Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is the etiologic agent of coronavirus disease 2019 (COVID-19), causes an excessive inflammatory response and hemostatic abnormalities in the lungs, kidney, and skin. Four patients with COVID-19 admitted to an acute care community hospital developed nonblanchable purpuric macules, patches, and retiform purpura-like lesions at the sacrum, buttocks, lower extremities, and upper back. These lesions can be misdiagnosed as deep tissue pressure injuries. One patient also developed a vesicular-like rash at the upper back and another one developed pernio (chilblains)-like lesions to the third toe of the left foot. Previous studies suggest that the vascular hyperinflammation status and microthrombosis may be responsible for the cutaneous manifestations in patients with SARS-CoV-2. These cutaneous manifestations observed in patients with SARS-CoV-2 may be related to progression of the disease.
Highlights
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is the etiologic agent of coronavirus disease 2019 (COVID-19), causes an excessive inflammatory response and subsequent uncontrolled pulmonary inflammation
The National Pressure Injury Advisory Panel (NPIAP) has released a white paper to help wound care clinicians to determine whether the purpuric lesions seen in COVID-19 patients are a deep tissue pressure injury (DTPI) or a skin manifestation of the disease [10]
One study had performed a biopsy of the skin lesion and found an extensive pattern of pauci-inflammatory vascular thrombosis with endothelial cell injury and microvascular deposits of the complements C5b-9 and C4d [9]. These findings suggest that the extensive deposition of C5b-9 and C4d could be responsible for the microvascular endothelial cell injury leading to microthrombosis observed at the skin lesions as well as in the lungs of patients with SARS-CoV-2 [9]
Summary
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is the etiologic agent of coronavirus disease 2019 (COVID-19), causes an excessive inflammatory response and subsequent uncontrolled pulmonary inflammation. Right buttock and gluteal cleft developed a purpuric nonblanchable patch measuring 9 x 3 cm, resembling retiform purpura that evolved to a bullae on day 14 (Figures 2C, 2D). Of note, this patient developed a marked systemic inflammatory response, evidenced by large elevations of serum C-reactive protein levels and increase in pro-coagulation markers, including high serum fibrinogen and D-dimer concentrations. Right buttock had a purpuric patch that was resembling retiform purpura, the periwound skin presented with blanchable erythema, no tenderness or induration was noted, and the lesion measured 13 x 11 cm. Metoprolol, methylprednisolone, minocycline, cefepime, labetalol, heparin, propofol, fentanyl, diltiazem, norepinephrine, meropenem, vasopressin, piperacillin, ceftriaxone, and azithromycin were given to the patient during hospitalization
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