Dermatologic Findings Research Articles

Leukemia cutis and other dermatological findings in pediatric patients with acute myeloid leukemia.

Leukemia cutis (LC) is the infiltration of neoplastic leukocytes into the skin, causing skin lesions. In children, it appears more frequently in patients with acute myeloblastic leukemia (AML), particularly in subtypes with a monocytic component. We studied a retrospective cohort including all AML cases from the Hospital Infantil de México Federico Gómez between January 2009 to December 2019 and described the clinical characteristics of those who presented LC and other mucocutaneous manifestations. The information was collected from clinical records and analyzed using SPSS software (version 17). We identified 54 AML cases: 53.7% were males, and 75.9% of the patients presented at least one dermatosis in the course of the disease. LC was clinically present in 14.8% of patients and was histologically confirmed in 9.2% of them; two congenital leukemia cases were identified. Among these patients, LC was more frequent in males. LC patients were younger than those without LC, the most frequent AML subtype was M2 (37.5%), and the most frequent clinical manifestations were plaques, chloromas, and gingival hyperplasia. None of the patients presented LC before AML diagnosis. Currently, only a few studies about LC on pediatric populations have been reported, and the existing ones have small sample sizes. We found clinical and epidemiological similarities with other populations in the studied sample.

Dermatological lesions among people living with HIV in Turkey

This study aimed to document the dermatoses and their relationships with CD4+ T lymphocyte counts and clinical stages of disease among people living with HIV followed by our Clinical Department, to investigate the effect of antiretroviral therapy (ART) on findings and to compare with real-world data. Medical records of people living with HIV were analyzed retrospectively in our outpatient clinic from January 2005 to June 2017. A total of 500 patient files were examined. 179 patients with dermatoses were included in the study. Demographic data, clinical and laboratory findings, dermatological findings, type and distribution of lesions, serological and histopathological examinations, diagnosis, treatment, and follow-up of patients were transferred to data forms. 84.4% of the patients were male and the mean age was 38.65 ± 11.6 years. The median CD4+ T lymphocyte count was 253/mm3 (range:0-1067). At least one dermatosis was present in 69.3% of the patients. Compared with their median CD4+ T lymphocyte counts, the ratio of CD4+ T lymphocytes was significantly lower in the group with three or more dermatoses (p = 0.019). Condyloma acuminatum (15.1%), drug eruption (13.4%), seborrheic dermatitis (11.7%), oral candidiasis (11.2%), dermatophytoses (11.2%), syphilis (8.4%), Kaposi's sarcoma (8.4%), and telogen effluvium (8.4%) were the most common dermatoses. Kaposi sarcoma (KS), oral candidiasis, onychomycosis, and molluscum contagiosum were significantly higher in the CD4+ T lymphocyte <200/mm³ group when CD4+ T lymphocyte threshold value was determined as 200/mm³. Compared with other TDF/FTC-containing regimens, a significantly higher proportion of alopecia was reported in patients receiving TDF/FTC/EVG/c (p = 0.007). Dermatoses may be a good clinical marker for detecting clinical stage and diagnosing HIV infection; also, there may be a significant increase in the number of dermatoses in advanced stages. Although there are only a few studies in the literature, it should be kept in mind that ART-associated alopecia rates may increase nowadays when ART is targeted at everyone.

Spongiotic reaction patterns in autoimmune bullous dermatoses (Review).

Spongiosis or a spongiotic reaction pattern is the histological hallmark of intercellular epidermal edema, viewed as clear spaces within the epidermis. Although considered a histopathological term, spongiosis has clinical correlations, with the variable degrees of spongiotic reaction leading to different dermatological findings. This review aimed to highlight the spongiotic reactive patterns found in different autoimmune bullous dermatoses, considering the paucity of publications in this domain. The pathogenesis of spongiosis assumes the passage of extravasated edema fluid from the dermis into the epidermis, frequently accompanied by dermal inflammatory cells, and classification of the spongiotic reaction patterns, as well as their associated spongiotic dermatitis, take into consideration the type and distribution of these inflammatory cells. It is mandatory to consider different reactive processes, specific for other skin disorders, which act as simulants of different spongiotic patterns for the diagnosis. Considering the possible transient occurrence, the heterogeneity and non-specificity of the histopathological features of these diseases, the diagnosis is very complex, requiring clinicopathological correlations and additional analyses. A deep insight into spongiosis pathogeny may open the perspectives of a classification refinement of autoimmune bullous dermatoses.

Arap Sabununun Neden Olduğu İrritan Kontakt Dermatit: Bir Olgu Sunumu

Irritant contact dermatitis (ICD) is a condition caused by chemicals that damage skin structures in a direct non-allergic way. Dermatologic findings may present in a broad spectrum due to frequency and route of exposure and individual susceptibility. The most critical point in the diagnosis and treatment of ICD is to determine the irritant since its cessation is the best treatment. Specifically, in geriatric patients, questioning about any irritant exposure should be done carefully. In this report, we present a 71-year-old woman with ICD that was caused by exposure to potassium hydrochloride in Arab soap and exaggerated amid the coronavirus pandemic.

Dermatological Findings Observed After Renal Transplantation in Patients

Dermatological Findings Observed After Renal Transplantation in Patients

Assessment of Dermatological Disorders with Chronic Hepatitis C Virus Infection

Aim: Although hepatitis C virus (HCV) is essentially hepatopathic, there are many extra-hepatic symptoms that may develop with associated HCV infection. Of these, dermatological findings constitute a significant proportion of extra-hepatic symptoms. The aim of this study was to evaluate dermatological diseases accompanying to chronic HCV infection in our region. Patients and Methods: From a total of 2050 patients diagnosed and followed up for chronic HCV infection in the Infectious Diseases and Clinical Microbiology Clinics in a 12-years period between 2008 and 2020, 394 determined with concurrent dermatological disease were included in the study. Results: Chronic HCV patients diagnosed with dermatological disease comprised 218 (%58.6) females and 176 (%41.4) males with a mean age of 56±17 years. In the patients with chronic HCV infection presenting at the dermatology outpatient clinic, pruritus was determined most (%18.5) and followed by contact dermatitis (%17.5). At univariate analyses female gender (p:0,005, OR:3,329, CI 95% [1,439-7,701]) and advanced age (p:0,013, OR:1,029, CI 95% [1,006-1,052]) were detected as significant variables of frequent dermatological diseases. The female gender ( p: 0,038, OR:2,682, CI 95% [1,054-6,826]) was detected as the predictor of most frequent dermatological diagnoses in chronic HCV infection at multivariate logistic regression analysis. Conclusion: The most common reasons for presentation of patients with HCV infection at the dermatology outpatient clinic were determined to be pruritus and contact dermatitis. The frequency and variability of the diagnoses seen in chronic hepatitis C patients after presentation at the dermatology outpatient clinic suggest the need for further studies in this area with more standardised patient groups using standard laboratory techniques.

Dermatological manifestations during COVID-19 pandemic – Case series from Nepal

SARSCov-2 infection primarily targets the respiratory system, but other organs, including skin can also be affected with varied manifestations. The most common dermatological findings of COVID-19 include urticarial, maculopapular rash, papulovesicular exanthema, chilblain-like acral pattern, livedoreticularis-like pattern and purpuric “vasculitic” pattern. Here, we present a case series with skin findings in COVID-19 from Nepal.

Mucocutaneous Manifestations of Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) is a chronic and incurable disease, of unknown etiology, associated with an unregulated immune response to environmental triggers in a genetically predisposed host. IBD affects mainly the gastrointestinal (GI) tract and includes Crohn's disease (CD) and ulcerative colitis (UC). However, a large percentage of patients may present with extraintestinal manifestations, including mucocutaneous ones (which are the most common) and dermatologic findings, such as erythema nodosum, pyoderma gangrenosum, and aphthous stomatitis (which are the most frequently occurring). According to pathophysiologic mechanisms, mucocutaneous manifestations of IBD are classified into five categories, namely, specific manifestations, associated manifestations, reactive manifestations, adverse effects of IBD therapy, and malabsorption manifestations. Recognizing such manifestations should not be performed only by a dermatologist but also other specialties such as internal medicine, gastroenterology, among others. This is because these manifestations can present before the IBD diagnosis, even in the absence of GI symptoms. Therefore, these skin lesions could be a fundamental tool for the earlier diagnosis of IBD. This review provides a comprehensive overview of the most common cutaneous manifestations of IBD with a focus on their epidemiology, diagnostic criteria, clinical presentation, and available medical treatment.

26622 The impact of neuropathic itch on patients’ quality of life

The negative impact of chronic itch on patients’ quality of life (QoL) has been well established in literature, with similar burden of disease and effects on self-esteem as the more well-studied chronic pain. However, most studies to date have focused on chronic inflammatory pruritic conditions, like atopic dermatitis and psoriasis. Neuropathic pruritus, a subset of pruritic conditions including notalgia paresthetica, brachioradial pruritus, scalp dysthesia, postherpetic neuralgia, and itch secondary to spinal cord compression/injury, is unique from other chronically itchy conditions as it is less frequently associated with visible primary dermatologic findings but can be just as bothersome and debilitating.

Deep Herpes.

Herpes viruses are known for infecting epithelial cells and manifesting as vesicles. However, herpes viruses can also infect stromal cells. While established in the ocular setting, cutaneous stromal herpes (deep herpes) is previously unreported and may evade clinical and microscopic detection. We searched for skin biopsies with herpes stromal disease. Clinical information was retrieved via electronic medical records and pathology records system. Hematoxylin and eosin slides, immunohistochemical staining, and polymerase chain reaction detection of viral DNA was performed. We identified 12 specimens from 10 patients with cutaneous stromal herpes simplex virus 1/2 (n=7) or varicella-zoster virus infection (n=5). The most common site involved was the buttocks/perianal region (n=6). Ulceration was a frequent dermatologic finding (n=8). Pyoderma gangrenosum was clinically suspected in 6 specimens (50%). Eight patients (80%) were immunosuppressed. Biopsies frequently demonstrated a dense dermal mixed inflammatory infiltrate with subcutaneous extension and enlarged cells with viral cytopathic changes confirmed by herpes simplex virus 1/2 or varicella-zoster virus immunohistochemistry (n=10) or polymerase chain reaction (n=2). Most specimens (67%) lacked evidence of characteristic epidermal keratinocyte infection. This study presents the first known report of the ability of herpes virus to infect deep stromal cells of the dermis. We raise awareness of cutaneous stromal herpes in patients presenting with atypical clinical lesions, particularly while immunocompromised. Establishing the correct diagnosis is critical for initiating therapy.

Hypercoagulability States in COVID-19 Patients and Cutaneous Findings as Its Marker

Patients diagnosed with COVID-19 have a higher risk for thrombosis, which is the term used to denote an occlusion or blood clot that occurs in a vein [1-4]. These, in turn, can lead to detrimental consequences including motor impairments, as well as increased morbidity and mortality rates. Therefore, it is vital to assess routine laboratory and cutaneous findings to prevent any ensuing organ damage. German physician Rudolf Virchow identified some of the primary factors that may increase an individual’s susceptibility to developing thrombophilia [1-5]. Virchow’s triad comprises endothelial vessel wall injury, stasis or slowing down of the blood, and finally, hypercoagulability [2-4]. These three factors can be exacerbated by many components, including an individual’s genetic predisposition, or acquired factors like COVID-19, smoking, or hypertension [1,3,4]. Their contribution to hypercoagulability is discussed next. Endothelial injury can lead to turbulences in blood vessels, subsequently altering blood flow dynamics. If left unchanged, an inflammatory response is mounted via the complement system. Activation of the complement system results in an increased concentration of proinflammatory cytokines, thus promoting a hypercoagulable state [1,2]. As discussed above, stasis, which is used to describe immobilization of blood flow can result from prolonged stillness and directly increases hypercoagulability in patients [1,2]. Finally, prothrombic factors from the coagulation cascade system of our body can be altered, thus leading to a hypercoagulable state [1,2]. The correlation of Virchow’s triad as it relates specifically to COVID-19 patients will be discussed in detail below. Studies have shown that endothelial cell injury can occur as a direct response to the COVID-19 virus [1-4]. The damage created by the virus leads to activation of the complement-mediated system factors C5b-9, which subsequently leads to hypercoagulability [2,3]. In addition, endothelial injury can also result from the catheterization and intubation procedures implemented in severe COVID-19 cases, which can cause physical damage to blood vessels. Additionally, COVID-19 patients, especially those necessitating hospitalization and ICU care, are at an increased risk of thrombosis due to their prolonged immobility. This largely sedentary state directly impacts blood flow dynamics, for it promotes the genesis of stasis. Thirdly, the elevation of prothrombic factors such as fibrinogen and D-dimmer levels have been reported in COVID-19 patients, which directly lead to prolongation of Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) [1-3]. Routine monitoring of blood labs, including Complete Blood Count (CBC), platelet count, coagulation studies (PT and aPTT), fibrinogen, and D-dimer levels should be assessed to evaluate the coagulability state of COVID-19 patients. Moreover, given the fact that a hypercoagulable state can also manifest as a dermatological condition, physicians can also use this as a metric to diagnose hypercoagulability in patients [5]. Some of the most common cutaneous manifestations of hypercoagulability include purpura, livedo reticularis, livedo vasculopathy, chronic venous ulcers, and superficial venous thrombosis [4,5]. The clinical manifestation of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), stroke, limb ischemia, bleeding, and any associated dermatological findings urge us to investigate the relationship between COVID-19 and increased susceptibility to bleeding and thrombosis [1-3]. This way, physicians can predict hypercoagulability state severity in COVID-19 patients and be better equipped to assess the overall risk of morbidity and mortality.

Dermatological Findings in COVID-19 Patients: A Review

Introduction: In the day 16th June 2020, the number of deaths is up to 430000 and the confirmed cases are more than 8 million in the world. The dermatology clinical findings on COVID-19 patients were cutaneous manifestations as pressure injury, contact dermatitis itch, pressure urticarial and exacerbation of pre-existing skin diseases, including seborrheic dermatitis and acne Objective: This work means to show the researches doing in dermatology about COVID-19 and the findings related to them Methodology: In this research article were founded in PubMed with free texts, clinical tests and published in the last 5 years Results: Were founded 13 articles published using the terms proposed: dermatology and coronavirus and COVID-19. Five of them were written about cutaneous manifestations of COVID-19 Conclusion: Although several cutaneous manifestations had been associated with COVID-19, none so far is specific to this disease. The dermatological approach has been valued and, in the future, It is expected that dermatologists can help both in the early diagnosis of the disease and in its prognosis

Heterogeneous cutaneous findings associated with intrauterine HSV infection: A case series and literature review.

Herpes simplex virus (HSV) infection acquired in utero may present with non-vesicular dermatologic findings in affected newborns, which may pose a diagnostic dilemma. We aimed to describe and assess the range of non-vesiculobullous skin lesions that neonates with intrauterine HSV infection may manifest at birth. We collected a multicenter case series and conducted a literature review of neonates with intrauterine HSV infection presenting with non-vesiculobullous cutaneous lesions. Twenty-two cases were reviewed, including six managed clinically by members of our team and 16 identified in the literature. Four (18%) were associated with twin pregnancies, and thirteen (59%) cases occurred in premature infants. Only four (18%) mothers had a documented history of HSV infection. Twelve (55%) cases resulted in poor outcomes, including long-term neurologic sequelae or death. Cutaneous manifestations included erosions, ulcerations, crusted papules or plaques, calcinosis cutis, excoriations, macules (erythematous, hypopigmented, or hyperpigmented), cutaneous atrophy, contractures, and bruising. About one-third of neonates developed new-onset vesicular lesions within a week of birth; in each of these cases, accurate diagnosis and therapy were delayed until appearance of vesicles. The range of dermatologic findings associated with intrauterine HSV is extremely broad, and the various morphologies present at birth likely reflect different stages of the ongoing evolution of an HSV infection that began in utero. Clinicians should have a low threshold for HSV testing in premature neonates born with atypical cutaneous lesions, since early detection and treatment of HSV may reduce morbidity and mortality from systemic complications.

Early onset of clinical leishmaniosis in a litter of pups with evidence of in utero transmission

BackgroundCanine leishmaniosis (CanL) is a zoonotic disease caused by Leishmania infantum. Although usually transmitted by phlebotomine sand flies, infection by vertical transmission and by blood transfusion have also been reported.MethodsWe describe the very early onset of clinical leishmaniosis, starting from 2 months of age, in a litter of pups born to an infected dam and sire. Seven pups from the litter of nine living in different households showed alopecic, exfoliative dermatitis and ulcerative cutaneous lesions. All pups and both parents were tested on at least one occasion both serologically, by enzyme-linked immunosorbent assay (ELISA), and by polymerase chain reaction (PCR) targeting the Leishmania ribosomal operon internal transcribed spacer 1 region and a short fragment of the kinetoplast minicircle; positive amplicons were sequenced.ResultsAll nine pups were PCR positive for L. infantum verified by DNA sequencing, seven were positive by conjunctival, five by blood, four by lymph node, and one by skin PCR from an ulcerative lesion. Both pups with no clinical signs were seronegative, while five of the seven pups with dermatologic abnormalities were seropositive by ELISA. The sire had typical clinical dermatologic and visceral findings of CanL, was seropositive and PCR positive for L. infantum in the lymph node and fluid from the vas deferens tested after the testes were removed by castration. The dam was sub-clinically infected and seronegative, but positive by blood, lymph node and conjunctival PCR for L. infantum. Allopurinol administered to all clinically affected dogs resulted in clinical recovery.ConclusionsInfection with L. infantum in both parents, the very early age of clinical onset among most of the pups, and the fact that the puppies were born and detected with signs of leishmaniosis in the winter, which is a season without sand fly activity in Israel, strongly suggest vertical transmission. Awareness of the possibility of vertical transmission of L. infantum and infection in littermates should be increased. It is recommended that littermates of young dogs with clinical leishmaniosis should be tested for sub-clinical infection as they may also be infectious to sand flies and thus to other dogs and to humans. Restricting the mating of infected bitches should also be considered to prevent the vertical transmission of the infection.Graphic abstract

COVID-19 Tanısı Olan Bir Hastada Ürtiker ve Anjiyoödem: Olgu Sunumu

Coronavirus disease 2019 (COVID-19) disease caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) virus, which has affected the whole world, can cause clinical pictures ranging from mild cold symptoms to severe lower respiratory tract infections that can cause mortality. Recently, reports of dermatological findings associated with COVID-19 such as urticaria has been increasing. Here, a COVID-19 case presenting with urticaria and angioedema is described. A 26-year-old female patient, who was found to be SARS-CoV-2 positive by polymerase chain reaction performed for being in contact, presented to our outpatient clinic with complaints of itchy, erythematous lesions on her body and swelling in the eyes and throat for four days. The patient received favipiravir treatment for 5 days and these complaints started 4 days after the treatment ended. History of food and other drug allergies, insect bites and chemicals were questioned in the differential diagnosis for etiology, however, no relationship was detected. Systemic corticosteroid and antihistamine treatment was initiated, and edema in the eyes completely regressed and urticaria plaques faded on the 3rd day of the treatment. Dermatological findings may occur simultaneously with the classic symptoms of the disease or before or after symptoms. Although the pathogenesis between dermatological findings and COVID-19 has not been fully elucidated, studies have suggested that viral infections and SARS-CoV-2 can be an etiological agent for chronic or acute urticaria. It is thought that some rashes may be causally related to the viral effect and others to the immune response. It is emphasized that there may be atypical findings such as urticaria/angioedema in order to diagnose COVID-19 disease early and prevent its spread and should be considered in differential diagnosis.

Psychiatric morbidity, stress and quality of life among geriatric dermatology patients: Therapeutic considerations from an Indian perspective.

We aimed to determine the prevalence of psychiatric morbidities, stress and quality of life, the pattern of skin diseases and associated psychosocial factors in geriatric population. Patients aged 60 years and older were recruited. Demographics and dermatological history and findings were collected using a preset Proforma. Geriatric depression scale (GDS), hospital anxiety and depression scale (HADS), perceived stress scale (PSS), and dermatology life quality index (DLQI) were instituted in all the patients. A total of 310 patients were included in the study, 173 males and 137 females. Infectious diseases (39.6%), papulosquamous diseases (17.1%), and eczema (15.5%) were common disorders. 45.5% were depressed and 43.2% had anxiety (hospital anxiety and depression scale). 55.8% had depression (geriatric depression rating scale), 20.3% had high stress and 11% had extremely large effect on DLQI. Divorced/widowed patients experienced more depression (p = 0.037) and had more impairment in quality of life (p = 0.05). Patients living in three generation family experienced more impairment in quality of life (p = 0.000). Our study demonstrated high prevalence of psychiatric morbidities in geriatric dermatology patients. It implies the need of special care with more attention to psychiatric co morbidities. The role of psychiatry-dermatology liaison clinic may benefit these patients.

Dermatologic findings in individuals with genetically confirmed Proteus syndrome.

Proteus syndrome, caused by a mosaic activating AKT1 variant, typically presents in toddlers with progressive, asymmetric overgrowth of the skin and bones. We aimed to define the spectrum of dermatologic disease in individuals with genetically confirmed Proteus syndrome. We conducted a retrospective review of records from dermatologic examinations of individuals evaluated at the NIH with a molecular diagnosis of Proteus syndrome. The types, prevalence, and localization of dermatologic findings were assessed. Fifty-one individuals (29 males, 22 females, mean age: 9years) with clinical features of Proteus syndrome had the mosaic c.49G>A, p.Glu17Lys AKT1 variant. Fifty (98%) had at least one cutaneous feature constituting current clinical diagnostic criteria, including vascular malformations in 42 (82%), epidermal nevus in 41 (80%), volar cerebriform connective tissue nevi in 34 (67%), and adipose dysregulation in 30 (59%). Forty-nine (96%) had at least one dermatologic finding not included within the diagnostic criteria, including confluent volar skin-colored to hypopigmented papules or nodules (n=33, 65%), papules or nodules on the digits or face (n=27, 53%), and nonlinear epidermal nevi (n=15, 29%). Other frequently observed features include nail changes (n=28, 55%), hyperpigmented macules (n=27, 53%), patchy dermal hypoplasia (n=18, 35%), gingival/oral mucosal overgrowth (n=17, 33%), hypopigmented macules (n=16, 31%), dental enamel changes (n=9, 18%), acrochordons (n=6, 12%), and lingual overgrowth (n=4, 8%). The range of mucocutaneous features occurring in Proteus syndrome is broader than previously considered. These observations may assist in earlier diagnosis and management and provide novel insights regarding the pathogenesis of the condition.

Multisystem inflammatory syndrome in children with COVID-19.

BackgroundMultisystem inflammatory syndrome in children (MIS-C) is a dangerous pediatric complication of COVID-19.ObjectiveThe purpose of this review article is to provide a summary of the diagnosis and management of MIS-C with a focus on management in the acute care setting.DiscussionMIS-C is an inflammatory syndrome which can affect nearly any organ system. The most common symptoms are fever and gastrointestinal symptoms, though neurologic and dermatologic findings are also well-described. The diagnosis includes a combination of clinical and laboratory testing. Patients with MIS-C will often have elevated inflammatory markers and may have an abnormal electrocardiogram or echocardiogram. Initial treatment involves resuscitation with careful assessment for cardiac versus vasodilatory shock using point-of-care ultrasound. Treatment should include intravenous immunoglobulin, anticoagulation, and consideration of corticosteroids. Interleukin-1 and/or interleukin-6 blockade may be considered for refractory cases. Aspirin is recommended if there is thrombocytosis or Kawasaki disease-like features on echocardiogram. Patients will generally require admission to an intensive care unit.ConclusionMIS-C is a condition associated with morbidity and mortality that is increasingly recognized as a potential complication in pediatric patients with COVID-19. It is important for emergency clinicians to know how to diagnose and treat this disorder.

Dermatological Findings in COVID-19 Patients: A Review

Introduction: In the day 16th June 2020, the number of deaths is up to 430000 and the confirmed cases are more than 8 million in the world. The dermatology clinical findings on COVID-19 patients were cutaneous manifestations as pressure injury, contact dermatitis itch, pressure urticarial and exacerbation of pre-existing skin diseases, including seborrheic dermatitis and acne Objective: This work means to show the researches doing in dermatology about COVID-19 and the findings related to them Methodology: In this research article were founded in PubMed with free texts, clinical tests and published in the last 5 years Results: Were founded 13 articles published using the terms proposed: dermatology and coronavirus and COVID-19. Five of them were written about cutaneous manifestations of COVID-19 Conclusion: Although several cutaneous manifestations had been associated with COVID-19, none so far is specific to this disease. The dermatological approach has been valued and, in the future, It is expected that dermatologists can help both in the early diagnosis of the disease and in its prognosis

Do Pruritus and Urticaria Predict For Response to Antihistamine Therapy in COVID-19 Patients with Pulmonary Symptoms?

Dear Editor,&#x0D; Skin manifestations and respiratory symptoms are commonly seen in patients with COVID-19. While infection by SARS-CoV-2 and an accompanying cytokine storm are proposed to account for respiratory symptoms, additional inflammatory mediators including histamine may also contribute. In this regard, we report the resolution of dyspnea associated with urticaria in a 61-year-old female patient acutely infected with SARS-CoV-2. The patient’s medical history is significant for idiopathic thrombocytopenic purpura, hypertension, and gastroesophageal reflux disease, and her long-standing medications consisted of eltrombopag, hydrochlorothiazide, lisinopril, and pantoprazole. The patient had no prior history of urticaria, angioedema, or respiratory illness. Due to the severity of her symptoms which developed over the course of a few days, the patient was referred to an urgent care clinic where intravenous methylprednisolone was administered, and tapering doses of prednisone were prescribed starting at 50mg. Nevertheless, all of her symptoms, particularly the urticaria (Figure 1 a,b), continued to worsen, prompting her to visit our dermatology clinic where she was started on hydroxyzine 25mg q.d. and topical triamcinolone acetonide 0.1%. A first-generation antihistamine was selected to address both pruritus and associated insomnia. Additionally, prednisone was discontinued as there was no response to the medication. The patient experienced relief of urticaria within 4 hours after starting hydroxyzine and reported improvement of her dyspnea by the following morning. A SARS-CoV-2 test performed at the urgent care clinic was positive for the detection of viral antigen. The patient’s symptoms completely resolved within 5 days after initiating hydroxyzine. The signs and symptoms of mast cell activation including urticaria and pruritus and response to antihistamines suggest that mast cells and their chemical mediators play a significant role in the pathophysiology of some COVID-19 patients. While case reports have described improvement of urticaria and other mast cell-mediated symptoms in COVID-19 patients following the administration of antihistamines, these cases were co-founded by the concomitant addition of new medications; this issue is less relevant in our report.1&#x0D; Urticaria is a common dermatologic manifestation of COVID-19 patients, with an incidence of 19% in a prospective study of 375 patients.2 No correlation between urticaria and disease severity, or timing of onset has been described.3 Possible etiologies of urticaria in COVID-19 patients include a reaction to viral infection, medications, and stress. The SARS-CoV-2 virus itself may directly activate mast cells via toll-like receptors or signaling molecules such as interferon type 1, TNF-α, and/or chemokines.4 It is thought that mast cell degranulation may either be caused directly by the virus or indirectly through viral stimulation of complement fragments C3a and C5a activating G-protein-coupled receptors.4&#x0D; While cytokine storms, and more recently, bradykinin storms, are proposed as mediators in the pathophysiology of COVID-19, mast cells and histamine may also contribute to the development of pulmonary manifestations of COVID-19 patients.5 The clinical course of our patient indicates her respiratory symptoms appeared solely related to SARS-CoV-2 induced urticaria. Release of histamine, prostaglandin-D2, and leukotriene-C4 by mast cells cause bronchoconstriction.6 Further, the release of mast cell cytokines such as IL-1 and IL-6 contribute to the development of pulmonary and systemic inflammation, as well as urticaria in COVID-19 patients.3,4,6,7 Preliminary clinical trial reports suggest antihistamine treatment mitigates pulmonary symptoms in COVID-19 patients. Trials of dual-histamine receptor blockade with cetirizine-famotidine in hospitalized COVID-19 patients with severe pulmonary symptoms resulted in marked reductions in rates of intubation, mortality, and length of hospital stay.8 Additionally, a retrospective study of 1,620 COVID-19 patients who received the H2 receptor antagonist famotidine, showed a statistically significant reduction in the rates of intubation and death.9&#x0D; Based on the observations that urticaria and pruritus may accompany pulmonary symptoms, we postulate these patients may better respond to antihistamine therapy. Therefore, we suggest these dermatologic findings are incorporated into the analysis plans of clinical studies assessing antihistamines in COVID-19 patients with pulmonary symptoms. Further, we suggest considering antihistamines as a component of the first-line treatment for COVID-19 patients with urticaria.