Background To date, very few studies on clinical-histopathological correlations of cutaneous disorders associated with COVID-19 have been conducted. Case presentation The Case 1 was a 90-year-old man, who tested positive for SARS-CoV-2 from a nasopharyngeal swab. Two days later, he was hospitalized and after eleven days transferred to Intensive Care Unit. A chest CT showed bilateral ground-glass opacities. Just that day, an erythematous maculo-papular rash appeared on trunk, shoulders and neck, becoming purpuric after few days. Histological evaluations revealed a chronic superficial dermatitis with purpuric aspects. The superficial and papillary dermis appeared edematous, with a perivascular lympho-granulocytic infiltrate and erythrocytic extravasation. At intraepithelial level, spongiosis and a granulocyte infiltrate were detected. Arterioles, capillaries and post-capillary venules showed endothelial swelling and appeared ectatic. The patient was treated with hydroxychloroquine, azithromycin, lopinavir-ritonavir and tocilizumab. Regrettably, due to severe lung impairment, he died. The Case 2 was a 85-year-old man, admitted to Intensive Care Unit, where he was intubated. He had tested positive for SARS-CoV-2 from a nasopharyngeal swab two days before. A chest RX showed bilateral atypical pneumonia. After seven days, a cutaneous reddening involving trunk, upper limbs, neck and face developed, configuring a sub-erythroderma. Histological evaluations displayed edema in the papillary and superficial reticular dermis, and a perivascular lymphocytic infiltrate in the superficial dermis. The patient was treated with hydroxychloroquine, azithromycin, lopinavir-ritonavir and tocilizumab. Sub-erythroderma as well as respiratory symptoms gradually improved until healing. Conclusions The endothelial swelling detected in the Case 1 could be a morphological expression of SARS-CoV-2-induced endothelial dysfunction. We hypothesize that cutaneous damage could be initiated by endothelial dysfunction, caused by SARS-CoV-2 infection of endothelial cells or induced by immune system activation. The disruption of endothelial integrity could enhance microvascular permeability, extravasation of inflammatory cells and cytokines, with cutaneous injury. The Case 2 developed a sub-erythroderma associated with COVID-19, and a non-specific chronic dermatitis was detected at histological level. We speculate that a purpuric rash could represent the cutaneous sign of a more severe coagulopathy, as highlighted histologically by vascular abnormalities, while a sub-erythroderma could be expression of viral hematogenous spreading, inducing a non-specific chronic dermatitis.
【저자키워드】 COVID-19, Case report, Histopathology, skin, Endothelial swelling, 【초록키워드】 SARS-CoV-2, Cytokines, Hospitalized, Azithromycin, Hydroxychloroquine, Tocilizumab, Pneumonia, SARS-COV-2 infection, Lopinavir, Ritonavir, intensive care unit, lung, immune system, Endothelial dysfunction, Coagulopathy, Nasopharyngeal swab, Morphological, Viral, Ground-glass opacities, Chest CT, endothelial cells, Chest, Patient, edema, respiratory, capillary, correlation, expression, Rash, non-specific, Endothelial cell, Lopinavir-ritonavir, Injury, Atypical pneumonia, Atypical, Capillaries, Disruption, respiratory symptoms, granulocyte, inflammatory cells, papillary dermis, inflammatory cell, Neck, healing, endothelial, Activation, Intubated, respiratory symptom, swelling, microvascular permeability, disorder, dermatitis, impairment, positive, endothelial integrity, extravasation, Arterioles, edematous, erythroderma, Reticular dermis, spongiosis, trunk, upper limbs, vascular abnormalities, ENhance, Seven, tested, caused, died, conducted, treated, initiated, histological, perivascular, erythematous, hematogenous, transferred, with COVID-19, 【제목키워드】 SARS-CoV-2, endothelial, hematogenous,