Inflammatory Skin Lesions in Three SARS-Cov-2 Swab-Negative
Total Page:16
File Type:pdf, Size:1020Kb
Article Inflammatory Skin Lesions in Three SARS-CoV-2 Swab-Negative Adolescents: A Possible COVID-19 Sneaky Manifestation? Giuseppe Ingravallo 1,* , Francesco Mazzotta 2, Leonardo Resta 1 , Sara Sablone 3 , Gerardo Cazzato 1 , Antonietta Cimmino 1, Roberta Rossi 1, Anna Colagrande 1, Beniamino Ferrante 2, Teresa Troccoli 2 and Ernesto Bonifazi 4 1 Department of Emergency and Organ Transplantation, Section of Pathology, University of Bari Aldo Moro, 11, 70124 Bari, Italy; [email protected] (L.R.); [email protected] (G.C.); [email protected] (A.C.); [email protected] (R.R.); [email protected] (A.C.) 2 Pediatric Dermatology and Surgery Outpatients Department, Azienda Sanitaria Locale Barletta-Andria-Trani, 76123 Andria, Italy; [email protected] (F.M.); [email protected] (B.F.); [email protected] (T.T.) 3 Section of Forensic Medicine, Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70124 Bari, Italy; [email protected] 4 Pediatric Dermatology, University of Bari Aldo Moro, 11, 70124 Bari, Italy; [email protected] * Correspondence: [email protected] Abstract: Coronavirus disease 19 (COVID-19), caused by severe acute respiratory syndrome coro- Citation: Ingravallo, G.; Mazzotta, F.; navirus 2 (SARS-CoV-2), is associated with various clinical manifestations, including skin lesions. Resta, L.; Sablone, S.; Cazzato, G.; In particular, during the COVID-19 pandemic lock-down period numerous chilblain-like lesions, Cimmino, A.; Rossi, R.; Colagrande, mainly located on the feet, were observed in adolescents. The latter were often asymptomatic or A.; Ferrante, B.; Troccoli, T.; et al. associated with very mild respiratory symptoms. Here, we report three cases of acral nodular lesions Inflammatory Skin Lesions in Three in SARS-CoV-2 swab-negative adolescents with histological findings of chronic immune-mediated SARS-CoV-2 Swab-Negative inflammation and immunohistochemical evidence of SARS-CoV-2 spike glycoproteins in endothe- Adolescents: A Possible COVID-19 Sneaky Manifestation? lial cells and eccrine sweat glands. In one of these cases, the virus presence was confirmed by Pediatr. Rep. 2021, 13, 181–188. electron microscopy. https://doi.org/10.3390/ pediatric13020025 Keywords: SARS-CoV-2; skin; granuloma annulare; chilblains Academic Editor: Maurizio Aricò Received: 12 March 2021 1. Introduction Accepted: 7 April 2021 During the COVID-19 pandemic, increasing numbers of skin lesions have been de- Published: 9 April 2021 scribed in positive individuals [1–4]. Various reports [1–6] have offered clinical documen- tation of cutaneous lesions in adults, such as Erythema Pernio, Erythema Multiforme, Publisher’s Note: MDPI stays neutral Chilblains, Urticated Erythema, Morbilliform, Varicelliform, Chickenpox-like exanthem, with regard to jurisdictional claims in etc. In the pediatric population, the incidence of skin manifestations reported by vari- published maps and institutional affil- ous authors is low: 0.25% [7,8]. Biopsies from skin lesions in children with confirmed iations. or suspected COVID-19 have rarely been described in the literature [8]. Most of the histopathological descriptions were of isolated cases or small series, and some types of lesions have been biopsied only in adults. In general, the histopathological patterns were similar to chilblains [9,10], maculopapular eruptions [11,12], Erythema Multiforme [13,14], Copyright: © 2021 by the authors. and purpuric and livedoid forms [15–17]. Licensee MDPI, Basel, Switzerland. In this brief article, we present three cases of SARS-CoV-2 swab-negative adolescents, This article is an open access article with no flu-like symptoms in the previous months, who developed nodular lesions of the distributed under the terms and feet reminiscent of deep granuloma annulare. A thorough histopathological analysis was conditions of the Creative Commons carried out in these cases. Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Pediatr. Rep. 2021, 13, 181–188. https://doi.org/10.3390/pediatric13020025 https://www.mdpi.com/journal/pediatrrep Pediatr. Rep. 2021, 13, FOR PEER REVIEW 2 Pediatr. Rep. 2021, 13 182 2.2. CaseCase PresentationPresentation CaseCase 1:1:An An 11-year-old11-year-old boyboy waswasobserved observedfor formultiple multiple swelling swelling of of the the feet feet associated associated withwith mildmild burning.burning. HisHis familyfamily andand personalpersonal historyhistory waswas negativenegative forfor connectiveconnective tissue,tissue, autoimmuneautoimmune oror otherother noteworthynoteworthy diseases.diseases. AA physicalphysical examinationexamination showedshowed 7–87–8 lesions lesions (Figure(Figure1 )1) on on the the lateral lateral surface surface of of the the feet, feet, that that were were slightly slightly erythematous erythematous and and of of a a hard- hard- elasticelastic consistency.consistency. The The nodules nodules were were not not painful painful onon palpation,palpation, mobilemobile onon thethe deepdeep plane,plane, withwith aa diameterdiameter rangingranging betweenbetween 66 andand 1212 mm,mm, andand hadhad appearedappeared aboutabout 2020 daysdays earlier.earlier. DueDue toto thethe uncertainuncertain clinicalclinical features,features, wewe decideddecided toto performperform aa biopsy,biopsy, afterafter molecular molecular testingtesting for for SARS-CoV-2 SARS-CoV-2 resulted resulted negative. negative. A A histological histological examination examination (Figure (Figure2 a)2a) showed showed acralacral skinskin withwith mildmild hypergranulosis,hypergranulosis, acanthosis,acanthosis, andand focalfocal vacuolizationvacuolization ofof thethe basalbasal keratinocytes.keratinocytes. BelowBelow thethe dermo-epidermaldermo-epidermal junctionjunction therethere was was ectasia ectasia of of the the vessels vessels of of the the superficialsuperficial capillarycapillary plexus,plexus, thatthat presentedpresented aa narrow narrow lumen lumen with with protruding protruding endothelial endothelial cellscells (hobnail).(hobnail). AccentuatedAccentuated dermo-hypodermicdermo-hypodermic mucinosismucinosis coexistedcoexisted with with fragmentation fragmentation oror eveneven dissolutiondissolution of of the the collagencollagen and and elasticelastic fibers fibers (Figure (Figure2 b).2b). The The nodules nodules were were treated treated withwith topical topical corticosteroids corticosteroids and and subsided subsided in in about about 4 4 months. months. A A serological serological test test carried carried out out afterafter 33 andand aa halfhalf monthsmonths was was positive positive for for IgG. IgG. FigureFigure 1.1. AsymptomaticAsymptomatic firm firm nodules nodules measuring measuring 2–3 2–3 cm cm in in diameter diameter on on the the lateral lateral aspect aspect of ofthe the leftleft foot. foot. CaseCase 2:2: A 14-year-old 14-year-old boy, boy, already already known known since since he he suffers suffers from from persistent persistent atopic atopic der- dermatitis,matitis, was was observed observed during during the pandemic the pandemic due to due exacerbation to exacerbation of his dermatitis. of his dermatitis. During Duringthe examination the examination we observed we observed the presence the presence of asymptomatic of asymptomatic nodules, nodules,clinically clinicallycompara- comparableble to those toof thosecase 1, of which case 1, ha whichd appeared had appeared about 20 about days 20earlier. days earlier. Therefore,Therefore, we we performed performed a puncha punch biopsy. biopsy. A histological A histological examination examination showed showed orthoker- or- atosis and mild acanthosis. Immediately below the dermal-epidermal junction, the vessels thokeratosis and mild acanthosis. Immediately below the dermal-epidermal junction, the of the superficial capillary plexus presented a narrow lumen with protruding endothelial vessels of the superficial capillary plexus presented a narrow lumen with protruding en- cells (hobnail), sometimes completely occluding the vessel lumens. In the middle and deep dothelial cells (hobnail), sometimes completely occluding the vessel lumens. In the middle dermis an ample area of edema, with extensive and marked fragmentation or even dissolu- and deep dermis an ample area of edema, with extensive and marked fragmentation or tion of the collagen and elastic fibers, was evident, as well as thrombotic foci (Figure2c) of even dissolution of the collagen and elastic fibers, was evident, as well as thrombotic foci the small vessels, which showed sclero-hyalinosis of the wall and hemorrhagic suffusion. (Figure 2c) of the small vessels, which showed sclero-hyalinosis of the wall and hemor- There were also fibroblasts of a likely reactive significance around extensive, widespread rhagic suffusion. There were also fibroblasts of a likely reactive significance around ex- dermal mucinosis. A serological test carried out after 4 months was positive for IgG. tensive, widespread dermal mucinosis. A serological test carried out after 4 months was Case 3: An 11-year-old girl, with no notable medical history, developed acro-localized positive for IgG. nodular lesions similar to those of cases 1 and 2 during the pandemic period. We again Case 3: An 11-year-old girl, with no notable medical history, developed acro-local- performed a punch biopsy. A histological examination showed acanthosis and mucinosis ized nodular lesions similar to those of cases 1 and 2 during the pandemic period. We Pediatr.