Livedo, Purpura and Coagulopathy in Severe COVID-19 Save

JAMA Dermatology expands the spectrum of complications seen with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection describing cutaneous purpura and livedo lesions in patients with severe COVID-19.

A flurry of recent reports have described livedoid and necrotic eruptions in confirmed COVID-19 cases many of whom had severe disease.

This series  describes4 patients who presented with severe COVID-19 and acute respiratory distress syndrome requiring intubation who also exhibited acral fixed livedo racemosa and retiform purpura.

The age range of these patients was 40-80 years. Skin biopsy shows a pauci-inflammatory thrombogenic vasculopathy involving capillaries, venules, and/or arterioles or small arteries and 3 of 4 patients, dermal arterial thrombosis was noted (reminiscent of antiphospholipid syndrome; yet no lab confirmation was done). All biopsy samples had deposits of complement including C5b-9, suggesting complement activation  Lastly, all patients had elevated d-dimer levels and suspected pulmonary embolus. All were started on anticoagulation. 

Findings of livedo racemosa and retiform purpura are further evidence of the coagulopathy that accompanied COVID-19. .

Clinicians should be aware that livedoid and purpuric rashes in COVID-19 are potential manifestations of an underlying hypercoagulable state.