Severe skin ulcer in systemic scleroderma due to severe acute respiratory syndrome coronavirus 2 infection

Dear Editor,

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic is still spreading rapidly. SARS‐CoV‐2 infection reportedly has a variety of dermatological manifestations. ¹ , ² , ³ , ⁴ , ⁵ We report a rare case of a patient with systemic scleroderma (SSc) who developed severe skin ulcers and ischemia on her toes without systemic deterioration associated with SARS‐CoV‐2 infection.

A 56‐year‐old Japanese woman with SSc and systemic lupus erythematosus was treated with long‐term oral prednisone 10 mg daily and bosentan 62.5 mg daily, and the disease was stable for a long time. Although she had significant chilblain‐like lesions during winter, the ulcers on her toes did not get worse (Figure 1a). The chilblain‐like lesions always improved in the spring. She received prostaglandin injections twice weekly during winter, and her hands and feet were well protected and treated for skin ulcers. However, at the end of December 2020, she noticed severe toe pain, her toes were pale, and the ulcers produced more exudate (Figure 1b).

FIGURE 1.

(a) The skin ulcers on her toes did not deteriorate before severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. (b) Ischemia on her toes. The skin ulcers on the toes produced more exudate and the pain was very severe. Polymerase chain reaction test for SARS‐CoV‐2 was positive. (c) The pale appearance and severe pain disappeared after she tested negative for SARS‐CoV‐2

Her symptoms did not improve; therefore, 10 days later, she presented to our department. There was no fever, upper respiratory symptoms, or malaise. Blood test results did not show any abnormality. Chest computerized tomography indicated no complications, such as interstitial pneumonia and severe ischemic limb.

She was not exposed to cold and atmospheric temperatures were not lower than usual, but the severe pain, ischemia, and ulcers on the toes, persisted. At that time, the coronavirus disease 2019 (COVID‐19) pandemic had begun in Japan, and we confirmed she had SARS‐CoV‐2 infection with a positive polymerase chain reaction (PCR) test.

Therefore, we diagnosed her with severe skin ulcers due to SARS‐CoV‐2 infection. The pale appearance and severe pain resolved rapidly within 5 days, without any systemic symptoms associated with SARS‐CoV‐2. The size of the skin ulcer and amount of exudates decreased (Figure 1c). Afterwards, SARS‐CoV‐2 PCR test was negative.

Pseudo‐chilblains, are reportedly the most common skin manifestations of COVID‐19, and are more prevalent in younger patients. ³ , ⁴ , ⁵ In contrast, vaso‐occlusive lesions (livedo racemosa, retiform purpura, and acral ischemia) are the least common, and tend to affect elderly patients. Patients with vaso‐occlusive lesions due to COVID‐19 are at a higher risk of severe pneumonia than those with other skin conditions; furthermore, it reportedly appears late in the course of the illness. ³ In our case, the time of SARS‐CoV‐2 PCR negativity coincided with improvement of the skin lesions, so we think that they appeared in the later stage of the disease. The location of the lesions and the age of the patient were also consistent with those in previous reports. However, there were no systemic symptoms during the course of SARS‐CoV‐2 infection.

In patients with SSc, SARS‐CoV‐2 aggravates narrowing of peripheral blood vessels, and causes vaso‐occlusive lesions and skin ulcers more easily than in the general population. During the COVID‐19 pandemic, clinicians should consider SARS‐CoV‐2 infection as a differential diagnosis in patients with connective tissue diseases, such as SSc, that rapidly develops vaso‐occlusive lesions and skin ulcers, even without any systemic symptoms of SARS‐CoV‐2.

CONFLICT OF INTEREST

None declared.