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Practice

SARS-CoV-2-related chilblains

Malika A. Ladha and Elaine C. Dupuis
CMAJ July 13, 2020 192 (28) E804; DOI: https://doi.org/10.1503/cmaj.201348
Malika A. Ladha
Division of Dermatology, Department of Medicine, University of Calgary, Calgary, Alta.
MD
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Elaine C. Dupuis
Division of Dermatology, Department of Medicine, University of Calgary, Calgary, Alta.
MD
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  • RE: young female with chilblains and positive serology for covid-19
    Catharine L. Dewar [BSc, PhD, MD, FRCPC]
    Posted on: 16 July 2020
  • Response to C Dewar comment on 'SARS-CoV-2-related chilblains'
    Malika A. Ladha [MD] and Elaine Dupuis [MD, FRCPC, DABD]
    Posted on: 15 July 2020
  • RE: SARS-CoV-2-related chilblains in a 16 year old female
    Catharine L. Dewar [BSc, PhD, MD, FRCPC]
    Posted on: 13 July 2020
  • Posted on: (16 July 2020)
    Page navigation anchor for RE: young female with chilblains and positive serology for covid-19
    RE: young female with chilblains and positive serology for covid-19
    • Catharine L. Dewar [BSc, PhD, MD, FRCPC], Rheumatologist (retired 2020), Lions Gate Hospital Rheumatology Division, North Vancouver, BC (retired)

    I thank the authors for responding to my concerns regarding this diagnosis. The authors mention an examination was performed in the Emergency Department, but a muscoskeletal examination was not done. In the setting of possible ANA negative lupus, a Rheumatologist's examination would include a chest radiograph looking for a pleural effusion, a microscopic examination of the urine, an examination of the nares in addition to the oral cavity for painless ulcers, an examination of the fundi for vascular pathology and an examination of the joints for subtle synovitis. The patient's digits were painful due to the chilblains, but pain contributed by subtle synovitis may have been overlooked. The photographs appear to show subtle synovitis in a few IP joints of the toes and fingers. It seems a thorough review by a clinical Rheumatologist was overlooked in this case, which is most unfortunate. It weakens the argument in favour of covid-19 being the etiology of chilblains, in this case.

    Competing Interests: None declared.

    References

    • Malika A. Ladha, Elaine C. Dupuis. SARS-CoV-2-related chilblains. CMAJ 2020;192:E804-E804.
  • Posted on: (15 July 2020)
    Page navigation anchor for Response to C Dewar comment on 'SARS-CoV-2-related chilblains'
    Response to C Dewar comment on 'SARS-CoV-2-related chilblains'
    • Malika A. Ladha [MD], Resident Physician - Dermatology, Division of Dermatology, Department of Medicine, University of Calgary
    • Other Contributors:
      • Elaine Dupuis, Dermatologist

    We thank C. Dewar for her interest in our publication. We first iterate that a broad workup for contributory and aggravating causes was considered and a complete assessment was conducted during the clinical encounter. However, this could not all be captured within the article’s word limit. For clarification, we provide further details.

    During the early months of the COVID-19 pandemic, our patient was assessed in-person in the emergency room, enabling a thorough history and a complete physical examination. Our patient had no history of nicotine or psychostimulant consumption. In addition, her review of systems was negative, including for those of autoimmune disorders and malignancy (i.e. no fevers, night sweats, weight changes, oral/genital ulcerations, photosensitivity, arthritis, arthralgias, morning stiffness, myalgias, muscle weakness, sicca symptoms, or other cutaneous eruptions). The patient also did not have a family history of known autoimmune conditions. Other than the acral lesions described in our article, her physical examination was unremarkable. In particular, she had a normal body habitus without clinical signs of anorexia nervosa, no other cutaneous findings such as oral ulcerations or photo-distributed lesions, and, normal nail capillaroscopy. Muscoskeletal examination was not pursued given lack of symptoms.

    A thorough panel of investigations was completed to rule out systemic causes of chilblains. Imaging investigations were not conducted giv...

    Show More

    We thank C. Dewar for her interest in our publication. We first iterate that a broad workup for contributory and aggravating causes was considered and a complete assessment was conducted during the clinical encounter. However, this could not all be captured within the article’s word limit. For clarification, we provide further details.

    During the early months of the COVID-19 pandemic, our patient was assessed in-person in the emergency room, enabling a thorough history and a complete physical examination. Our patient had no history of nicotine or psychostimulant consumption. In addition, her review of systems was negative, including for those of autoimmune disorders and malignancy (i.e. no fevers, night sweats, weight changes, oral/genital ulcerations, photosensitivity, arthritis, arthralgias, morning stiffness, myalgias, muscle weakness, sicca symptoms, or other cutaneous eruptions). The patient also did not have a family history of known autoimmune conditions. Other than the acral lesions described in our article, her physical examination was unremarkable. In particular, she had a normal body habitus without clinical signs of anorexia nervosa, no other cutaneous findings such as oral ulcerations or photo-distributed lesions, and, normal nail capillaroscopy. Muscoskeletal examination was not pursued given lack of symptoms.

    A thorough panel of investigations was completed to rule out systemic causes of chilblains. Imaging investigations were not conducted given the absence of respiratory symptoms before, during and after clinical encounter, and because chest imaging is not recommended to diagnose COVID-19 in patients with mild features (1). In addition, imaging would not have altered the cutaneous management.

    We agree that a skin biopsy is not always required for diagnosis of chilblains as the findings are not pathognomonic but rather supportive of a clinical diagnosis. Our patient presented early during the pandemic when little was known about SARS-CoV-2-related chilblains. For SARS-CoV-2-related chilblains, there have been reports of classic chilblains histology, as well as superficial and deep lichenoid lymphocytic changes with basal vacuolar changes (2,3); microthrombi have also been described (4,5). A biopsy was completed to assess for microthrombi and rule out vaso-occlusive pathology.

    Idiopathic chilblains remains a diagnosis of exclusion. Patients presenting with chilblains should thus be appropriately examined and investigated to rule out secondary systemic causes. Our patient’s thorough history, physical examination and subsequent work-up did not support any underlying disorder. SARS-CoV-2-related chilblains was favoured due to negative secondary work-up, absence of cool/damp exposure and positive serology. The understanding of SARS-CoV-2-related chilblains and its pathogenesis will continue to evolve in the coming months.

    Show Less
    Competing Interests: None declared.

    References

    • Dennie C, Hague C, Lim RS, et al. Canadian Society of Thoracic Radiology/Canadian Association of Radiologists consensus statement regarding chest imaging in suspected and confirmed COVID-19. Can Assoc Radiol J 2020 [epub ahead of print]. doi:10.1177/08465
    • Kolivras A, Dehavay F, Delplace D, et al. Coronavirus (COVID-19) infection-induced chilblains: a case report with histopathological findings. JAAD Case Rep 2020;6:489-92.
    • Cordoro KM, Reynolds SD, Wattier R, et al. Clustered Cases of Acral Perniosis: Clinical features, histopathology and relationship to COVID-19. Pediatr Dermatol 2020;37:419-23.
    • Andina D, Noguera-Morel L, Bascuas-Arribas M, et al. Chilblains in children in the setting of COVID-19 pandemic. Pediatr Dermatol 2020;37:406-11.
    • de Masson A, Bouaziz JD, Sulimovic L, et al. Chilblains are a common cutaneous finding during the COVID-19 pandemic: a retrospective nationwide study from France. J Am Acad Dermatol 2020;83:667-70.
  • Posted on: (13 July 2020)
    Page navigation anchor for RE: SARS-CoV-2-related chilblains in a 16 year old female
    RE: SARS-CoV-2-related chilblains in a 16 year old female
    • Catharine L. Dewar [BSc, PhD, MD, FRCPC], Rheumatologist, (Rheumatology, Lions Gate Hospital, North Vancouver, BC: Retired in 2020)

    I read this article (1) with interest but it raised a few concerns. In females in this age group, the association between anorexia nervosa and pernio or chilblains has been noted for several decades (2,3). This case report makes no mention of the patient's body habitus or BMI, in fact there is no description of a physical examination which is seminal in ruling out autoimmune disorders such a lupus, or malignancy. The laboratory investigations are thorough, but a normal chest radiograph and CT scan of the abdomen would have added weight to the final diagnosis of covid-19 related chilblains. The dermal pathology of pernio or chilblains is non-specific (4) and therefore a skin biopsy is not recommended (4). There is no description of the patient's smoking history, including e-cigarette usage ('vaping') as nicotine will exacerbate the vasospasm seen in pernio or chilblains (4). During the current pandemic, clinicians are adopting a 'hands-off' or telehealth approach to reviewing patients, including history taking. However, there are individuals for which an office visit and physical examination is very important. I fear this may be one of those cases; the positive covid-19 antibody serology may be incidental and unrelated to her skin condition.

    Competing Interests: None declared.

    References

    • 1.Malika A. Ladha, Elaine C. Dupuis. SARS-CoV-2-related chilblains. CMAJ 2020;192:E804-E804.
    • 2.Rustin MHA, Foreman JC, Dowd PM. Anorexia nervosa associated with acromegaloid features, onset of acrocyanosis and Raynaud’s phenomenon and worsening of chilblains.
    • 3.White KP, Rothe MJ, Milanese A, Grant-Kels JM. Perniosis in association with anorexia nervosa. Pediatr Dermatol 1994;11: 1-5.
    • 4.Whitman PA, Crane JS. Pernio (Chilblains) [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549842/
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Canadian Medical Association Journal: 192 (28)
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SARS-CoV-2-related chilblains
Malika A. Ladha, Elaine C. Dupuis
CMAJ Jul 2020, 192 (28) E804; DOI: 10.1503/cmaj.201348

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SARS-CoV-2-related chilblains
Malika A. Ladha, Elaine C. Dupuis
CMAJ Jul 2020, 192 (28) E804; DOI: 10.1503/cmaj.201348
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