Before the coronavirus outbreak, Dr. Lindy Fox, a dermatologist in San Francisco, used to see four or five patients a year with chilblains – painful red or purple lesions that usually appear on her fingers or toes in winter.
In the past few weeks, she has seen dozens.
"Suddenly, we are inundated with fingers," said Fox, who works at the University of California, San Francisco. "I have clinics filled with people who arrive with new toe injuries. And it's not people who have had chilblains before – they've never had anything like that."
It is also not the time of year for chilblains, caused by inflammation in small blood vessels in response to cold or wet conditions. "We usually see this in the dead of winter," said Fox.
Fox is not the only one that is full of cases. In Boston, Dr. Esther Freeman, director of global health dermatology at Massachusetts General Hospital, said that her telemedicine clinic is also "completely fingered." I had to add extra clinical sessions, just to take care of toe appointments. People are very concerned. "
The lesions are emerging as another symptom of infection with the new coronavirus. The most important signs are dry cough and shortness of breath, but the virus has been associated with a number of unusual and diverse effects, such as mental confusion and a decreased sense of smell.
Federal health officials do not include toe injuries in the coronavirus symptom list, but some dermatologists are pushing for a change, saying the so-called COVID toe should be sufficient reason for testing. (COVID-19 is the name of the disease caused by the coronavirus).
Several medical articles from Spain, Belgium and Italy described an increase in complaints about painful injuries to patients 'toes, Achilles' heels and soles; whether patients were infected was not always clear, because they were healthy and the test was limited.
Most cases have been reported in children, adolescents and young adults, and some experts say they may reflect a healthy immune response to the virus.
"The most important message for the public is not to panic – most of the patients we are seeing with these injuries are doing very well," said Freeman.
"They are taking what we call a benign clinical course. They are staying home, they are getting better, the toe injuries are disappearing."
Scientists are just beginning to study the phenomenon, but so far, cold-type lesions seem to signal, curiously, a mild or even asymptomatic infection. They can also develop several weeks after the acute phase of an infection has ended.
I diagnosed a patient (presumably) with Coronavirus based on her skin exam today. She had her toes covered for six weeks and was otherwise asymptomatic. She had a public job. I've seen several patients like that. It is hard to imagine that this virus is not yet everywhere. pic.twitter.com/nrcub7D3Nz
– Dennis (@pourteaux) April 29, 2020
Patients who develop swollen fingers and red and purple lesions should consult their doctor or a dermatologist to rule out other possible causes. But, experts said, they should not rush to the emergency room, where they are at risk of being exposed to the coronavirus or exposing others if they are infected.
"The good news is that cold-type injuries usually mean you're going to be fine," Fox said. "It's usually a good sign that your body has seen COVID and is doing a good immune reaction to it."
Patients who suffer painful injuries are often alarmed. They appear most often on the toes, often affecting several fingers on one or both feet, and the wounds can be extremely painful, causing a burning or itching sensation.
At first, the toes appear swollen and take on a reddish hue; Sometimes a part of the toe is swollen, and individual lesions or swelling can be seen. Over time, the lesions turn purple.
Hannah Spitzer, 20, a sophomore at Lafayette College, who is finishing the academic year remotely at her home in Westchester County, New York, has 10 toe injuries, so uncomfortable – painful during the day and with itching at night – that she cannot put anything on her feet, not even socks.
Walking is difficult, and she has trouble sleeping. "At first, I thought it was my shoes, but it just got worse," said Spitzer. “Most of my fingers are red, swollen, almost shiny. It looks like freezing.
She used hydrocortisone and Benadryl to relieve discomfort and said that ice is also useful. Doctors say the lesions disappear on their own within a few weeks.
In addition to the mystery, some adolescents and young adults with injuries have shown negative results for coronavirus.
Amy Paller, chairman of the dermatology department at Northwestern Feinberg University School of Medicine, said one possible explanation is that these patients had such a mild disease and that viral replication was limited, making the virus undetectable.
Another possibility, she said, is that injuries are what is called an epiphenomenon – a symptom can accompany a disease without being causally related. For example, perhaps more people are developing lesions because they stay inside and walk barefoot more than normal.
But she also dismissed that idea as highly unlikely. "I don't think that's it – I think it's a mild inflammatory process that manifests itself in that way," said Paller. "It is a real phenomenon. We really don't understand anything."
Spitzer did a test shortly after the lesions developed, and the result was negative, but she is convinced that the toe injuries are a late response to a previous infection that was so mild that she barely noticed.
"I never had anything like it," she said. "It's completely new."
A recent article by doctors in Spain, published in the International Journal of Dermatology, described six cases of patients with injuries to their toes and included photos of the chilblain-like swellings that patients emailed to doctors.
Most patients were adolescents or young adults, including a 15-year-old who discovered he had COVID-19 pneumonia when he went to the emergency room for medical care for his toes.
Another patient was a 91-year-old man who had been hospitalized with the coronavirus three weeks earlier and had recovered and returned home.
Although dermatologists say it is not uncommon for rashes to appear together with viral infections – such as measles or chickenpox – the toe injuries surprised them.
Other problems, such as urticaria, have also been associated with coronavirus, but the COVID fingers have been the most common and striking cutaneous manifestation.
Viral infection patients often have a rugged pink rash called a morbiform, or hive, Fox said, but added that the toe injuries are "unexpected".
Toe cases make up half of all reports submitted by dermatologists around the world to a new international registry initiated by the American Academy of Dermatology, which tracks complications.
No one knows exactly why the new coronavirus can cause cold-type injuries. One hypothesis is that they are caused by inflammation, a prominent feature of COVID-19. Inflammation also causes one of the most serious syndromes associated with the coronavirus, the acute respiratory distress syndrome.
Other hypotheses are that the lesions are caused by inflammation in the walls of the blood vessels, or by small micro-clots in the blood. (Coagulation has been another feature of the disease.)
The lesions seen in healthy people appear to be different from those that doctors are observing in some critical patients of COVID-19 in intensive care, prone to developing blood clots.
Some of these clots can be very small and can block the small vessels at the ends, causing rashes on the toes, said Dr. Humberto Choi, a pulmonologist and intensive care physician at the Cleveland Clinic.
Now, some experts believe that COVID toe should be recognized as a sufficient basis for testing, even in the absence of other symptoms.
"This should be a criterion for testing, as well as loss of smell, shortness of breath and chest pain," said Fox.
Roni Caryn Rabin, c.2020 – The New York Times Company
Update date: May 13, 2020 11:26:38 IST