Infectious Disease

Diagnosing “COVID toes” and other challenges in derm rheumatic overlap

August 18, 2021

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Femia AN. Dermatology for the Rheumatologist, Part II. Presented at: Congress of Clinical Rheumatology-East annual symposium; 12-15 August 2021 (hybrid meeting).

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Femia does not report any relevant financial information.

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So-called “COVID toes” and other cutaneous manifestations of the virus are not the only dermatological challenges a rheumatologist can face, according to a moderator at the Congress for Clinical Rheumatology 2021 East.

“I wanted to continue some of the overlaps in our two specialties in a very clinically oriented and case-by-case manner.” Alisa N. Femia, MD, a dermatologist at NYU Langone Health told attendees. “The focus is on cases that rheumatologists may not see often.”

Alisa N.
Feminine
, MD,
admits she was “fairly skeptical” of reports of so-called “COVID toes” emerging from early hotspots such as Israel and Italy. “I haven’t seen much of it,” she told the participants.

She first described a patient with lupus who had bullous, blistering dermatoses on the lining of the mouth and other parts of her skin. “When I see bullous lupus on the skin, I think of a severe acute cutaneous flare-up of lupus,” said Femia.

The malar rash can look like disseminated acute cutaneous lupus with severe lymphocytic and neutrophil involvement. However, the patient had other areas that were not as inflammatory and the bulla was “exposed” according to Femia.

“The diagnosis was epidermis bullosa acquisita, or EBA,” she said. “I wanted to draw your attention to this because of its overlap with rheumatological diseases. It can be seen in systemic lupus and inflammatory bowel disease with straight blistering in the dermis / epidermal junction. “

Regarding the treatment of EBA for lupus, Femia found that the condition generally does not respond well to immunosuppressive therapy. “It can be easier to deal with underlying cases [systemic lupus erythematosus],” She said.

Femia moved on to acral purpura, emphasizing that an unexplained purpura can mean systemic disease. She examined a patient with purplish skin bleeding whose blood values ​​showed elevated creatinine and NPL antibodies. “A relatively subtle purpura can indicate systemic disease,” she said.

With that in mind, she sent samples for biopsy. “I need proof that it’s not bad.”

As for the clinical examination of a patient with suspected acral purpura, Femia noted that there is currently no algorithm in place. “It’s based on symptoms, underlying diseases and medications,” she said. An important point is to do enough tests to make sure there is no end organ involvement.

Ultimately, the case patient was diagnosed with ANCA-associated vasculitis, confirming Femia’s view that purpura can mean something systemic.

Another clinical puzzle that can arise in a rheumatology clinic is pernio, or chilblains versus vasculitis. “Pernio performs in cooler, wetter weather,” said Femia. “Besides, Pernio doesn’t get necrotic. These patients do not run the risk of losing their fingers. “

Femia concluded her talk with an overview of dermatological manifestations related to COVID-19. She admits she was “fairly skeptical” of reports of so-called “COVID toes” emerging from early hotspots such as Israel and Italy. “I haven’t seen much of it.”

That changed in May 2020 when her clinic saw an increasing incidence of new onset pernions that coincided with COVID-19 infection or exposure to the virus. “That was pretty consistent,” she says. “About 2 to 4 weeks after a peak of COVID-19 there would be a peak of Pernio or chilblains. It was certainly an epiphenomenon. “

The jury is unsure whether these events are actually part of the progression of the COVID-19 virus, according to Femia. One possibility is that COVID-19 triggers autoimmune processes that are associated with disruptions in the type I interferon signaling pathway. Another is that Pernio has always been triggered virally, and it was only COVID-19 that this aspect of the disease came into clear focus.

“But it can only be linked to lockdown and lockdown-related behavior changes,” said Femia.

Another possible cutaneous manifestation of COVID-19 is retiform purpura, according to Femia. “One possible etiology is ulceration in COVID,” she said. “Many patients developed retiform purpura with no other explanation.”

Femia suggested that doctors should look for this manifestation in patients who require mechanical ventilation. But she stressed that nothing was certain.

“This is an evolving virus,” she said. “There are things we don’t know about this virus.”

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Congress for Clinical Rheumatology Annual Meeting

Congress for Clinical Rheumatology Annual Meeting

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