Personal Experience Of A COVID 19 Infected Patient With Underlying Stroke And Dementia Presenting With Mucocutaneous Manifestations

Keywords

Covid – 19, cutaneous manifestations, mucosal manifestations

Summary

During the COVID-19 outbreak in Myanmar in July 2021, an old man suffering from a previous stroke and dementia developed fever with dry cough. After performing the necessary tests, he was diagnosed with a corona virus infection. The cutaneous manifestations of this patient in the early seven days were erythematous-violaceous macules, and patches on the toes, as well as dryness of the skin. Over the next three days, mucosal manifestations such as aphthous ulcers, hemorrhagic crusts, and mucositis appeared on his lips. Then, bedsores appeared due to long-term immobilization and did not heal even after one month. Thereafter, petechiae and purpura were apparent on the limbs. Two months later, hemorrhages on his digits were observed. Later, he suffered mucosal bleeding which presented as melena and subconjunctival hemorrhages. He was treated according to the accepted treatment guideline of our country, but he passed away 63 days after the corona virus infection due to severe lung and multisystem involvement.

Background

A study in the United States found that patients with dementia had a higher risk of COVID-19 infection. Skin manifestations of this infection include urticaria, maculopapular, papulovesicular, purpuric, livedoid, and thrombotic-ischemic lesions ¹, and the incidence was about 1% to 20% ². Adults with COVID-19 infection may have either skin or mucosal characteristics, and those indicate a more serious clinical course³. This case report describes the mucocutaneous manifestations of a COVID-19 infected patient with underlying neurological disorders during July – August 2021.

Case presentation

On July 16, 2021, an 84-year-old man with a known history of dementia and stroke developed dry cough and fever. According to clinical suspicion, a nasal swab test (RDT) was performed which revealed that he was infected with the corona virus. He had moderate to severe pulmonary manifestations just like other patients. In addition, after a week of COVID infection, the patient’s skin showed subungual erythema, dryness, and scaling of the palms and feet (figure 1), as well as erythematous-violaceous macules and patches on the toes (in literature, known as “COVID toes” (figure 2). Mucosal changes, including aphthous-like ulceration (figure 3), hemorrhagic ulcer, crust (figure 4), and mucositis with the mucopurulent membrane of the lips and mouth (figure 5), were observed in the following week. Because of the unavailability for hospitalization, the patient was treated with necessary medications at home.

On August 2, the patient had a persistent fever with the development of atrial fibrillation and a decreasing SpO2 level, so he was hospitalized. Petechiae and purpura appeared on his forearms (figure 6) after 30 days of illness, and he suffered from poor healing bedsores on the sacral area due to prolonged bedridden status (figure 7). The hemorrhages on the digits (figure 8) and conjunctiva appeared two months later, at the height of his illness. On his chest X-ray (PA view), expected radiological abnormalities such as pneumonia and consolidation (figure 9) were identified. Furthermore, laboratory tests revealed elevated ESR, C – reactive protein, ferritin, and procalcitonin with marked neutrophilic leukocytosis, lymphopenia, and thrombocytopenia. Hypoproteinemia was also a prominent feature for him. The D- Dimer level rose considerably, from 900 to 2898 ng FEU/ml after 30 days (reference 500 ng FEU/ml). Surprisingly, the ultrasound scan (abdomen) was unremarkable. Then, the significant decline in lymphocyte count and platelet count with melena and conjunctival hemorrhage necessitated an emergency blood transfusion. Despite the optimal treatment according to the accepted clinical guideline, the patient’s condition deteriorated. Then, SpO2 suddenly dropped because of the multisystem complications, and the patient passed away (after two months of COVID infection).

Discussion

In this patient, COVID-19 virus disease manifested as many systemic involvements such as chest infection, pneumonia, atrial fibrillation, and bleeding. He also had mucocutaneous manifestations, although he had no previous dermatological problems, which could be due to immune system deterioration, medication, or corona virus. According to literature, “COVID toes”, also known as pseudo-chilblain or pernio-like lesions, are vasculopathy rashes located in acral areas, affecting up to 63% of patients⁴.

In this case, after a week of infection, this patient’s skin showed significant changes of erythematous-violaceous plaques on the toes without any trauma. Moreover, the patient’s skin was scaly and dry, particularly on the limbs.

An international multicenter study in 2020 found that D-dimer levels above 1850 ng/mL predicted significant mucosal abnormalities in COVID -19 infected patients and linked to ischemic colitis⁵. In this case, the D dimer level was high, and at that time, mucosal ulceration, hemorrhagic crust, aphthous-like ulcers, and the mucopurulent membrane on the lips and mouth were found. Later, the patient suffered from melena and ischemic colitis. Therefore, the mucosal features appeared during the most severe period of the disease.

In the previous study, the prevalence of purpura in hospitalized patients with COVID -19 infection was 25.7% ³. In this case, purpura and petechia were discovered, when there was a substantial low platelet count. Furthermore, bleeding from the eyes, digits and stool was noted, which could be due to multifactorial causes, indicating COVID-19 severity.

Patients with COVID -19 infection who are elderly or have underlying chronic conditions are more likely to develop pressure ulcers6. In this patient, he suffered bedsores which were healing poorly even after a month of infection, which might have been caused by hypoproteinemia and prolonged bedridden posture while on oxygen therapy (unable to frequently change the position).

Take-home message

COVID-19 is a life-threatening and devastating viral infection. Patients with dementia and stroke have an increased risk of mortality and morbidity during the corona virus disease outbreak. The appearance of mucocutaneous manifestations in COVID -19 infected patients is under-observed and under-mentioned. In this patient, mucocutaneous symptoms such as mucositis, melena, and COVID toes appeared at the height of infection. It implies that the skin and mucosa are the windows through which disease status and medication risks are reflected. Therefore, awareness and close monitoring of mucocutaneous features are critical to prevent potential complications of corona virus infection and possible risks of medication. Moreover, those patients will undoubtedly require intensive medical and nursing care throughout the disease, in addition to conventional medical treatment.

Acknowledgment

I appreciate the hospital’s doctors, nurses, and staff or their care and the patient’s family members for allowing me to use the relevant photos.

Conflict of Interest Statement

The author has no conflict of interest to declare.

Figure 1: Subungual erythema, dryness, and scaling of left foot

Figure 2: Erythematous macules and plaques (Covid toes) on the left foot

Figure 3: Aphthous like ulcers on lips

Figure 4: Hemorrhagic ulcers and crust on lips

Figure 5: Mucositis and mucopurulent membrane of lips and mouth

Figure 6: petechia and purpura on forearms

Figure 7: Bedsores on the sacral area

Figure 8: Bleeding periungual skin on the left hand

Figure 9: Chest X-Ray – pneumonia and consolidation

References

1. Elmas ÖF, Demirbaş A, Özyurt K, Atasoy M, Türsen Ü. Cutaneous manifestations of COVID-19: A review of the published literature. DermatolTher. 2020;33(4):e13696. doi:10.1111/dth.13696
2. Novak N, Peng W, Naegeli MC, et al. SARS-CoV-2, COVID-19, skin, and immunology – what do we know so far? Allergy. 2021; 76: 698- 713. https://doi.org/10.1111/all.14498
3. Rekhtman S, Tannenbaum R, Strunk A, Birabaharan M, Wright S, Grbic N, Joseph A, Lin SK, Zhang AC, Lee EC et al. Eruptions and related clinical course among 296 hospitalized adults with confirmed COVID-19. J. Am. Acad. Dermatol. 2021;84(4): 946–952. doi: 10.1016/j.jaad.2020.12.046.
4. MohseniAfshar Z, Babazadeh A, Hasanpour A, et al. Dermatological manifestations associated with COVID-19: A comprehensive review of the current knowledge. J Med Virol. 2021; 93(10):5756-5767. doi:10.1002/jmv.27187
5. Vanella G, Capurso G, Burti C, et al. Gastrointestinal mucosal damage in patients with COVID-19 undergoing endoscopy: an international multicentre study. BMJ Open Gastroenterol. 2021;8(1):e000578. doi:10.1136/bmjgast-2020-000578
6. Baykan H. (2021). Evaluation of pressure ulcer development and follow-up in Covid-19 patients followed in pandemic intensive care units. Family Practice and Palliative Care, 6 (2): 86-91. doi: 10.22391/fppc.883135

Author Information

Myat Sanda Kyaw
M.B.,B. S, Diploma in Dermatology, Diploma in Medical Education, M.Med.Sc (Dermatology) Professor, Department of Dermatology, University of Medicine 2, Yangon, Myanmar