Chilblain-like lesions with prominent bullae in a patient wi
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Some of the more commonly reported dermatological manifestations associated with COVID-19 disease include erythematous rashes, maculopapular and urticarial eruptions, and chilblain-like (also called pernio-like) lesions. This case report illustrates an atypical presentation of a cutaneous lesion associated with COVID-19 and reviews the potential pathophysiology and clinical relevance.

A 27-year-old woman requested a teledermatology consult concerning a 2-day history of bilateral, progressively oedematous and pruritic toes that were painful when confined by shoes. The patient had no underlying medical conditions, including any history of collagen vascular disease, Raynaud’s phenomenon, chilblains and cold exposure, and was not taking any medications. However, 6 weeks prior to her toe manifestation, she experienced 10 days of ageusia and anosmia with no other symptoms.

On examination, multiple bilateral non-haemorrhagic bullae of various sizes up to approximately 1.5 cm in diameter were present on the dorsa of her toes. Her toes were oedematous with widespread erythema. Acrocyanosis and livedo reticularis were not present. Two days following her initial presentation, the bullae appeared haemorrhagic. No other clinical changes were noted and there were no petechiae or signs of bruising or bleeding elsewhere. The patient was advised to self-isolate and subsequent test results for SARS-CoV2 were positive.

At a 3-month follow-up, acral oedema and pruritus had completely resolved. The bullous lesions on the dorsa of the toes healed with residual scaling and cutaneous violaceous hyperpigmentation. The patient remained otherwise asymptomatic.

Learning points
- Chilblain-like lesions are one of the numerous skin manifestations associated with COVID-19. They tend to occur in younger patients who exhibit otherwise minimal COVID-19 signs and symptoms, and typically in the convalescent phase of the infection.

- Upregulation of interferon and other cytokine signalling pathways is associated with clinical conditions that produce chilblains. Cytokine production may follow the infection of dermal endothelial cells by SARS-CoV-2 recently identified by electron microscopy in patients with chilblain-like lesions.

- Clinicians should be alert to atypical presentations of cutaneous lesions associated with COVID-19 such as the presence of acral haemorrhagic bullae.