DISCUSSION
The exact cause of PR remains to be unknown. A number of studies significantly associated human herpesvirus 6 and 7 (HHV-6 and HHV-7) with PR. However, this remains to be controversial and a number of pathogens including bacteria, fungi, vaccines, and most notably, viruses, were speculated to play a causative role.10 Ehsani et al reported a case of pityriasis rosea in a 27-year-old otherwise healthy male who was later diagnosed to have COVID-19.11
It was confirmed that COVID-19 infection is accompanied by a reduction in lymphocytes, monocytes, and eosinophils, along with a significant reduction of CD4/CD8 T cells, B cells, and natural killer (NK) cells. It was further revealed that non-survivor COVID-19 patients continued to show a decrease in lymphocyte count along the course of their disease until death.12-15
Diminished levels of natural killer (NK) cells and B-cells activity in the lesions of PR have been observed.16 This suggests the role of a T-cell mediated immunity. Besides, increased amounts of CD4 T cells and Langerhans cells have been found in the dermis, which possibly points towards viral antigen processing and presentation. However, this matter is still debated since some individuals are infected with HHV 6–7 and do not develop the disease.17
New information and cutaneous manifestations possibly related to COVID-19 are emerging every day. Further studies are needed to evaluate whether these lesions are associated with the virus or not. Careful documentation and robust reporting of cutaneous manifestations associated with COVID-19 are needed to augment our understanding of disease presentation and epidemiology.
It was confirmed that COVID-19 infection is accompanied by a reduction in lymphocytes, monocytes, and eosinophils, along with a significant reduction of CD4/CD8 T cells, B cells, and natural killer (NK) cells. It was further revealed that non-survivor COVID-19 patients continued to show a decrease in lymphocyte count along the course of their disease until death.12-15
Diminished levels of natural killer (NK) cells and B-cells activity in the lesions of PR have been observed.16 This suggests the role of a T-cell mediated immunity. Besides, increased amounts of CD4 T cells and Langerhans cells have been found in the dermis, which possibly points towards viral antigen processing and presentation. However, this matter is still debated since some individuals are infected with HHV 6–7 and do not develop the disease.17
New information and cutaneous manifestations possibly related to COVID-19 are emerging every day. Further studies are needed to evaluate whether these lesions are associated with the virus or not. Careful documentation and robust reporting of cutaneous manifestations associated with COVID-19 are needed to augment our understanding of disease presentation and epidemiology.
DISCLOSURES
The authors have no relevant conflicts to report.
ACKNOWLEDGMENT
The authors would like to thank all the health workers who have
been fighting against COVID-19 in Egypt.
REFERENCES
1. Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020;382:1199–207.
2. Zhang YZ and Holes EC. A genomic perspective on the origin and emergence of sars-cov-2. Cell. 2020 Apr 16;181(2):223-227.
3. Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: Lessons learned from SARS and MERS epidemic. Asian Pac J Allergy Immunol. 2020;38(1):1-9.
4. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506.
5. Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respi Med. 2020;8:420–422.
6. Wollina U, KaradaÄŸ AS, Rowland-Payne C, Chiriac A, Lotti T. Cutaneous signs in COVID-19 patients: A review. Dermatol Ther. 2020 May 10. doi: 10.1111/ dth.13549. Epub ahead of print. PMID: 32390279.
7. Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB. Pharmacologic treatments for coronavirus disease 2019 (COVID-19): a review. JAMA. 2020. https://doi.org/10.1001/jama.2020.6019.
8. Urbina F, Das A, Sudy E. Clinical variants of pityriasis rosea. World J Clin Cases. 2017;5(6):203-211.
9. Li A, Li P, Li Y, Li W. Recurrent pityriasis rosea: A case report. Hum Vaccin Immunother. 2018;14(4):1024-1026. 10. Drago F, Ciccarese G, Rebora A, Broccolo F, Parodi A. Pityriasis Rosea: A comprehensive classification. Dermatology. 2016;232(4):431-437.
11. Ehsani, A.H., Nasimi, M. and Bigdelo, Z. (2020), Pityriasis rosea as a cutaneous manifestation of COVID-19 infection. J Eur Acad Dermatol Venereol. (Accepted) doi:10.1111/jdv.16579
12. Henry BM, de Oliveira MHS, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis. Clin Chem Lab Med. 2020 Apr 10:/j/cclm.ahead-of-print/cclm-2020-0369/ cclm-2020-0369.xml. doi: 10.1515/cclm-2020-0369. Epub ahead of print. PMID: 32286245 13. Cai Q, Huang D, Ou P, et al. COVID-19 in a designated infectious diseases hospital outside Hubei Province, China. Allergy. 2020 Apr 2. doi: 10.1111/ all.14309. Epub ahead of print. PMID: 32239761
14. Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020 May;46(5):846-84
15. Kumar A, Anil A, Praveen S, et al. Clinical features of COVID-19 and factors associated with severe clinical course: a systematic review and meta-analysis. Available at SSRN 3566166 (2020).
16. Papakostas D, Stavropoulos PG, Papafragkaki D, et al. An atypical case of pityriasis rosea gigantea after influenza vaccination. Case Rep Dermatol. 2014;6:119–123
17. Drago F, Ciccarese G, Broccolo F, et al. The role of cytokines, chemokines, and growth factors in the pathogenesis of pityriasis rosea. Mediators Inflamm. 2015;2015:438963
2. Zhang YZ and Holes EC. A genomic perspective on the origin and emergence of sars-cov-2. Cell. 2020 Apr 16;181(2):223-227.
3. Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: Lessons learned from SARS and MERS epidemic. Asian Pac J Allergy Immunol. 2020;38(1):1-9.
4. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506.
5. Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respi Med. 2020;8:420–422.
6. Wollina U, KaradaÄŸ AS, Rowland-Payne C, Chiriac A, Lotti T. Cutaneous signs in COVID-19 patients: A review. Dermatol Ther. 2020 May 10. doi: 10.1111/ dth.13549. Epub ahead of print. PMID: 32390279.
7. Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB. Pharmacologic treatments for coronavirus disease 2019 (COVID-19): a review. JAMA. 2020. https://doi.org/10.1001/jama.2020.6019.
8. Urbina F, Das A, Sudy E. Clinical variants of pityriasis rosea. World J Clin Cases. 2017;5(6):203-211.
9. Li A, Li P, Li Y, Li W. Recurrent pityriasis rosea: A case report. Hum Vaccin Immunother. 2018;14(4):1024-1026. 10. Drago F, Ciccarese G, Rebora A, Broccolo F, Parodi A. Pityriasis Rosea: A comprehensive classification. Dermatology. 2016;232(4):431-437.
11. Ehsani, A.H., Nasimi, M. and Bigdelo, Z. (2020), Pityriasis rosea as a cutaneous manifestation of COVID-19 infection. J Eur Acad Dermatol Venereol. (Accepted) doi:10.1111/jdv.16579
12. Henry BM, de Oliveira MHS, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis. Clin Chem Lab Med. 2020 Apr 10:/j/cclm.ahead-of-print/cclm-2020-0369/ cclm-2020-0369.xml. doi: 10.1515/cclm-2020-0369. Epub ahead of print. PMID: 32286245 13. Cai Q, Huang D, Ou P, et al. COVID-19 in a designated infectious diseases hospital outside Hubei Province, China. Allergy. 2020 Apr 2. doi: 10.1111/ all.14309. Epub ahead of print. PMID: 32239761
14. Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020 May;46(5):846-84
15. Kumar A, Anil A, Praveen S, et al. Clinical features of COVID-19 and factors associated with severe clinical course: a systematic review and meta-analysis. Available at SSRN 3566166 (2020).
16. Papakostas D, Stavropoulos PG, Papafragkaki D, et al. An atypical case of pityriasis rosea gigantea after influenza vaccination. Case Rep Dermatol. 2014;6:119–123
17. Drago F, Ciccarese G, Broccolo F, et al. The role of cytokines, chemokines, and growth factors in the pathogenesis of pityriasis rosea. Mediators Inflamm. 2015;2015:438963
AUTHOR CORRESPONDENCE
Mohamed L. Elsaie MD Egydoc77@yahoo.com
