Case did not consider all potential causes of chilblains

I read the CMAJ Practice article on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related chilblains in a 16-year-old female by Ladha and Dupuis1 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 body mass index, and there is no description of a physical examination, which is seminal in ruling out autoimmune disorders, such as lupus, or malignant disease. The laboratory investigations are thorough, but a normal chest radiograph and computed tomography scan of the abdomen would have added weight to the final diagnosis of SARS-CoV-2-related chilblains. The dermal pathology of pernio or chilblains is nonspecific4 and, therefore, a skin biopsy is not suggested.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 coronavirus disease 2019 pandemic, clinicians are adopting a “hands-off” or telehealth approach to reviewing patients, including history taking. However, there are individuals for whom an office visit and physical examination is important. This may be one of those cases: the positive result for SARS-CoV-2 antibody serology testing may be incidental and unrelated to her skin condition.5