Covid Toes and other Dermatologic Manifestations of Covid 19

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Covid Toes and other Dermatologic Manifestations of Covid 19

Post by trader32176 »

Covid Toes and other Dermatologic Manifestations of Covid 19 ... of-covid19

As the world continues to struggle with the COVID-19 pandemic, new symptoms of the virus continue to be identified. One such symptom, purple or red lesions on the toes and hands, has been dubbed “COVID toes” and has gained attention over recent weeks.

Even before we started hearing any reports about dermatologic manifestations of COVID-19, we were wondering about how we could better understand what would happen to our existing dermatologic patients who contracted Covid-19. In particular, we were concerned about patients who were on biologics, or those with preexisting dermatologic conditions such as psoriasis, eczema or lupus, to name a few. We appreciated collaboration from the Global Rheumatology Alliance, who had launched a similar database for Rheumatology and helped share their experience with us. While we were building the registry, we started hearing more and more reports about different skin manifestations in COVID-19, and we realized the registry was capable of collecting all of this data at the same time.

In terms of viruses and their effect on the skin, in dermatology we are used to viruses causing different viral rashes and eruptions. It was certainly not out of the ordinary for any of us to think there may be some viral rashes that we would end up seeing with COVID-19, like we see with many other viruses. But what has been more surprising is these increasing reports around these pernio-like lesions of the toes.

Q. What are COVID toes, and what should patients do if they notice them?

A. Pernio, a condition where you get red or purple tender bumps on the fingers or toes, also known as chilblains, is usually a reaction to cold temperatures. In COVID-19, I prefer to call it “pernio-like” rather pernio, since we don’t yet know if it’s truly the same process. A lot of these patients adamantly deny being exposed to any sort of cold temperatures whatsoever. These skin lesions have been dubbed “COVID toes.”

What patients are experiencing are red or purple bumps on their toes or hands, as well as a burning sensation, often with pain and tenderness. The good news is it seems to go away after about 2-3 weeks.

For the most part, we have seen this in young and relatively healthy patients, both in children and adults. So, I want to emphasize I do not want people to panic and think “Oh I have purple toes, I’m going to go on a ventilator.” While we have had a few reports of sicker patients that have developed this finding, for the most part, that is not what we have been seeing.

I recommend concerned individuals contact their board-certified dermatologist or their primary care doctor to discuss if they are concerned about new onset of toe lesions. There are other conditions that can cause something similar, so you will want someone to evaluate you and go through a thorough medical history.

Q. What should dermatologists be on the lookout for in terms of COVID toes, or how should they react when patients report them?

A. One of the challenges around these lesions is that our knowledge is continuing to evolve around how we counsel patients regarding quarantine at this time. People should be following CDC and local guidelines in terms of self-isolating, regardless. We know that some patients who develop the pernio-like lesions of their feet are still infectious, because they are testing PCR positive for the virus. This means that there is a potential risk of transmitting the virus to others. It seems that some people may develop these lesions while they are still infectious, while others may develop them somewhat later in the disease course. We need more data on the timing of these pernio-like lesions so we can better guide our providers on how to counsel their patients. That is an area we are actively working on.

This has public health implications because if your patient is potentially still infectious when their toes are purple, that is a different story than if they are not infectious and they are already basically over the infectious stage of the virus.

Q. What other dermatologic manifestations are being reported in patients with COVID-19?

A. COVID toes are kind of stealing the spotlight, but about half our registry is conditions other than these pernio-like lesions of the feet and hands. We are seeing other virally induced rashes and eruptions such as morbilliform, also known as measles-like eruptions, and urticaria, also known as hives, among many others.

One of challenges is that patients with COVID-19 are often on multiple medications, and so when a rash develops it can be hard to sort out whether the skin findings are related to a medication or to the virus itself.
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Re: Covid Toes and other Dermatologic Manifestations of Covid 19

Post by trader32176 »

new info on skin rash-like lesions inside the mouth as a symptom of Covid 19 :

Mouth lesions may be a new coronavirus symptom, study suggests
Enanthems were spotted in some COVID-19 patients who also had skin rash ... us-symptom

According to the Centers for Disease Control and Prevention, COVID-19 symptoms usually include fever, cough, aches and difficulty breathing, among others. A new study, however, suggests that skin rashes, which are not listed by the CDC, are also a sign of the deadly virus.

The research, published in JAMA Dermatology, notes that enanthems (skin rash-like lesions inside a person's mouth) were observed in some (6 of 21) patients with COVID-19 and skin rash. The patients were aged between 40 and 69 and four of the six were female.

"This work describes preliminary observations and is limited by the small number of cases and the absence of a control group," researchers from Ramon y Cajal University Hospital in Madrid wrote in the study. "Despite the increasing reports of skin rashes in patients with COVID-19, establishing an etiological diagnosis is challenging. However, the presence of enanthem is a strong clue that suggests a viral etiology rather than a drug reaction, especially when a petechial pattern is observed."

The researchers added that "many patients with suspected or confirmed COVID-19 do not have their oral cavity examined," largely due to safety concerns. Given the fact that patients are wearing masks and the mouth is not examined, it's possible additional COVID-19 patients may have these symptoms.

The rashes were split into four different categories, according to the researchers: "petechial, macular, macular with petechiae, or erythematovesicular.”

Enanthems were previously identified in some COVID-19 patients in Italy, the researchers explained.

In June, the CDC added congestion or runny nose, nausea, and diarrhea to its ongoing list of COVID-19 symptoms, Fox News reported.

In April, a separate group of scientists in Spain found lesions on feet they said may be linked to the novel coronavirus.

A CDC spokesperson pointed Fox News to the list of symptoms associated with COVID-19 and did not comment on the study.
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Re: Covid Toes and other Dermatologic Manifestations of Covid 19

Post by trader32176 »

A rare Covid-19 complication was reported in children. Now, it's showing up in adults.

"This needs to be in the forefront of every intensive care unit physician's mind," said one expert.

10/16/20 ... s-n1243161

It was a rash that tipped Dr. Alisa Femia off.

Femia, director of inpatient dermatology at NYU Langone Health in New York City, was looking at a patient's chart, which included several photos of the 45-year-old man who had, in recent weeks, cared for his wife while she was sick with Covid-19. The man had dusky-red circular patches on the palms of his hands and the soles of his feet. His eyes were pink, and his lips were extremely chapped.

His body was erupting with the kind of extreme inflammation noted almost exclusively in children at the time.

"Before I even saw the patient," Femia recalled, "I said: 'This hasn't been reported yet. This must be MIS-A.'"

MIS-A stands for "multi-system inflammatory syndrome in adults.

" When the condition was identified in children this spring, it was named MIS-C, with the C standing for "children."

Kids were developing dangerous inflammation around the heart and other organs, often weeks after their initial infections with SARS-CoV-2, the virus that causes Covid-19.

The Centers for Disease Control and Prevention alerted physicians to MIS-C in May. As of Oct. 1, the CDC had reported 1,027 confirmed cases of MIS-C, with more cases under investigation. Twenty children have died.

In some cases, the children developed rashes like the one Femia noted in her adult patient.

Femia and colleagues published details of the case in The Lancet in July to alert other physicians to be on the lookout for similar patients.

"The skin's right there in front of your eyes," Femia said. "You can't not see it."

But many doctors may not, in fact, be recognizing the condition in adults. Just a few dozen cases of MIS-A have been reported. And not all patients have obvious rashes.

Dr. Sapna Bamrah Morris, clinical lead for the Health Care Systems and Worker Safety Task Force, part of the CDC's Covid-19 response, detailed 27 cases in a report the agency published last week.

MIS-A's "true prevalence is unknown," Morris said. "We have to get physicians realizing that. It may be rare, but we don't know. It might be more common than we think."

Negative tests

Part of the problem is that the virus has been circulating among humans for less than a year. Doctors worldwide are still learning about how SARS-CoV-2 acts in patients.

Typically, severely ill Covid-19 patients tend to arrive at the hospital because they're having trouble breathing. That hasn't been the case with MIS-A.

Many MIS-A patients report fevers, chest pain or other heart problems, diarrhea or other gastrointestinal issues — but not shortness of breath. And diagnostic tests for Covid-19 tend to be negative.

Instead, patients will test positive for Covid-19 antibodies, meaning they were infected two to six weeks previously, even if they never had symptoms.

"Just because someone doesn't present with respiratory symptoms as their primary manifestation does not mean that what they're experiencing isn't as a result of Covid-19," Morris said.

The illness can be life-threatening. Patients usually have some kind of severe dysfunction of at least one organ, such as the heart or the liver.

Ten patients in the CDC report needed to be hospitalized in intensive care units. Some needed to be put on ventilators. Two have died.

What's more, the CDC report showed that members of racial and ethnic minority groups appear to be disproportionately affected. Nearly all patients with MIS-A were African American or Hispanic. But far too few cases have been reported to fully understand the underlying mechanisms at play.

While some kind of genetic link may be possible, Covid-19 has been shown to "disproportionately affect underrepresented minorities, probably due to socioeconomic factors," Femia said. Underlying health conditions that raise the risk for Covid-19 complications, such as obesity and Type 2 diabetes, also tend to be more prevalent among members of racial and ethnic minority groups.

Over the summer, doctors in Florida started seeing surges in Covid-19 cases. Dr. Lilian Abbo, chief of infection prevention for Jackson Health System in Miami, recalls a "very high volume of people coming through our emergency departments or hospitals getting very sick."

The most sensitive and reliable test for Covid-19, called a PCR test, wasn't always available, and it could take several days to return results. Abbo turned to antibody testing to get the influx of patients triaged to a Covid-19 unit or elsewhere in the health system.

People generally develop antibodies to an infection within about a week or so. At least it would give Abbo and her colleagues an indication that Covid-19 was involved somehow in their patients' symptoms, she reasoned.

It was then that Abbo discovered a subset of patients who were critically ill after having had Covid-19, but without the telltale pulmonary issues of an acute infection.

"We were a little disconcerted," Abbo said. "We would do the molecular PCR tests, and they would be negative. Then the antibody tests were positive."

Further blood tests revealed extremely high levels of inflammation in the body.

What's more, while most severely ill Covid-19 patients tend to be over age 65 or to have multiple underlying health problems, these patients "were younger people that you would expect to not get sick," Abbo said.

"That's what caught our attention."

MIS-A treatment

There's no proven treatment for MIS-A. "We need to recognize this syndrome and develop data" to figure out which therapies may be most effective," Abbo said. "We are all just shooting blind."

Dr. Jill Weatherhead, an assistant professor of infectious diseases and tropical medicine at Baylor College of Medicine in Houston, points out that the CDC case reports show that doctors have tried a variety of medications for MIS-A patients, including steroids and drugs that might affect the immune system, called interleukin-6 inhibitors.

"The problem with these diseases is that we don't know the mechanisms that are causing MIS-A and MIS-C," Weatherhead said. "It's difficult to know what the standard treatment should be until we have more information."

In children, MIS-C is generally treated with intravenous immunoglobulin, a blood product containing a variety of antibodies. That can be used for adults, too, but the effects are largely unproven.

Intravenous immunoglobulin, or IVIG, is different from another blood-derived antibody treatment, convalescent plasma. The latter is taken from patients who have recovered from Covid-19 and have antibodies specifically targeted to the virus in their blood. IVIG, on the other hand, is more of a hodgepodge of antibodies that aren't specific to the coronavirus.

The thinking is that MIS-A patients already have Covid-19 antibodies, so adding more with convalescent plasma is unlikely to help.

The current theory for MIS-A patients is that "the infection, as far as we know, is gone," said Dr. Hugh Cassiere, director of critical care services for Sandra Atlas Bass Heart Hospital at North Shore University Hospital, part of Northwell Health, on Long Island, New York.

"It's the antibodies that have been produced that seem to be causing a problem," he said.

Cassiere was part of a large team of physicians who treated the surge of Covid-19 patients in New York this spring. Even though MIS-A hadn't been identified at the time, Cassiere is convinced that such patients existed all along.

"We were seeing patients who admitted to the ICU with organ failure," Cassiere said. They would test negative for Covid-19, he said, but test positive for Covid-19 antibodies, suggesting they'd been infected previously.

"You look back, and they probably had this multi-system inflammatory syndrome
," Cassiere said. "We didn't have all the pieces to put together."

Months later, the puzzle is beginning to reveal itself. But it will take an all-hands-on-deck approach to identify patients with MIS-A.

"This needs to be in the forefront of every intensive care unit physician's mind who's seeing patients, especially when they have Covid-19 antibodies," Cassiere said.

Given Femia's experience, that includes those who specialize in dermatology.

"This is really the beauty of medicine, where, for this syndrome, many different specialists need to come together to help make the diagnosis," Femia said.

Physicians worry that many MIS-A patients will go undetected — and perhaps untreated.

"There's not enough data for me to tell you what the long-term effects of this could be," Cassiere said. "This may be the tip of the iceberg. That's what I'm worried about."
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Re: Covid Toes and other Dermatologic Manifestations of Covid 19

Post by trader32176 »

20-year-old Boulder County resident develops rare, dangerous condition following coronavirus

10/17/20 ... ronavirus/

A 20-year-old Boulder County resident appeared to have fully recovered from the coronavirus. Three weeks later, the resident developed multisystem inflammatory syndrome.

Multisystem inflammatory syndrome is a newly identified condition that primarily occurs in children and has symptoms similar to Kawasaki disease, a news release from Boulder County Public Health states.

In Boulder County, there have been 4,998 coronavirus cases in Boulder County, reported as of Friday. Of those, there have been 2,873 positive or probable cases between residents age 18 to 28, Public Health spokeswoman Chana Goussetis said Friday.

The University of Colorado Boulder’s coronavirus dashboard shows since Aug. 24, 1,114 on-campus tests have returned positive as of Friday. Colorado Department of Public Health and Environment has determined a coronavirus outbreak at CU Boulder, and data updated Wednesday shows 16 staff members and 1,527 students have tested positive for the virus, and 168 students are considered probable.

To date, there have been 227 hospitalizations in Boulder County. There have been 84 deaths — 61 of which are tied to long-term care facilities, county data shows.

Within the 18- to 28-year-old age range, 15 individuals have been hospitalized and none have died, Goussetis said.

Still, infectious disease Dr. Heather Pujet said she hopes residents understand the virus can have serious complications for young people.

“This should serve as a warning for the younger people in the community to please not disregard their own personal risks with COVID-19,” Pujet stated in the release. “The patient became extremely ill very quickly with multiorgan system involvement. They fortunately recovered after a period of severe illness.”

The 20-year-old resident had mild symptoms of the coronavirus. They later developed severe abdominal pain, and had watery diarrhea and a fever, the release states. The individual was hospitalized and required intensive care.

Conditions improved, and the resident was eventually discharged from the hospital, the release states.

Health officials say the best way to prevent multisystem inflammatory syndrome is the same as protecting against COVID-19.

“The same simple tools we use to fight COVID-19 — wearing a mask, keeping our distance, limiting gatherings and staying home when we’re sick — can help keep your family safe from this terrible condition,” Boulder County Public Health Executive Director Jeff Zayach stated in the release.

Multisystem inflammatory disease can cause different body parts to become inflamed, including the heart, lungs, kidneys, brain, skin, eyes or gastrointestinal organs, the release states. Common symptoms include fever, severe abdominal pain, vomiting, diarrhea, rash, red eyes, red lips, trouble breathing and seeming confused or sleepy.

“Much remains unknown about how MIS (multisystem inflammatory syndrome) develops, but it’s related to the body’s attempts to fight an invader,” pediatric infectious disease specialist Sam Dominguez stated in the release. “It’s very important for parents to promptly seek medical care if they notice any of these symptoms.”

Anyone experiencing symptoms of either the coronavirus or multisystem inflammatory syndrome is advised to contact their health care provider for guidance on testing and treatment.
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