Leucocytoclastic vasculitis in a patient with COVID-19 with positive SARS-CoV-2 PCR in skin biopsy

Leukocytoclastic Vasculitis Secondary to Severe Fever with Thrombocytopenia Syndrome

A 75-year-old Japanese woman was admitted to our hospital and diagnosed with hemophagocytic syndrome secondary to severe fever with thrombocytopenia syndrome (SFTS). The patient recovered after steroid treatment and was discharged from the hospital. Two months after the onset of SFTS, the patient revisited our hospital with a fever and palpable purpura on the extremities and trunk. A histopathological examination of a punch skin biopsy specimen revealed leukocytoclastic vasculitis. Symptomatic treatment resolved the fever, and palpable purpura disappeared 14 days later. No other clinical symptoms or abnormal immunological findings contributed to the leukocytoclastic vasculitis. This is the first report to describe leukocytoclastic vasculitis secondary to SFTS, highlighting a potential association between the two conditions.

Acute neutrophilic vasculitis (leukocytoclasia) in 36 COVID-19 autopsy brains

BACKGROUND

Hypercytokinemia, the renin-angiotensin system, hypoxia, immune dysregulation, and vasculopathy with evidence of immune-related damage are implicated in brain morbidity in COVID-19 along with a wide variety of genomic and environmental influences. There is relatively little evidence of direct SARS-CoV-2 brain infection in COVID-19 patients.

METHODS

Brain histopathology of 36 consecutive autopsies of patients who were RT-PCR positive for SARS-CoV-2 was studied along with findings from contemporary and pre-pandemic historical control groups. Immunostaining for serum and blood cell proteins and for complement components was employed. Microcirculatory wall complement deposition in the COVID-19 cohort was compared to historical control cases. Comparisons also included other relevant clinicopathological and microcirculatory findings in the COVID-19 cohort and control groups.

RESULTS

The COVID-19 cohort and both the contemporary and historical control groups had the same rate of hypertension, diabetes mellitus, and obesity. The COVID-19 cohort had varying amounts of acute neutrophilic vasculitis with leukocytoclasia in the microcirculation of the brain in all cases. Prominent vascular neutrophilic transmural migration was found in several cases and 25 cases had acute perivasculitis. Paravascular microhemorrhages and petechial hemorrhages (small brain parenchymal hemorrhages) had a slight tendency to be more numerous in cohort cases that displayed less acute neutrophilic vasculitis. Tissue burden of acute neutrophilic vasculitis with leukocytoclasia was the same in control cases as a group, while it was significantly higher in COVID-19 cases. Both the tissue burden of acute neutrophilic vasculitis and the activation of complement components, including membrane attack complex, were significantly higher in microcirculatory channels in COVID-19 cohort brains than in historical controls.

CONCLUSIONS

Acute neutrophilic vasculitis with leukocytoclasia, acute perivasculitis, and associated paravascular blood extravasation into brain parenchyma constitute the first phase of an immune-related, acute small-vessel inflammatory condition often termed type 3 hypersensitivity vasculitis or leukocytoclastic vasculitis. There is a higher tissue burden of acute neutrophilic vasculitis and an increased level of activated complement components in microcirculatory walls in COVID-19 cases than in pre-pandemic control cases. These findings are consistent with a more extensive small-vessel immune-related vasculitis in COVID-19 cases than in control cases. The pathway(s) and mechanism for these findings are speculative.

Henoch-schonlein purpura following exposure to SARS-CoV2 vaccine or infection: a systematic review and a case report

BACKGROUND

Henoch-Schonlein purpura (HSP) is an IgA-mediated systemic small-vessel vasculitis (IgAV) that typically presents with a variable tetrad of symptoms. HSP if often preceded by respiratory tract infections, vaccinations, drugs or malignancies. During the recent COVID-19 pandemic multiples cases of HSP have been described after both infection and vaccination for SARS-CoV2. This study aims to perform a systematic review of literature and describe an additional complicated case of de-novo HSP appeared after the administration of the third dose of a mRNA-SARS-CoV2 vaccination.

METHODS

Electronic bibliographic research was performed to identify all the original reports describing cases of de-novo HSP or IgAV appeared after respiratory infection or vaccine administration for SARS-CoV2. We included all case series or case reports of patients who respected our inclusion and exclusion criteria.

RESULTS

Thirty-eight publications met our pre-defined inclusion criteria, for an overall number of 44 patients. All patients presented with palpable purpura variable associated with arthralgia, abdominal pain or renal involvement. Increased levels of inflammation markers, mild leukocytosis and elevated D-dimer were the most common laboratory findings. Up to 50% of patients presented proteinuria and/or hematuria. Almost all skin biopsies showed leukocytoclastic vasculitis, with IgA deposits at direct immunofluorescence in more than 50% of cases.

CONCLUSIONS

Our results suggest that the immune response elicited by SARS-CoV2 vaccine or infection could play a role in the development of HSP. Current research suggests a possible role of IgA in immune hyperactivation, highlighted by early seroconversion to IgA found in some COVID-19 patients who develop IgA vasculitis.

Henoch-Schönlein purpura in the setting of COVID-19 infection: Two pediatrics cases and review of the literature

Henoch-Schönlein purpura (HSP) is the most common systemic vasculitis in children, often following a viral infection. Various types of rashes attributed to COVID-19 infection have been described in the literature; however, HSP has rarely been reported. We report two children with HSP associated with acute COVID-19 infection with a review of the available literature. We highlight the clinical presentation, medical management, outcome and age-related difference of reported patients. A limitation of this article is the retrospective nature, limiting full patient history and associated conditions. The findings of this review show that HSP in the setting of COVID-19 is more common in children than adults, with a male predominance, involving various body systems creating a constellation of presentations. Given that HSP can have long-term morbidity from renal disease if untreated, this review may help guide the practitioner's approach to HSP and recognition in the setting of COVID-19 infection.

Atypical Immunologic Manifestations of COVID-19: a Case Report and Narrative Review

COVID-19 usually presents with classic signs and symptoms, but it can involve multiple systems in atypical cases. SARS-CoV-2 has a complex interaction with the host immune system leading to atypical manifestations. In our case, a 32-year-old male patient presented with fatigue, sores on hands and feet, headache, productive cough with blood-tinged mucus, conjunctival hyperemia, purpuric rash on hands and feet, and splinter hemorrhages of fingernails for 2 weeks. The patient's SARS-CoV-2 antigen and PCR test were positive. Chest X-ray showed mixed density perihilar opacities in both lungs. Computed tomography of the chest showed extensive airspace opacities in both lungs, suggesting COVID-19 multifocal, multilobar pneumonitis. A renal biopsy indicated limited thrombotic microangiopathy and tubulointerstitial nephritis, for which he was started on steroids, and his renal functions gradually improved. He tested positive for C-ANCA during an immune workup. He was discharged with a steroid taper for nephritis. Once the taper reached less than 10 mg/day, he developed acute scleritis and a new pulmonary cavitary lesion of 6 cm. The biopsy via bronchoscopy revealed acute inflammatory cells with hemosiderin-laden macrophages. He was restarted on systemic steroids for scleritis after failing topical steroids, which incidentally also reduced the size of the cavitary lesion, indicating an immune component. Our case demonstrates the involvement of kidneys and vasculitis of the skin, sclera, and lungs by COVID-19. The patient's symptoms were not explained by any diseases other than COVID-19. Atypical cases of COVID-19 disease with multifocal systemic symptoms involving the skin, sclera, lungs, and kidneys should be high on differentials. Early recognition and intervention may decrease hospital stays and morbidity.

Cutaneous vasculitis: Lessons from COVID-19 and COVID-19 vaccination

Cutaneous vasculitis (CV) is an inflammatory skin-limited vascular disease affecting the dermal and/or hypodermal vessel wall. From the pathogenetic point of view, idiopathic forms are described as well as the induction from various triggers, such as drugs, infections, and vaccines. Following SARS-CoV-2 pandemic outbreak, cases of CV induced by both COVID-19 and COVID-19 vaccinations have been reported in literature. The aim of our work was to collect multiple cases available in the literature and analyze the frequency of the different forms of induced vasculitis, as well as their histological and immunopathological features. Although rare, CV induced by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and vaccines may provide interesting insights into the pathogenesis of these inflammatory processes that may in the future be useful to understand the mechanisms underlying cutaneous and systemic vasculitis.

Two case reports of skin vasculitis following the COVID-19 immunization

The coronavirus 2019 (COVID-19) disease is now responsible for one of the most challenging and concerning pandemics. Since December 2020, the world has had access to COVID-19 prophylaxis; thus, we encounter adverse events from vaccination more often due to the vast vaccination range. We present two case reports of difficult-to-treat skin vasculitis due to COVID-19 vaccination that were successfully treated in a tertiary-level university hospital. When encountering systemic treatment, resistant skin vasculitis plasmapheresis could be a choice of treatment.

Cutaneous vasculitis and vasculopathy in the era of COVID-19 pandemic

Cutaneous vasculitides encompass a heterogeneous group of clinicopathological entities, which may occur as single-organ vasculitis of the skin or present as skin-limited variant of systemic vasculitis (i.e., skin-limited ANCA-associated vasculitis), and are triggered by various factors, including infections, drugs and vaccines. The COVID-19 pandemic has challenged us with a variety of both disease- and vaccine-associated skin manifestations, including vasculitis. Among the latter, cutaneous small-vessel vasculitis, previously known as leukocytoclastic vasculitis, seems to be the most reported in either scenario, i.e., natural infection and vaccination. Vasculopathy without true vasculitic changes on histology develops in but a minority of cases, mostly severe/critical COVID-19 patients, and appears to be the result of endothelial injury due to pauci-immune thromboembolic mechanisms. Herein, we provide an overview of the available literature on COVID-19-associated and anti-SARS-CoV-2-vaccine-associated cutaneous vasculitis. Although evidence is mostly limited to isolated reports, with a proportion of cases lacking histopathological confirmation, ample overlap with pre-pandemic forms is shown.

Vasculitis flare after COVID-19: report of two cases in patients with preexistent controlled IgA vasculitis and review of the literature

COVID-19 has been related to several autoimmune diseases, triggering the appearance of autoantibodies and endothelial dysfunction. Current evidence has drawn attention to vasculitis-like phenomena and leukocytoclastic vasculitis in some COVID-19 patients. Moreover, it has been hypothesized that COVID-19 could induce flares of preexisting autoimmune disorders. Here, we present two patients with previously controlled IgA vasculitis who developed a renal and cutaneous flare of vasculitis after mild COVID-19, one of them with new-onset ANCA vasculitis. These patients were treated with glucocorticoids and immunosuppressants achieving successful response. We also provide a focused literature review and conclude that COVID-19 may be associated with triggering of vasculitis and could induce flares of previous autoimmune diseases.

COVID-19 and Intestinal Ischemia: A Multicenter Case Series

Introduction

Gastrointestinal symptoms are common among COVID-19 patients. Although gastrointestinal involvements are mostly benign, they rarely indicate a severe pathology like intestinal ischemia. The present case series describes 21 patients with bowel ischemia, necrosis, or perforation.

Methods

The present case series was conducted from April 2020 to February 2022 in the surgical wards of two Iranian hospitals. We retrospectively included adult patients with concomitant COVID-19 and intestinal ischemia. Primary outcomes were defined as the length of stay and survival.

Results

Twenty-four patients with a median age of 61.5 years were included in the study. Sixteen (67%) patients were male, and 13 (54%) were without any comorbidities. Macrovascular mesenteric ischemia was not identified in 21 patients (87.5%). Gastrointestinal manifestations appeared on the median of seven days (range 2–21) after the diagnosis of COVID-19, with the most common symptom being abdominal pain. All the patients had a significantly elevated C-Reactive Protein prior to surgery, ranging from 68 to 362. D-dimer was measured in eight patients and was significantly elevated, ranging from 1,878 to over 5,000 ng/mL. One patient was managed conservatively due to a good clinical condition. Except for one patient with angioinvasive mucormycosis and one other with leukocytoclastic vasculitis, pathologic evaluation revealed general features of intestinal necrosis, including ulcer, hemorrhage, necrosis, neutrophilic infiltration (in seven patients), neutrophilic abscess (in four patients), and edema. Bowel necrosis accompanied mortality of 15 (62.5%) patients and a median of 6.5 days of hospital stay.

Conclusion

Intestinal ischemia in COVID-19 patients is associated with a high mortality rate. Further research is needed to elucidate the dynamics of intestinal ischemia in the setting of COVID-19.

Skin manifestations in patients with coronavirus disease 2019

PURPOSE OF REVIEW

Coronavirus disease 2019 (COVID-19) is a well established respiratory tract illness. Recent studies in adults and children have shown an increasing number of patients reporting polymorphic cutaneous manifestations during COVID-19, including different types of rashes, from maculopapular, vascular, vesicular to atypical forms.

RECENT FINDINGS

Although pathogenesis of skin manifestations is still not fully understood, it has been proposed that cutaneous involvement during COVID-19 may be the results of the activation of the immune response against severe acute respiratory syndrome coronavirus-2, the reactivation or co-infection of herpesviruses or drug hypersensitivity.

SUMMARY

According to available literature, skin manifestations in patients with COVID-19 may be categorized on the basis of their clinical presentations as follows: erythematous rashes, lesions of vascular origin, vesicular rash, urticarial rash and acute generalized exanthematous pustulosis (AGEP), erythema multiforme and other polymorphic erythema/atypical reactions. Prompt recognition of these cutaneous manifestations represents a crucial point to facilitate diagnosis and management of COVID-19 patients.

Cutaneous leukocytoclastic vasculitis secondary to COVID-19 infection leading to extensive skin necrosis

A wide range of extrapulmonary manifestations in patients with COVID-19 has been reported during the ongoing pandemic, thus making the clinical spectrum of this new disease very heterogeneous. While COVID-19–associated vasculitis and vasculopathy have been described, cutaneous leukocytoclastic vasculitis (cLcV) due to SARS-CoV-2 has rarely been reported, and if it has, with relatively mild courses. We present the case of a 93-year-old man who, after having survived classic COVID-19 infection, developed a fulminant cLcV leading to extensive skin necrosis and tissue damage that resulted in his death. Considering the negative workup for other triggers of vasculitis, we find that cLcV is a secondary manifestation of COVID-19, even though SARS-CoV-2 polymerase chain reaction in the skin biopsy was not present in the tissue. We hypothesize this by providing a pathophysiologic rationale (eg, SARS-CoV-2–induced endotheliitis, complement activation, and interleukin 6 dominant intra- and perivascular inflammation).

The pathogenesis of COVID-19-induced IgA nephropathy and IgA vasculitis: A systematic review

OBJECTIVE

IgA nephropathy (IgAN) and IgA vasculitis (IgAV) are part of a similar clinical spectrum. Both clinical conditions occur with the coronavirus disease 2019 (COVID-19). This review aims to recognize the novel association of IgAN and IgAV with COVID-19 and describe its underlying pathogenesis.

METHODS

We conducted a systematic literature search and data extraction from PubMed, Cochrane, ScienceDirect, and Google Scholar following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Our search identified 13 cases reporting IgAV and IgAN associated with COVID-19 infection and 4 cases of IgAN following COVID-19 vaccination. The mean, mode, and median ages of patients were 23.8, 4, and 8 years, respectively. Most cases associated with COVID-19 infection were reported in males (77%). Rash and purpura (85%) were the most common clinical features, followed by gastrointestinal symptoms (62%). In symptomatic cases, skin or renal biopsy and immunofluorescence confirmed the diagnosis of IgAN or IgAV. Most patients were treated with steroids and reported recovery or improvement; however, death was reported in two patients.

CONCLUSION

There is a paucity of scientific evidence on the pathogenesis of the association of IgAN and IgAV with COVID-19, which thus needs further study. Current research suggests the role of IgA-mediated immune response, evidenced by early seroconversion to IgA in COVID-19 patients and the role of IgA in immune hyperactivation as the predominant mediator of the disease process. Clinicians, especially nephrologists and paediatricians, need to recognize this association, as this disease is usually self-limited and can lead to complete recovery if prompt diagnosis and treatment are provided.

COVID-19 associated vasculitis: A systematic review of case reports and case series

Vasculitis is one of the complications of COVID-19. We conducted a systematic review analysing the association of COVID-19 with vasculitis. We searched Google Scholar and PubMed from December 1, 2019, to October 11, 2021. The review included 8 studies (7 case reports and 1 case series) reporting 9 cases of vasculitis secondary to COVID-19. The mean age was 29.17 ± 28.2 years, ranging from 6 months to 83 years. The male to female ratio was 4:5. Maculopapular, violaceous, papular and erythematous rash were common. Heparin(n = 2), corticosteroids (n = 6) (methylprednisolone) and intravenous immunoglobulin (n = 4) were prescribed in these patients. Significant clinical improvement was observed in 8 out of 9 patients. One person died during treatment. Our study discusses vasculitis as one of the complications of COVID-19. Furthermore, the pathophysiology, clinical presentation, and management of COVID-19 associated vasculitis is discussed.

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This is a systematic review of all published cases of vasculitis secondary to COVID-19 from the start of COVID-19 outbreak to date.

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Most common forms of vasculitis reported were Kawasaki disease Vasculitis, IgA vasculitis and Leucocytoclastic Vasculitis with symptoms being predominantly skin limited.

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Steroids, LMWH and IVIG were the most common line of treatment.

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An good overall prognosis was seen following treatment.

Eosinophilic granulomatosis with polyangiitis after COVID-19: A case report

COVID-19 can damage the endothelial cells of every organ in the body and lead to vasculopathy and vasculitis. It has been shown that various types of vasculitis could be a new manifestation of COVID-19. Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic necrotizing vasculitis that affects small vessels. Here we report our experience with a 42-year-old man with a 3-weeks history of fever of unknown origin after two months from COVID-19 recovery presented with loss of appetite, loss of weight, and paresthesia in his lower extremities. After required evaluations including nerve biopsy, EGPA was diagnosed for him.

Leukocytoclastic Vasculitic Rash Following Second Dose of Moderna COVID-19 Vaccine

The immunization against coronavirus disease (COVID-19) via vaccination serves as a significant milestone in the fight against the pandemic. Rapid introduction of various COVID-19 vaccines to stem the spread of virus has researchers scrambling to document the adverse effects left in its wake. Thus far, there have been singular examples of cutaneous vasculitis associated with COVID-19. A history of vasculitis leaves little error to miss its inclusion in diagnostic differentials. It also invokes the physiologic possibility that afflicted patients possess a more susceptible landscape for recurrence that was then triggered by the vaccine when compared with those who lack similar history. In our case report, we build on those findings with one of the first documented examples of vaccination-induced vasculitic rash in a previously asymptomatic patient.

Leukocytoclastic vasculitis (cutaneous small-vessel vasculitis) after COVID-19 vaccination

Vaccinations may induce cutaneous adverse events, due to nonspecific inflammation or immuno-mediated reactions. Several types of vasculitis have been observed. We report on a 71-year-old woman who developed cutaneous small-vessel vasculitis after the second dose of Vaxzevria COVID-19 vaccination, showing leukocytoclastic vasculitis on histopathological examination of a skin biopsy.

Cutaneous small-vessel vasculitis is a rare condition which can be idiopathic or secondary to underlying infections, connective tissue disorders, malignancy, and medications. The pathogenesis involves immune complex deposition in small blood vessels, leading to activation of the complement system and recruitment of leukocytes.

Exacerbation of small-vessel vasculitis has been reported following the administration of various vaccines, particularly influenza vaccine. It is expected that SARS-CoV-2 vaccine results in the activation of B- and T-cells and antibody formation. We hypothesize that leukocytoclastic vasculitis caused by immune complex deposition within cutaneous small vessels could be a rare side effect of Vaxzevria COVID‐19 vaccination.

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.

Skin manifestations associated with COVID-19

This article will address the main aspects of skin manifestations associated with COVID-19, based on a review of the literature published to date. Since the beginning of the pandemic, more than 1,500 articles have been published on the subject. Regarding the pathophysiology, it is believed that the same mechanisms responsible for the disease in the main target organs also act in the skin, although they are not yet fully elucidated. The actual frequency of dermatological manifestations remains uncertain – it can range from 0.2% to 45%, being close to 6% in systematic reviews. Pioneering studies of large case series conducted in European countries and the USA provide the first information on the main skin manifestations associated with COVID-19 and propose classifications regarding their clinical presentation, pathophysiology, as well as their frequencies. Although there is yet no consensus, maculopapular eruptions are considered the most frequent presentations, followed by erythema pernio-like (EPL) lesions. Manifestations such as urticaria, vesicular conditions and livedo/purpura/necrosis are rare. The time of onset, severity, need for specific treatment and prognosis vary according to the clinical presentation pattern. The increasing histopathological description of skin conditions can contribute to the diagnosis, as well as to the understanding of the pathophysiology. Also, in the dermatological field, the relationship between COVID-19 and androgens has been increasingly studied. Despite all the generated knowledge, the actual biological meaning of skin manifestations remains uncertain. Therefore, the exclusion of the main differential diagnoses is essential for the correlation between skin manifestation and COVID-19.

The skin as a critical window in unveiling the pathophysiologic principles of COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiologic agent of coronavirus disease 2019 (COVID-19), is a single-stranded RNA virus whose sequence is known. COVID-19 is associated with a heterogeneous clinical phenotype ranging from asymptomatic to fatal disease. It appears that access to nasopharyngeal respiratory epithelia expressing angiotensin-converting enzyme (ACE) 2, the receptor for SARS-CoV-2, is followed by viral replication in the pulmonary alveolar septal capillary bed. We have demonstrated in earlier studies that incomplete viral particles, termed pseudovirions, dock to deep subcutaneous and other vascular beds, potentially contributing to the prothrombotic state and systemic complement activation that characterizes severe and critical COVID-19. A variety of skin eruptions have been described in the setting of SARS-CoV-2 infection and more recently, after COVID-19 vaccination. The vaccines deliver a laboratory-synthesized mRNA that encodes a protein that is identical to the spike glycoprotein of SARS-CoV-2, allowing the production of immunogenic spike glycoprotein that will then elicit T cell and B cell adaptive immune responses. In this contribution, we review an array of cutaneous manifestations of COVID-19 that provide an opportunity to study critical pathophysiologic mechanisms that underlie all clinical facets of COVID-19, ranging from asymptomatic/mild to severe and critical COVID-19. We classify cutaneous COVID-19 according to underlying pathophysiologic principles. In this regard we propose three main pathways: (1) complement mediated thrombotic vascular injury syndromes deploying the alternative and mannan binding lectin pathways and resulting in the elaboration of cytokines like interleukin 6 from endothelium in the setting of severe and critical COVID-19 and (2) the robust T cell and type I interferon-driven inflammatory and (3) humoral-driven immune complex mediated vasculitic cutaneous reactions observed with mild and moderate COVID-19. Presented are novel data on cutaneous vaccine reactions that manifest a clinical and morphologic parallel with similar eruptions observed in patients with mild and moderate COVID-19 and in some cases represent systemic eczematoid hypersensitivity reactions to a putative vaccine-based antigen versus unmasking subclinical hypersensitivity due to immune enhancing effects of the vaccine. Finally, we demonstrate for the first time the localization of human synthesized spike glycoprotein after the COVID-19 vaccine to the cutaneous and subcutaneous vasculature confirming the ability of SARS-CoV-2 spike glycoprotein to bind endothelium in the absence of intact virus.

Microvascular Skin Manifestations Caused by COVID-19

Hypercoagulability and vascular injury, which characterize morbidity in COVID-19 disease, are frequently observed in the skin. Several pathomechanisms, such as inflammation caused by angiotensin-converting enzyme 2-mediated uptake into endothelial cells or SARS-CoV-2-initiated host immune responses, contribute to microthrombus formation and the appearance of vascular skin lesions. Besides pathophysiologic mechanisms observed in the skin, this review describes the clinical appearance of cutaneous vascular lesions and their association with COVID-19 disease, including acro-ischemia, reticular lesions, and cutaneous small vessel vasculitis. Clinicians need to be aware that skin manifestations may be the only symptom in SARS-CoV-2 infection, and that inflammatory and thrombotic SARS-CoV-2-driven processes observed in multiple organs and tissues appear identically in the skin as well.

Unraveling the Immunopathogenesis and Genetic Variants in Vasculitis Toward Development of Personalized Medicine

Leukocytoclastic vasculitis (LCV) is a systemic autoimmune disease characterized by the inflammation of the vascular endothelium. Cutaneous small vessel vasculitis (CSVV) and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) are two examples of LCV. Advancements in genomic technologies have identified risk haplotypes, genetic variants, susceptibility loci and pathways that are associated with vasculitis immunopathogenesis. The discovery of these genetic factors and their corresponding cellular signaling aberrations have enabled the development and use of novel therapeutic strategies for vasculitis. Personalized medicine aims to provide targeted therapies to individuals who show poor response to conventional interventions. For example, monoclonal antibody therapies have shown remarkable efficacy in achieving disease remission. Here, we discuss pathways involved in disease pathogenesis and the underlying genetic associations in different populations worldwide. Understanding the immunopathogenic pathways in vasculitis and identifying associated genetic variations will facilitate the development of novel and targeted personalized therapies for patients.

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.

Leukocytoclastic vasculitis as a cutaneous manifestation of ChAdOx1 nCoV-19 corona virus vaccine (recombinant)

With the present COVID-19 vaccination drive across the world, adverse skin reactions post COVID-19 vaccine is expected. Majority of these reactions seen were transient or local injection site reactions. However, as the larger population is being vaccinated, certain uncommon dermatological presentations including leukocytoclastic vasculitis, pityriasis rosea, and exacerbation of pre-existing autoimmune diseases are now being reported. Among all the COVID-19 vaccines, most of these reactions are seen with messenger ribonucleic acid-based Pfizer/BioNTech (BNT162b2) and Moderna (mRNA-1273) vaccine. We report two cases of leukocytoclastic vasculitis following ChAdOx1 nCoV-19 corona virus vaccine (recombinant) that bring out potential new dermatological manifestations of recombinant corona virus vaccine being administered across the European, South American, and Asian countries. It is important for all health care workers and patients to be aware of the corona virus vaccine associated adverse cutaneous reactions.

COVID-19-related skin manifestations: Update on therapy

An increasing body of evidence has been produced in a very limited period to improve the understanding of skin involvement in the current coronavirus 2019 disease pandemic, and how this novel disease affects the management of dermatologic patients. A little explored area is represented by the therapeutic approach adopted for the different skin manifestations associated with the infection. An overview of the current scenario is provided, through review of the English-language literature published until October 30, 2020, and comparison with the personal experience of the authors. As dermatologists, our primary aim is to support patients with the highest standard of care and relieve suffering, even with lesions not life-threatening. With asymptomatic COVID-19 patients, patient discomfort related to skin lesions should not be undervalued and intervention to accelerate healing should be provided. Consensus protocols are warranted to assess the best skin-targeted treatments in COVID-19 patients.

Adaptive Immunity and the Risk of Autoreactivity in COVID-19

While first and foremost considered a respiratory infection, COVID-19 can result in complications affecting multiple organs. Immune responses in COVID-19 can both protect against the disease as well as drive it. Insights into these responses, and specifically the targets being recognised by the immune system, are of vital importance in understanding the side effects of COVID-19 and associated pathologies. The body's adaptive immunity recognises and responds against specific targets (antigens) expressed by foreign pathogens, but not usually to target self-antigens. However, if the immune system becomes dysfunctional, adaptive immune cells can react to self-antigens, which can result in autoimmune disease. Viral infections are well reported to be associated with, or exacerbate, autoimmune diseases such as multiple sclerosis (MS) and systemic lupus erythematosus (SLE). In COVID-19 patients, both new onset MS and SLE, as well as the occurrence of other autoimmune-like pathologies, have been reported. Additionally, the presence of autoantibodies, both with and without known associations to autoimmune diseases, have been found. Herein we describe the mechanisms of virally induced autoimmunity and summarise some of the emerging reports on the autoimmune-like diseases and autoreactivity that is reported to be associated with SARS-CoV-2 infection.

Rheumatological complications of Covid 19

Introduction

COVID-19 has caused unprecedented hardships in the 21st century with more than 150 million infections. Various immunological phenomena have been described during the course of the infection, and this infection has also triggered autoimmunity. Rheumatological illnesses have been described following resolution of the acute infection; hence we sought to conduct a review of the rheumatological complications of COVID-19.

Methods

We conducted a literature search for articles relating to sequelae of COVID-19 from Jan 2020 to 30th April 2021.

Results

We found a number of reports of inflammatory arthritis after SARS-CoV-2 infection. SLE and renal disease have been described, and vasculitis also appears to be a common complication. Rhabdomyolysis and myositis has also been reported in a number of patients. We also found some evidence of large vessel vasculitis in ‘long COVID’ patients.

Conclusions

This review highlights a number of important complications such as inflammatory arthritis, lupus-like disease, myostis and vasculitis following SARS-CoV-2 infection.

Time of Onset of Selected Skin Lesions Associated with COVID-19: A Systematic Review

INTRODUCTION

Distinct skin lesions associated with coronavirus disease 2019 (COVID-19) have been described, but data regarding their time of onset during the COVID-19 course are scant. Our objective was to systematically review the studies reporting the time of onset of selected skin lesions with respect to the reported onset of the COVID-19 core symptoms.

METHODS

A comprehensive search of studies published before 21 January 2021 was performed on MEDLINE via PubMed database using a predefined strategy to identify relevant articles.

RESULTS

Out of 354 references, 87 were selected, reporting a total of 895 patients with skin lesions associated with COVID-19. The most frequent pattern was exanthema (n = 430, 48%), followed by vascular (n = 299, 33%), urticarial (n = 105, 12%) and others (n = 66, 7%). Skin lesions occurred more frequently in the first 4 weeks from the COVID-19 onset (n = 831, 92%), whereas prodromal or late lesions were rarer (n = 69, 8%). The urticarial and exanthema patterns were more frequent in the first 2 weeks. About the vascular pattern some differences were noted among its subtypes. Livedoid lesions occurred mainly in the first 2 weeks, while chilblain-like lesions between weeks 2 and 4. Purpuric/petechial lesions were equally distributed during the first 4 weeks. Several skin manifestations did not fall into the pattern classification, including erythema multiforme, generalized pruritus, Kawasaki disease and others.

CONCLUSION

The diversity in the time of onset of skin lesions as well as their polymorphic nature likely reflects the diversity of the pathogenetic underlying mechanisms.

PROSPERO DATABASE REGISTRATION NUMBER

CRD42021236331.

Leucocytoclastic vasculitis secondary to COVID-19 infection in a young child

The current case report describes a 13-year-old young boy who presented with purpuric rashes following a completely asymptomatic COVID-19 infection and biopsy-confirmed leucocytoclastic vasculitis, mild haematuria and mild elevation of serum IgA. This case highlights one of the dermatological manifestations of COVID-19 infection which has not been reported so far. Paediatricians should explore the history of this infection when evaluating any child presenting with a vasculitic rash.

Dermatologic comorbidities of the patients with severe COVID-19: A case-control study

The current studies focus on the association between COVID-19 and certain comorbidities. To the best of our knowledge, the association between severe COVID-19 and dermatologic comorbidities has not been reported yet. In this study, we aimed to describe the dermatologic comorbidities of patients with severe COVID-19 and compare it with the control group. Patients who have died at Uşak Training and Research Hospital due to COVID-19 and other diseases in the COVID-19 Intensive Care Units and Internal Medicine Intensive Care Units were recruited into the study. Two groups were compared with each other regarding the most common dermatologic comorbidities. A total of 198 patients including 111 patients with COVID-19 and 87 age and sex-matched patients with other diseases were enrolled in the study. The most common dermatologic comorbidities were pruritus (8.1%), eczema (6.3%), skin infections (3.6%), leukocytoclastic vasculitis (1.8%), and urticaria (0.9%) in the COVID-19 group while they were skin infections (9.2%), eczema (3.4%), pruritus (2.3%), and urticaria (1.1%) in the control group. None of patients in the control group had leukocytoclastic vasculitis. There were no significant differences between COVID-19 and control groups in terms of pruritus, eczema, skin infections, and urticaria (P values were .117, .517, .181, .505, and 1.000, respectively). In conclusion, although it is not statistically significant, it appears that pruritus and leukocytoclastic vasculitis are more common in severe COVID-19 patients. These cytokines-related diseases in the immuno-cutaneous systems may give some clues on the COVID-19 severity. Further studies are required to elucidate the relationship between the immuno-cutaneous system and COVID-19 severity.