Skin manifestations of COVID-19 in children: Part 3

Defining the short-term and long-term skin manifestations of COVID-19: insights after more than three years of the pandemic

AIM

This review aimed to assess the impact of coronavirus disease 2019 (COVID-19) on skin health to establish a classification of the skin lesions that occur most frequently during the disease and whether a particular category of skin damage is more likely to occur both in the short term and in the long term.

METHODS

We conducted a literature search of the PubMed database. Ultimately, 109 articles were included in this review. The exact phrases∕syntax and connectors used for the database search∕query were as follows: "Coronavirus and skin", "COVID-19 and skin", "SARS-CoV-2 and skin", "Coronavirus cutaneous manifestations", "COVID-19 cutaneous manifestations", "SARS-CoV-2 cutaneous manifestations", "Coronavirus dermatology", "SARS-CoV-2 and dermatology", "COVID-19 and dermatology", "COVID-19 and skin eruption", "Coronavirus and skin rash", "COVID-19 and hair", "Coronavirus and hair", "Coronavirus and nails", "SARS-CoV-2 and hair", and "SARS-CoV-2 and nails". Only articles with abstracts referring strictly to cutaneous manifestations of COVID-19 were chosen. Articles without abstracts were not considered.

RESULTS

We established six of the most frequently reported clinical patterns associated with COVID-19 and their probability of occurring during COVID-19 disease evolution based on the current literature reports. We did not identify the particular types of skin lesions that are most prone to long-term persistence; most such cases are rare, and no conclusion can be drawn based on them.

CONCLUSIONS

Apart from classified COVID-19-related skin disorders, this pandemic has been a challenge for dermatologists and a wide range of cutaneous side effects related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) treatments have been reported. We are aware of other polymorphic clinical presentations, with novel data being reported periodically, but the pathophysiological mechanisms and evolution are largely unknown.

COVID-19 Associated Vasculitis Confirmed by the Tissues RT-PCR: A Case Series Report

Background: Several cases of skin and central nervous system vasculopathy associated with COVID-19 in children have been published, but the information is rather limited. Our study aimed to describe these cases of vasculitis associated with COVID-19 in children. Methods: In the retrospective-prospective case series study we included information regarding four children with COVID-19-associated vasculitis. In every case, we had a morphological description and the etiology was confirmed via real-time polymerase chain reaction during a tissue biopsy. Results: The most involved systems were skin (4/4), respiratory (3/4), cardiovascular (2/4), nervous (1/4), eye (1/4), kidney (1/4), and inner year (1/4). All patients had increased inflammatory markers and thrombotic parameters (D-dimer). No patient met the criteria for multisystem inflammatory syndrome in children. Two patients met polyarteritis nodosa criteria, one met Henoch–Schonlein purpura criteria, and one met unclassified vasculitis criteria. All patients were treated with systemic glucocorticosteroids (two-pulse therapy). Non-biologic DMARDs were prescribed in all cases; 1/4 patients (25%) was treated with intravenous immunoglobuline, and 3/4 (75%) were treated with biologics (etanercept, tocilizumab, and adalimumab). Conclusions: Vasculitis associated with COVID-19 could be a life-threatening condition; SARS-CoV-2 might be a new trigger or etiological agent for vasculitis and other immune-mediated diseases. Further research and collection of similar cases are required.

Does Multisystem Inflammatory Syndrome Only Mimic Acute Appendicitis in Children or Can It Coexist: When Should We Suspect MIS-C?

Background and Objectives: Acute abdominal pain in children has been noticed to be a primary reason to seek medical attention in multisystem inflammatory disorder (MIS-C), which can prevail separately or together with acute appendicitis. Our aim was to distinguish regular appendicitis cases from MIS-C and to suggest the best clinical and laboratory criteria for it. Materials and methods: Cases of patients, admitted to the Pediatric Surgery Department over a six-month period in 2021, were retrospectively analyzed. Confirmed MIS-C or acute appendicitis cases were selected. MIS-C cases were either separate/with no found inflammation in the appendix or together with acute appendicitis. Acute appendicitis cases were either regular cases or with a positive COVID-19 test. Four groups were formed and compared: A-acute appendicitis, B-MIS-C with acute appendicitis, C-MIS-C only and D-acute appendicitis with COVID-19. Results: A total of 76 cases were overall analyzed: A-36, B-6, C-29 and D-5. The most significant differences were found in duration of disease A—1.4 days, B—4.5 days, C—4 days, D—4 days (p < 0.0001), C reactive protein (CRP) values A-19.3 mg/L B-112.5 m/L, C-143.8 mg/L and D-141 mg/L (p < 0.0001), presence of febrile fever A-13.9%, B-66.7%, C-96.6% and D-40% (p < 0.0001) and other system involvement: A 0%, B 100%, C 100% and D 20%. A combination of these factors was entered into a ROC curve and was found to have a possibility to predict MIS-C in our analyzed cases (with or without acute appendicitis) with an AUC = 0.983, p < 0.0001, sensitivity of 94.3% and specificity of 92.7% when at least three criteria were met. Conclusions: MIS-C could be suspected even when clinical data and performed tests suggest acute appendicitis especially when at least three out of four signs are present: CRP > 55.8 mg, symptoms last 3 days or longer, febrile fever is present, and any kind of other system involvement is noticed, especially with a known prior recent COVID-19 contact, infection or a positive COVID-19 antibody IgG test.

Evolving Skin Rash as a Rare Cutaneous Manifestation in a Pediatric Patient With COVID-19 Infection

COVID-19 has been one of the common infections that have affected numerous children across the world in the last two years. The clinical manifestations of this virus are varied, ranging from being asymptomatic to affecting multiple organ systems. There is a lot of ongoing research to find out the different manifestations that this infection can have in both adults and children. As with any viral illness, skin is one of the most commonly affected organs, and many viral illnesses can present with a rash. In our case, we found it interesting that our patient who tested positive for COVID-19 had a rash that began on the day of her initial presentation and evolved over time as the disease progressed, and hence, we thought it was important to highlight this rare case presentation as a cutaneous finding in children with COVID-19 infection.

[Skin manifestations of COVID-19 and after COVID-19 vaccination]

Coronavirus disease 2019 (COVID-19) is a systemic disease induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that frequently presents with skin manifestations. The five most common skin lesions are pseudo-chilblain and maculopapular, urticarial, vesicular, and livedo/necrotizing skin lesions. These skin lesions are of diagnostic and prognostic relevance. For example, in children, typical skin lesions may indicate a life-threatening inflammatory syndrome, which rarely occurs after corona infection. Skin lesions have also been described after COVID-19 vaccination. These usually show an uncomplicated, self-limiting course and therefore do not represent a contraindication for completing the vaccination status in the vast majority of cases.

COVID-19 Infection in Children: Diagnosis and Management

Purpose of Review

Due to the rapidly changing landscape of COVID-19, the purpose of this review is to provide a concise and updated summary of pediatric COVID-19 diagnosis and management.

Recent Findings

The relative proportion of pediatric cases have significantly increased following the emergence of the Omicron variant (from < 2% in the early pandemic to 25% from 1/27 to 2/3/22). While children present with milder symptoms than adults, severe disease can still occur, particularly in children with comorbidities. There is a relative paucity of pediatric data in the management of COVID-19 and the majority of recommendations remain based on adult data.

Summary

Fever and cough remain the most common clinical presentations, although atypical presentations such as “COVID toes,” anosmia, and croup may be present. Children are at risk for post-infectious complications such as MIS-C and long COVID. Nucleic acid amplification tests through respiratory PCR remain the mainstay of diagnosis. The mainstay of management remains supportive care and prevention through vaccination is highly recommended. In patients at increased risk of progression, interventions such as monoclonal antibody therapy, PO Paxlovid, or IV remdesivir × 3 days should be considered. In patients with severe disease, the use of remdesivir, dexamethasone, and immunomodulatory agents (tocilizumab, baricitinib) is recommended. Children can be at risk for thrombosis from COVID-19 and anticoagulation is recommended in children with markedly elevated D-dimer levels or superimposed clinical risk factors for hospital associated venous thromboembolism.

Chilblain or Perniosis-like Skin Lesions in children during the COVID-19 pandemic: A Systematic Review of Articles

COVID toes or chilblain-like skin lesions represent a widespread and specific skin presentation in the feet attributed to COVID-19 infection. They may last for several months. We conducted this study to investigate chilblain-like lesions in children during the COVID-19 pandemic, any predisposition, location, clinical course, and prognosis. We searched Google Scholar, Scopus, and Medline (PubMed) databases using the following keywords: "Coronavirus" OR "COVID-19" AND "Chilblains" OR "Pernio" OR "Perniosis" OR "Children" OR "Cutaneous" OR "skin." The inclusion criteria were: studies that described the specific vascular skin lesion. studies that included patients that were aged > one month till 18 years. . Case reports, case series, retrospective or prospective cohort studies, case-control studies. Twenty-eight articles were included. The total number of children with CLL was 433. The mean age of children presenting CLL during the COVID-19 pandemic was estimated as 12.58 ± 2.15. Of note, 53.6% of them were male. The nasopharyngeal SARS-CoV-2 RT-PCR test and anti-SARS-CoV-2 antibodies were mostly negative for the virus. In conclusion, it is crucial to be familiar with various presentations of COVID-19 infection and their clinical significance to approach the earliest diagnosis, immediate treatment, estimate the prognosis and finally isolate the patients to prevent spreading. Chilblain-like lesions as a possible cutaneous presentation of COVID-19 in children may last several months with the indolent course.

Dermatopathology of COVID-19 infection and vaccination

BACKGROUND

Many peculiar skin changes have been described in relation to both coronavirus disease 2019 (COVID-19) infection and vaccination.

OBJECTIVE

This paper provides an overview of these dermatologic manifestations, focusing on their dermatopathological appearances.

RESULTS

Most COVID-19 patients develop variegated maculopapular eruptions with a combination of histological patterns commonly including keratinocyte apoptosis and eosinophilia. Urticaria-like lesions often show a combination of spongiotic and lichenoid patterns and are more frequent in individuals with severe disease. Vesicular lesions can be disseminated; in some cases, they become pustular and in others show dyskeratosis and a peculiar form of ballooning. Some patients develop vesicular Grover disease on the trunk. Young patients with a strong immunological response can eliminate the virus easily but may develop chilblains as a consequence of the high interferon response. Conversely, older individuals with immunosenescence and a tendency toward hypercoagulability can present livedoid and ischemic areas. Regarding COVID-19 vaccination, hypersensitivity reactions are most frequent, including "COVID-arm." Nonetheless, a combination of local and systemic cutaneous manifestations (reactogenicity) is commonly seen. Histopathologically, lichenoid and spongiotic changes and a variable number of eosinophils are typical of rashes characterized by papules and plaques. Other dermatological side effects of COVID-19 vaccination include lesions mimicking well-defined dermatoses such as lichen planus or bullous pemphigoid and triggering of collagenous diseases.

CONCLUSION

Well-characterized skin manifestations of coronavirus disease 2019 (COVID-19) include chilblains, livedo necrotic lesions, vesicular eruptions, urticarial lesions, and maculopapular eruptions. Hypersensitivity reactions are common after SARS-CoV‑2 mRNA vaccination. Vaccine reactions may also mimic other dermatosis such as bullous pemphigoid or lichen planus, stimulate herpes reactivation, or trigger the development of autoimmune diseases.

Post-acute Sequelae in COVID-19 Survivors: an Overview

In the acute phase of SARS-CoV-2 infection, varying degrees of clinical manifestations have been noticed in patients. Some patients who recovered from the infection developed long-term effects which have become of interest to the scientific and medical communities, as it relates to pathogenesis and the multidisciplinary approach to treatment. Long COVID (long-term or long-haul) is the collective term used to define recovered individuals of SARS-CoV-2 infection who have presented with persistent COVID symptoms, as well as the emergence of disorders and complications. Following the review of literature from major scientific databases, this paper investigated long COVID and the resulting post-sequela effects on survivors, regardless of initial disease severity. The clinical manifestations and multisystem complications of the disease specifically, cardiovascular, neurologic and psychologic, hematologic, pulmonary, dermatologic, and other ailments were discussed. Patients with chronic COVID-19 were found to experience heart thrombosis leading to myocardial infarction, inflammation, lung fibrosis, stroke, venous thromboembolism, arterial thromboembolism, "brain fog", general mood dysfunctions, dermatological issues, and fatigue. As the disease continues to progress and spread, and with the emergence of new variants the management of these persisting symptoms will pose a challenge for healthcare providers and medical systems in the next period of the pandemic. However, more information is needed about long COVID, particularly concerning certain patient populations, variability in follow-up times, the prevalence of comorbidities, and the evolution of the spread of infection. Thus, continued research needs to be conducted concerning the disease pathology to develop preventative measures and management strategies to treat long COVID.

Pediatric COVID-19 and Gastrointestinal Symptoms in Africa

One year into the coronavirus disease 2019 (COVID-19) pandemic, the African continent still seems to be spared from the devastating effects the disease had in other continents. Africa's COVID-19 seems to be of a milder nature both in adults and children. However, lack of data from Africa is significant, and more studies are needed to validate the disease status, clinical manifestations, and future implications for Africa. In this study, we report pediatric COVID-19 features in Africa represented by 8 countries.

Cutaneous coronavirus disease 2019 in children: a clinical primer for diagnosis and treatment

PURPOSE OF REVIEW

This review examines the global literature regarding rashes encountered in children and adults infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and aims to provide practicing pediatricians with an understanding of the relationship between instances of rashes and coronavirus disease 2019 (COVID-19) in children in order to effectively evaluate and treat patients.

RECENT FINDINGS

The true incidence of cutaneous reactions in children infected with SARS-CoV-2 is not known. Children's immune systems differ from those of adults and rashes as a manifestation of immune responses, in turn, differ in morphology and distribution. Rarely, children develop a severe multisystem inflammatory syndrome that has overlapping clinical features with Kawasaki disease. In addition, vaccinations produce rashes similar to natural infections. The rashes associated with COVID-19 vaccination are mild and transient, and should not preclude vaccination. Lastly, children who chronically wear masks are more likely to experience flaring of acne around the nose and mouth ('maskne') and facial conditions such as seborrheic dermatitis.

SUMMARY

There are ongoing worldwide registries, clinical and basic science studies to better understand the burden of skin disease and pathophysiology of rashes seen in patients infected with COVID-19. Robust vaccination programs should be encouraged as a way to contain viral spread among children and the greater population.

Acral manifestations associated with infection

Acral lesions are well-known physical findings in various infectious disorders. Although they are often overlooked, they can be the key to the diagnosis of the underlying disease. Considering this, we present an overview of various infectious causes of acral lesions in childhood. In addition, we discuss their characteristic presentation, evolution, and appropriate treatment. To our knowledge, this is the first review covering viral, bacterial and mycotic causes.

Dermatological manifestations associated with COVID-19: A comprehensive review of the current knowledge

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has become a significant health problem globally. The virus has spread widely and become a global pandemic. The pathophysiology for SARS-CoV-2 has not been explained clearly. It has been associated with several multiorgan symptoms, among which its dermatological manifestations are of great interest. Primarily, there has been no report of skin features among COVID-19 patients. Nevertheless, recently there have been several reports regarding COVID-19 patients who presented with cutaneous manifestations. In the current review, we focus on the various cutaneous manifestations of COVID-19 infection.

The impact of the COVID-19 pandemic on the field of pediatric rheumatology

PURPOSE OF REVIEW

The purpose of this review is to discuss the clinical management of children with pediatric rheumatic disease (PRD) during the Coronavirus disease of 2019 (COVID-19) pandemic, as well as the unique role of the pediatric rheumatologist during a time of emerging post-COVID inflammatory sequelae including, multisystem inflammatory syndrome in children (MIS-C).

RECENT FINDINGS

To date, there has been little evidence to suggest that children with PRD, including those on immunomodulatory therapies, are at increased risk for severe COVID-19. Clinical guidance statements have been created to support clinical providers in providing care to children with PRD during the COVID-19 pandemic. Pediatric rheumatologists have also been called upon to assist in the identification and management of post-COVID sequelae, including the rapidly emerging inflammatory illness, MIS-C.

SUMMARY

The COVID-19 era has been defined by a rapid expansion in scientific knowledge and a time of extraordinary local and worldwide collaboration, both within the pediatric rheumatology community, as well as across multiple disciplines. Through collective efforts, we have learned that children with PRD, including those on immunomodulatory therapies, are not at increased risk for severe COVID-19. Pediatric rheumatologists have also worked alongside other disciplines to develop guidance for the management of MIS-C, with the majority of patients experiencing excellent clinical outcomes.

Urticaria multiforme in a child with SARS-CoV-2 infection

We present a case of a 10-month-old boy with urticaria multiforme in the course of coronavirus disease 2019 (COVID-19). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contributes to skin lesions in both children and adults. The main cutaneous manifestations of this infection include pseudochilblains, urticaria and maculopapular eruptions. Urticaria multiforme is a common yet underrecognized exanthem in children that is precipitated by viral infections among other causes.

Infectious-mononucleosis-like exanthema associated with COVID-19 in a child

Cutaneous manifestations of childhood COVID-19 differ from those of adults. Maculopapular rash is not specific and could be mistaken with other viral exanthema. A nasopharyngeal swab is strongly recommended to confirm the possible COVID-19 diagnosis.

Inflammatory Skin Lesions in Three SARS-CoV-2 Swab-Negative Adolescents: A Possible COVID-19 Sneaky Manifestation?

Coronavirus disease 19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with various clinical manifestations, including skin lesions. In particular, during the COVID-19 pandemic lock-down period numerous chilblain-like lesions, mainly located on the feet, were observed in adolescents. The latter were often asymptomatic or associated with very mild respiratory symptoms. Here, we report three cases of acral nodular lesions in SARS-CoV-2 swab-negative adolescents with histological findings of chronic immune-mediated inflammation and immunohistochemical evidence of SARS-CoV-2 spike glycoproteins in endothelial cells and eccrine sweat glands. In one of these cases, the virus presence was confirmed by electron microscopy.