Assessment of Acute Acral Lesions in a Case Series of Children and Adolescents During the COVID-19 Pandemic

Abstract

Importance: A novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has recently been identified as the cause of a pandemic called coronavirus disease 2019 (COVID-19). In this context, some associated skin diseases have been described. Cutaneous lesions referred to as acute acro-ischemia have been reported as a possible sign of COVID-19 in adolescents and children.

Objective: To evaluate the pathogenesis of these newly described acute acral lesions.

Design, setting, and participants: This prospective case series was conducted at La Fe University Hospital, a tertiary referral hospital in Valencia, Spain, between April 9 and April 15, 2020. Among 32 referred patients, 20 children and adolescents with new-onset inflammatory lesions did not have a diagnosis.

Exposures: Patients were not exposed to any drug or other intervention.

Main outcomes and measures: We performed reverse transcriptase-polymerase chain reaction for SARS-CoV-2 and a range of blood tests for possible origins of the lesions. Skin biopsies were performed in 6 patients.

Results: Of the 20 patients enrolled, 7 were female and 13 were male, with an age range of 1 to 18 years. Clinical findings fit into the following patterns: acral erythema (6 patients), dactylitis (4 patients), purpuric maculopapules (7 patients), and a mixed pattern (3 patients). None of the patients had remarkable hematologic or serologic abnormalities, including negative antibodies to SARS-CoV-2. Biopsies performed in 6 patients showed histologic findings characteristic of perniosis.

Conclusions and relevance: The clinical, histologic, and laboratory test results were compatible with a diagnosis of perniosis, and no evidence was found to support the implication of SARS-CoV-2 infection.

Figure 1.. Details of the Clinical Spectrum

A, Acral erythema pattern on the dorsal side of the toes. B, Inflammation of 1 toe showing a dactylitis pattern. C, Moderate vasculitic-like lesions on the feet demonstrating a maculopapular purpuric pattern. D, Mixed pattern composed of dactylitis and purpuric maculopapules.

Figure 2.. Main Histologic Features

A, Acral skin with moderate edema in the papillary dermis, perivascular/perieccrine lymphohistiocytic infiltrate, and lymphocytic vasculitis (hematoxylin-eosin). B, Severe perieccrine and deep perivascular infiltrate. Notice the presence of lymphocytic vasculitis as well as fibrin deposition in the vessel walls (hematoxylin-eosin).