Chilblain acral lesions in a patient with lupus after COVID-19 infection

Presentation A 58-year-old woman with lupus and psoriatic arthritis presented with acral lesions after coronavirus disease (COVID-19). She had mild upper respiratory symptoms and positive antigen testing 2 weeks earlier. After 1 week, her respiratory symptoms resolved and she developed skin lesions. She first noted painless erythematous papules on her dorsal hands (Fig. 1C). She then developed swelling of her digits, with tender, angulated purpura and targetoid macules to thin papules on the left palmar surface (Fig. 1D). Her right fifth digit had painful, black discoloration with a central bulla. She also developed nontender angulated purpura on the feet (Fig. 1B) and 2 painless ulcers on her posterior buccal mucosa (Fig. 1A).Figure 1.: Patient's presenting lesions showing (A) 2 painless ulcers on her posterior buccal mucosa, (B) nontender angulated purpura on the feet, and (C–D) angulated purpura and targetoid macules, as well as thin papules with black discoloration and a central bulla on the hands. (E) Marked improvement in the patient's clinical presentation with conservative management at 3 weeks after presentation.Workup revealed normal coagulation studies, and computed tomography angiography of her right upper extremity revealed no arterial occlusion. Autoimmune studies, including double-stranded DNA, C3 and C4, and anti-myeloperoxidase and anti-proteinase 3 antibodies, were unremarkable. The patient had known positive anticardiolipin immunoglobulin G (IgG); on presentation, her laboratory results were notable for positive anticardiolipin IgG, positive beta-2-glycoprotein IgG, and negative lupus anticoagulant. C-reactive protein and erythrocyte sedimentation rate were within normal limits. Her oral lesions were negative for herpes simplex virus. Topical corticosteroids were prescribed. Ten days after onset, she had scaling and crusting on the right fifth digit lesion, with improved discoloration of fingers and resolution of purpuric lesions 3 weeks after presentation (Fig. 1E). Discussion Chilblain acral lesions are a commonly reported phenomenon after COVID-19. A review of acral lesions in patients with suspected COVID-19 described a mean latency time of 9.2 days between onset of COVID-19 symptoms and skin lesions, with a mean lesion duration of 8.7 days.1 This time line overlaps well with our patient's presentation. Two presentations were described: A chilblain-like pattern in 72% of patients, with red-to-violet macules and plaques of distal digits. An erythema multiforme–like pattern was present in 28%, with erythematous macules and vesicles.1 In this report, we present a case of a patient with confirmed COVID-19 who developed chilblain lesions. Given a normal angiogram, her presentation was distinct from ischemic presentations of COVID-19.2 While the patient had a history of positive anticardiolipin IgG, she had never met the criteria for antiphospholipid syndrome. After assessment of her lupus anticoagulant panel, she was started on aspirin for thromboembolic risk associated with acute inflammation.3 Furthermore, her presentation time line and laboratory data were inconsistent with chilblain lupus because of lack of cold stimulus.4 She did not have a history of Raynaud phenomenon or cold exposure. We posit that her presentation is consistent with chilblains secondary to COVID-19. Primary management is watchful waiting, as lesions often self-resolve. We deferred biopsy because it would not have provided specific diagnostic features or changed management. Treatment options include topical corticosteroids and calcium channel blockers.2 We would consider additional treatment if symptoms recurred, especially because patients have reported persistent or relapse of cutaneous symptoms.5 Given her history of autoimmune disease, assessing vasculature was imperative. Consideration of inflammatory and infectious drivers in all cases of chilblain lesions is necessary. Identification and workup of these patients are critical to assess etiologies and provide appropriate treatment. Conflicts of Interest None. Disclosure Statement None.