419. Leucocytoclastic Vasculitis in the setting of COVID-19
Creators: name: Doyle1, Claire
Publisher: name: Zenodo
Year: 2022
Subjects: Vasculitis
ANCA
Abstracts
Giant Cell Arthritis
MPA
GPA
EGPA
Takayasu
IgA vasculitis

description: <strong>Presentation of Case:</strong> A 78-year-old man presented to the Emergency Department with a three-day history of a lower limb rash. The rash was asymptomatic, and he had no other symptoms. Examination revealed a macular purpuric rash on both lower limbs. The remainder of his skin was unremarkable. His past medical history was significant for JAK 2 positive myeloproliferative disorder. His medications included aspirin, hydroxyurea and Ferrograd C. No new recent medications had preceded the onset rash. Three days following presentation, he developed new onset cough and progressive shortness of breath. SARS‑CoV‑2 PCR was positive. He required oxygen to maintain his lung saturations, but his respiratory involvement improved. <strong>Diagnostic Testing:</strong> The patient underwent baseline haematological investigations. Full blood count showed a Haemoglobin of 11.1 and White cell count of 33.96 which were consistent with the baseline in the setting of his known myeloproliferative disorder. Renal function was normal. He had a urine dipstick which was negative for blood and protein. Vasculitic screen was showed a positive ANA of 1:320. ENA and dsDNA were negative. Complement levels, both C3 and C4 were low. ANCA was negative. Skin biopsy demonstrated acute inflammation of capillaries and possibly small venules with leukocytoclasis without evidence of fibrinoid necrosis. Direct immunofluorescence (DIF) showed fibrin positivity, suggestive of vascular injury, but no immune complexes were detected. <strong>Differential &amp; Final Diagnosis:</strong> Differential diagnosis on presentation was between cutaneous small vessel vasculitis and capillaritis, with histology favouring the former. Following the detection of SARS‑CoV‑2, the clinical impression was cutaneous small vessel vasculitis secondary to COVID-19 infection. <strong>Discussion of Management:</strong> As the rash was asymptomatic without extracutaneous involvement or clinical features suggestive of medium vessel involvement, an observational approach was taken, and the sole active treatment recommendation was for class 2 compression stockings. He was admitted for respiratory support with oxygen via nasal prongs in the setting of COVID-19. His rash fully resolved aften ten days prior to discharge home. <strong>Conclusion:</strong> While the respiratory manifestations of COVID-19 are well established, it has also been associated with dermatological manifestations<sup>1</sup>, most commonly urticaria, maculopapular (morbilliform) exanthem, papulovesicular rash, chilblain-like acral pattern, livedo reticularis pattern, and a cutaneous vasculitis<sup>2</sup>. Vasculitis represents 8.2% of skin manifestations of COVID-19 infection<sup>2</sup> and is seen more frequently in elderly patients with COVID-19 infection<sup>3</sup>. Vasculitic manifestations of COVID-19 are associated with more severe illness and higher mortality<sup>3</sup>. Purpuric lesions have been reported as generalised, localised to intertriginous regions or arranged in an acral distribution in COVID-19<sup>2</sup>. The proposed pathogenic mechanisms of cutaneous manifestations of COVID-19 include hyperactive immune responses, complement activation and microvascular injury<sup>1</sup>. Topical corticosteroids have been successfully used for treating mild cases of COVID-19 induced vasculitis. Systemic corticosteroid may be warranted in more severe cases with necrotic-ulcerative lesions<sup>2</sup>. This case underscores the importance of considering COVID-19 infection in patients presents with a cutaneous small vessel vasculitis. <strong>Disclosures:</strong> None