Infectious Disease

Immune response to SARS-CoV-2 could be responsible for “COVID toes”

October 08, 2021

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According to a study published in the British Journal of Dermatology, an immune response may be responsible for “COVID toes,” chilblains-like lesions associated with COVID-19 infection.

COVID toes that appear as purple or red lesions on the toes or hands are a dermatological symptom of COVID-19 that has mainly appeared in younger infected people but could affect anyone with the virus.

An immune response can be responsible for “COVID toes,” chilblains-like lesions associated with COVID-19 infection.

“A number of skin manifestations have been described in connection with SARS-CoV-2 infection during the COVID-19 pandemic. Among them, frostbite-like lesions (CLL) are more common than expected. ” Laure Frumholtz, MD, of the dermatology department of the Hôpital Saint-Louis in Paris, and colleagues wrote. “The aim of this study was to compare the immunological and vascular pathophysiology of CLL during the COVID-19 outbreak [seasonal chilblains]. “

All patients with first-time CLL at the Hôpital Saint-Louis between April 9, 2020 and April 16, 2020 were included in this non-interventional observational study.

Polymerase chain reaction tests for SARS-CoV-2 were negative in all 50 patients; However, 29 (58%) had extracutaneous COVID-19 symptoms such as asthenia (n = 14), fever (n = 11), upper respiratory tract and ear, nose and throat symptoms (n = 16), cough (n = 9) , Dyspnea (n = 2) and anosmia (n = 1).

CLL was present on the toes in 86% of the cases and on the fingers in 24% of the cases.

Blood samples taken from each patient were assessed for whole blood counts, hemostasis, IgA levels, isotypes of IgG and IgA, antineutrophil cytoplasmic antibodies, antinuclear antibodies, anti-double-stranded DNA antibodies, anti-double-stranded DNA antibodies, cryoglobulinemia, cryofibrinogen, and anticardiolipin and anti-cardiolipin and anti-cardiolipin antibodies -Beta-2 glycoprotein I IgG antibodies (IgM and IgG).

Skin biopsies were also performed in 13 patients.

Comparisons were made of the histological skin features of 13 patients with CLL and 13 with seasonal pre-pandemic chilblains, and all samples were found to have lymphocytic infiltration around the blood vessels.

Of the CLL group, 73% had a systemic immune response associated with anti-neutrophil cytoplasmic IgA antibodies associated with a systemic immune response.

In addition, the CLL group had higher levels of IgA tissue deposition.

“This study shows that both the immune system and endothelial cells play a decisive role in the development of CLL,” wrote Frumholtz and colleagues.

The researchers said their “results support an activation loop in the skin in CLL associated with endothelial alteration and immune infiltration of cytotoxic and type I IFN-polarized cells leading to clinical manifestation.”

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Esther Freeman, MD, PhD)

Esther E. Freeman, MD, PhD

In their article “Type I interferon response and vascular alteration in chilblain-like lesions during the COVID-19 expression”, Frumholtz and colleagues provide us with important additional insights into the pathophysiology of Pernio / Chilblains during the COVID-19 pandemic, also known as ” COVID toes. ”

The study adds to our knowledge of the role of type I interferon in the development of these lesions and supports the hypothesis that a robust host immune response to SARS-CoV-2 may induce Pernio / Chilblains in some patients. In addition, the authors found a high prevalence of anti-neutrophil cytoplasmic IgA antibodies in these patients, which was not previously detected but is consistent with previous evidence that these patients frequently have IgA antibody profiles (and may not be found with commercial IgM or IgG antibody tests be tested positive). ).

Much of the global research on COVID-19 has focused on patients with severe illness. However, patients with mild or moderate disease, such as patients with COVID toes enrolled in this study, also have important immunological and clinical clues about the virus.

Dermatologists continue to play an important role in the pandemic: in the early detection of SARS-CoV-2 in patients with rashes that may be the first sign or symptom of the virus, such as urticaria or morbilliform eruptions; in the treatment of patients with dermatological manifestations of COVID-19; and more recently in detecting skin reactions to COVID-19 vaccines, which are largely self-limiting, allowing us to reassure patients about the safety and importance of COVID-19 vaccines.

Esther E. Freeman, MD, PhD

Director, Global Health Dermatology, Massachusetts General Hospital

Associate Professor, Harvard Medical School

Chief Investigator, COVID-19 Dermatology Register

Disclosure: The COVID-19 dermatology registry received in-kind contributions from the AAD and financial support from the International League of Dermatological Societies. Freeman reports as a co-author of COVID-19 Dermatology for UpToDate.

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