Cutaneous findings in hospitalized and critically-ill patien
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Worldwide reports describe cutaneous findings, including maculopapules, pseudochilblain, vesicles, urticaria, livedo, and multi-system inflammatory syndrome, as manifestations of (COVID-19). The report on the cutaneous findings observed in hospitalized COVID-19 positive patients between 3/25/2020 and 5/1/2020 are discussed. Cases were included if COVID-19 was most likely associated with or contributed to skin findings observed after other potential causes were excluded. This study provides insights into the cutaneous manifestations of severe disease.

9 patients developed signs of acral ischemia, including duskiness, necrosis, and bulla. 8 of these with acral ischemia required admission to (ICU), and the location of ischemia included fingers, toes, ears, and genital skin. Two with severe lesions had a confirmed deep vein thrombosis, highlighting the potential for thrombotic events. 3 patients developed livedo racemosa, one of whom had livedo as a presenting sign of COVID-19, and two who developed livedoid during their hospitalization.

One patient developed vesicles in association with his livedoid eruption. All three required ICU admission and had evidence of coagulopathy. Two patients developed evidence of bleeding diatheses. One, a critically-ill male in his 60s developed petechiae, with perivascular lymphocytic infiltrate with prominent red cell extravasation on biopsy. He was mildly thrombocytopenic (114x103/uL) and had mild coagulopathy (PT/INR 14.7 seconds/1.2; aPTT 36.2 seconds and d-dimer 3.95 ug/mL). The other patient, a male in his 70s, developed purpura fulminans with areas of necrosis and superficial desquamation on the chest and axilla. Laboratory data was consistent with disseminated intravascular coagulation, and ultimately, the patient expired.

Erythema multiforme (EM)-like lesions were observed in a woman in her 80s one week following discharge after treatment for COVID-19-associated pneumonia. She had no other risk factors for development of EM-like lesions, including active HSV infection, and received no new medications in the last three days of her hospitalization or on discharge.

Interestingly, no pseudo-chilblain (Covid toes) was observed in the hospitalized patients evaluated. Pseudo-chilblain may be more strongly-associated with mild disease, or present after acute illness has resolved.

In summary, cutaneous manifestations in hospitalized COVID-19 patients are varied and are an important part of this potentially life-threatening illness.