Papular/Pustular: Twenty-three patients (51%) presented papular or pustular eruptions. This widespread papular/pustular eruption characterized by vesicobullous or pustular lesions and indurated pigmented nodules, appeared concomitantly or a few days after the onset of other symptoms (Figure 3A). Histopathology of pustular lesions showed lymphocytic infiltrate around dilated blood vessels with eosinophils, without damage of the vessel wall (Figure 3B).
Petechiae/Vasculitis: Six patients (13%) presented petechiae. These petechial rashes had purpuric lesions up to 2 mm, or areas of vasculitis with or without fever (Figure 4A). In our group of patients, this manifestation was associated with more severe cases of the disease that also presented laboratory abnormalities (high D-dimer, C-reactive protein). Histopathology of this type of lesion was characterized by dense lymphocytic infiltrate with vascular damage of the superficial plexus (Figure 4B).
Livedo Reticularis: Two (4%) patients showed livedo reticularis (Figure 5A). Both cases presented later in the disease course and were accompanied by abnormal laboratory values including elevated levels of D-dimer, and clinical symptoms such as fever and difficulty breathing. Histological analysis from biopsies showed ectasia of blood vessels of small and medium caliber, with little or no inflammation (Figure 5B).
Chilblains: Seven patients (15.6%) had chilblains predominantly appearing in the toes (Figure 6A). Chilblains were the only clinical symptom in the majority of the patients. Histopathology of the affected area showed vesicular spongiotic dermatitis with keratinocyte necrosis, of a dyshidrotic pattern, associated with a superficial perivascular lymphocytic infiltrate (Figure 6B).
Telogen Effluvium: Ten patients (22.2%) presented telogen effluvium (Figure 7A) a few days following the onset of systemic symptoms. This was diagnosed with pull test, trichoscopy, and scalp biopsy (Figure 7B). Histological analysis showed edema and dilation of the superficial vascular plexus and absence of inflammation (Figure 7C).
Chilblains: Seven patients (15.6%) had chilblains predominantly appearing in the toes (Figure 6A). Chilblains were the only clinical symptom in the majority of the patients. Histopathology of the affected area showed vesicular spongiotic dermatitis with keratinocyte necrosis, of a dyshidrotic pattern, associated with a superficial perivascular lymphocytic infiltrate (Figure 6B).
Telogen Effluvium: Ten patients (22.2%) presented telogen effluvium (Figure 7A) a few days following the onset of systemic symptoms. This was diagnosed with pull test, trichoscopy, and scalp biopsy (Figure 7B). Histological analysis showed edema and dilation of the superficial vascular plexus and absence of inflammation (Figure 7C).
