus modify the clinicopathological
presentation of acral vascular manifestations of COVID-19.
• Low-grade endothelial cell damage appears to be the most likely
cause of the skin lesions in this patient.
• It is plausible that direct viral induced endothelial damage is the
first step in the inflammatory and vaso-occlusive reaction, which is
known to be elicited by SARSCoV-2 infection.
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12. THANK YOU
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