The significance of pressure injuries and purpura in COVID-19 patients hospitalized at a large urban academic medical center: A retrospective cohort study
Authors: Renajd Rrapi, Sidharth Chand, Jennifer A. Lo, Colleen K. Gabel, Sarah Song, Zachary Holcomb, Christopher Iriarte, Kevin Moore, Connie R. Shi, Hannah Song, Fan Di Xia, Daniel Yanes, Rajesh Gandhi, Virginia A. Triant, Daniela Kroshinsky
Journal: Journal of the American Academy of Dermatology (2021)

To The Editor: Pressure injuries, a common skin finding that significantly impacts the quality of life in hospitalized patients, are associated with increased mortality and result in increased healthcare costs.1Mervis J.S. Phillips T.J. Pressure ulcers: pathophysiology, epidemiology, risk factors, and presentation.J Am Acad Dermatol. 2019; 81: 881-890Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar In COVID-19 infection, pressure injury sites are associated with purpuric lesions.2Chand S. Rrapi R. Lo J.A. et al.Purpuric ulcers associated with COVID-19 infection: a case-series.JAAD Case Rep. 2021; https://doi.org/10.1016/j.jdcr.2021.01.019Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar This study investigates the epidemiology and laboratory findings of these lesions to elucidate their etiology. From March 12, 2020, to May 31, 2020, at a single institution, 1216 adults hospitalized with laboratory-confirmed SARS-CoV-2 infection were retrospectively reviewed. A centralized clinical data registry with search functionality combined with a manual chart review identified patients with skin lesions. At least 2 dermatologists, with a third dermatologist for adjudication, evaluated patient records for pressure injury and identified the presence or absence of purpuric features. Altogether, 84 patients (6.9%) with 118 pressure injuries having onset concurrent with COVID-19 hospitalization were identified (Fig 1). The dermatologists were aided by photographs of 73.8% (n = 62/84) of the patients. The pressure injuries were associated with a prolonged length of stay (mean of 37.3 days) and high rates of endotracheal intubation (81.9%) (Table I). A portion of the patients (32.5%; n = 27/83) had pressure injuries with purpuric features. Laboratory values related to coagulopathy at lesion onset did not differ between patients with and without purpura, with the exception of D-dimer values, which were higher (P = .016) for patients with purpuric features (Supplemental Table I; available at https://doi.org/10.17632/vkzxr32ffr.1).Table IComparison of patients with nonpurpuric and purpuric pressure injuriesCharacteristicPatients with nonpurpuric pressure injury∗4 patients had multiple pressure injuries of which some had purpuric features and others had only nonpurpuric features. Values for these patients are tabulated in both columns. (n = 61)Patients with purpuric pressure injury∗4 patients had multiple pressure injuries of which some had purpuric features and others had only nonpurpuric features. Values for these patients are tabulated in both columns. (n = 27)Total patients with pressure injury (n = 84)P value†Statistical testing is performed comparing patients having pressure injuries with purpuric features to patients having pressure injuries none of which had purpuric features.Lesion evaluation Day of injury onset since admission (mean ± SD)11.2 ± 8.014.3 ± 10.012.0 ± 9.0.25 Dermatology consultation obtained4 (6.6%)7 (25.9%)10 (11.9%).0070 Photographs obtained40 (65.6%)25 (92.6%)62 (73.8%).0075Demographics Age in years (mean ± SD)60.9 ± 15.663.6 ± 14.861.9 ± 15.3.49 SexMale45 (73.7%)21 (77.8%)61 (73.5%).54Female16 (26.2%)6 (22.2%)22 (26.5%)Patient past medical history BMI (mean ± SD)31.8 ± 7.933.6 ± 9.632.1 ± 8.3.25 Hypertension25 (40.9%)15 (55.6%)38 (45.9%).21 Diabetes25 (40.9%)14 (51.9%)36 (43.4%).28 Chronic heart disease5 (8.2%)1 (3.7%)6 (7.2%).39 Chronic lung disease7 (11.5%)6 (22.2%)12 (14.5%).16 Stroke/cerebrovascular accident3 (4.9%)2 (7.4%)5 (6.0%).71 Smoking/cigarette use24 (39.3%)15 (55.6%)36 (42.9%).16Hospitalization Length of stay in days (mean ± SD)36.5 ± 20.442.3 ± 25.137.3 ± 21.9.15 Intensive care unit admission52 (85.2%)24 (88.9%)71 (85.6%).55 Death13 (21.0%)4 (14.8%)17 (20.5%).37 Treatment courseEndotracheal intubation50 (81.9%)23 (85.2%)68 (81.9%).59Orogastric/nasogastric intubation48 (78.6%)21 (77.8%)64 (77.1%).92Urinary catheterization52 (85.2%)24 (88.9%)71 (85.5%).55Rectal intubation49 (80.3%)22 (81.5%)66 (79.5%).76Parenteral nutrition11 (18.0%)3 (11.1%)12 (14.5%).55 Clinical courseCerebrovascular accident-1 (3.7%)1 (1.2%)-Deep vein thrombosis5 (8.2%)1 (3.7%)6 (7.2%).39Pulmonary embolism5 (8.2%)3 (11.1%)8 (9.6%).76Intracranial hemorrhage2 (3.3%)-2 (2.4%)- On therapeutic anticoagulation at onset of first injury12 (19.7%)8 (29.6%)18 (21.4%).26BMI, Body mass index; SD, standard deviation.∗ 4 patients had multiple pressure injuries of which some had purpuric features and others had only nonpurpuric features. Values for these patients are tabulated in both columns.† Statistical testing is performed comparing patients having pressure injuries with purpuric features to patients having pressure injuries none of which had purpuric features. Open table in a new tab BMI, Body mass index; SD, standard deviation. The incidence of pressure injury in this study (6.9%) is comparable to previous estimates of 5%-15% of hospitalized patients, depending on clinical context.1Mervis J.S. Phillips T.J. Pressure ulcers: pathophysiology, epidemiology, risk factors, and presentation.J Am Acad Dermatol. 2019; 81: 881-890Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar With respect to COVID-19 hospitalization specifically, the especially tenuous respiratory status in these critically ill patients frequently interfered with standard preventative measures to turn patients for inspection and pressure offloading.1Mervis J.S. Phillips T.J. Pressure ulcers: pathophysiology, epidemiology, risk factors, and presentation.J Am Acad Dermatol. 2019; 81: 881-890Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar,3Tang J. Li B. Gong J. Li W. Yang J. Challenges in the management of critical ill COVID-19 patients with pressure ulcer.Int Wound J. 2020; 17: 1523-1524Crossref PubMed Scopus (26) Google Scholar Placing patients in a prone position has been demonstrated to reduce the development of pressure injuries and is associated with improved outcomes in the setting of a poor respiratory status.4Li L. Li R. Wu Z. et al.Therapeutic strategies for critically ill patients with COVID-19.Ann Intensive Care. 2020; 10: 1-9Crossref PubMed Scopus (92) Google Scholar However, this study discovered 36 pressure ulcers (30.5%) occurring on the face, likely resulting from proning, emphasizing specific challenges affecting patients with COVID-19 and the importance of prophylactic measures to prevent these injuries in proned patients. This study only found elevated D-dimer levels in patients with purpuric pressure injuries, corroborating previous reports of elevation of fibrin and fibrinogen degradation products in COVID-19.5Connors J.M. Levy J.H. COVID-19 and its implications for thrombosis and anticoagulation.Blood. 2020; 135: 2033-2040Crossref PubMed Scopus (155) Google Scholar Thromboembolic events and abnormalities in other markers of coagulation were not found to be more common in patients with purpuric pressure injuries within our cohort. Biopsies were obtained in 4 patients and previously reported as exhibiting epidermal and eccrine gland necrosis, supportive of pressure-induced injury, with fibrin thrombi in superficial dermal vessels only.2Chand S. Rrapi R. Lo J.A. et al.Purpuric ulcers associated with COVID-19 infection: a case-series.JAAD Case Rep. 2021; https://doi.org/10.1016/j.jdcr.2021.01.019Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar These findings suggest that purpuric features of pressure injuries are less likely indicative of occult pathology resulting from COVID-19 infection and emphasize the usual prevalence of pressure injuries in critically ill patients, highlighting the importance of identifying risk factors, encouraging preventative measures, and reinforcing the known standard of care. Taking steps to address predisposing factors in hospitalized COVID-19 patients is essential in preventing these lesions and improving outcomes.1Mervis J.S. Phillips T.J. Pressure ulcers: pathophysiology, epidemiology, risk factors, and presentation.J Am Acad Dermatol. 2019; 81: 881-890Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar,3Tang J. Li B. Gong J. Li W. Yang J. Challenges in the management of critical ill COVID-19 patients with pressure ulcer.Int Wound J. 2020; 17: 1523-1524Crossref PubMed Scopus (26) Google Scholar The authors would like to thank the clinicians who cared for these patients during the COVID-19 pandemic and created the documentation necessary to make this study possible. None disclosed.