Petechial Skin Rash Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Infection

The coronavirus disease 2019 (COVID-19) pandemic is filling the headlines these days. Although it is known that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be associated with skin manifestations, a limited number of images are available in the literature at this time. This observation reports dermatologic findings associated with a confirmed case of COVID-19.

A 48-year-old man with a history of hypertension presented to the emergency department in March 2020, during the COVID-19 outbreak in Madrid, Spain. He reported an onset of fever (up to 39 °C) several days before admission, along with pleuritic chest pain and shortness of breath. He noticed the abrupt appearance of slightly pruritic skin lesions 3 days after the onset of fever. He had not taken any new drugs during the year before this episode.

Physical examination revealed confluent erythematous macules, papules, and petechiae in a symmetric periflexural distribution affecting the buttocks, popliteal fossae, proximal anterior thighs, and lower abdomen. A striking absence of lesions in the crural folds was noted (Figure 1). There were no acral or mucosal lesions.

Posteroanterior and lateral chest radiographs showed ground-glass opacities in both lower pulmonary fields consistent with atypical pneumonia. A complete blood cell count revealed a lymphocyte count of 750/μL (reference range, 1000-4500/μL) (to convert to ×10⁹/L, multiply by 0.001), a C-reactive protein level of 1.7 mg/dL (reference range, 0-0.5 mg/L) (to convert to mg/L, multiply by 10), and a D-dimer level of 0.68 μg/mL (reference range, 0-0.5 μg/mL) (to convert to nmol/L, multiply by 5.476). The platelet count and coagulation parameters were normal. Serologic test results were negative for HIV, hepatitis B virus, hepatitis C virus, and parvovirus B19. Results of real-time reverse transcriptase–polymerase chain reaction from a nasopharyngeal swab were positive for SARS-CoV-2.

A 5-mm punch biopsy specimen from the left buttock revealed a superficial perivascular lymphocytic infiltrate with abundant red cell extravasation and focal papillary edema, along with focal parakeratosis and isolated dyskeratotic cells. No features of thrombotic vasculopathy were present (Figure 2).

The patient was hospitalized and treated with hydroxychloroquine (200 mg twice a day), lopinavir-ritonavir (200 mg/50 mg twice a day), and azithromycin (250 mg/d). The patient continued to receive his regular hypertension medication, telmisartan. The rash was treated with 0.05% betamethasone dipropionate cream twice a day and loratadine (10 mg/d). The cutaneous lesions resolved after 5 days. The patient recovered from his respiratory illness and was released from the hospital after 12 days.

To our knowledge, there is only 1 other report of petechial skin lesions in a SARS-CoV-2–infected patient, initially believed to have dengue fever.¹ Other coronaviruses such as human coronavirus NL63 have been associated with purpuric eruptions, including acute hemorrhagic edema of infancy.² During the COVID-19 outbreak in China, dermatologic symptoms were regarded as possible comorbid conditions, drug reactions, or occupational skin diseases³—unrelated to SARS-CoV-2.

Viral rashes can be polymorphic. In this patient, the clinical picture resembled the periflexural petechial exanthem of parvovirus B19. Skin biopsy specimens from patients with this disease show a perivascular mononuclear inflammatory infiltrate, eosinophils, and extravasated erythrocytes; in addition, viral proteins from parvovirus B19 have been found within the endothelial cells of dermal vessels and could be implicated in the pathogenesis of purpura.⁴ We hypothesize that SARS-CoV-2 could affect the skin in a similar way. Some histologic features in this case (ie, mounds of parakeratosis, mild spongiosis, extravasated erythrocytes) overlap with those of pityriasis rosea, which is suspected to have a viral pathogenesis.⁵ Adverse drug reactions to supportive medications used in patients with severe viral infections are an important diagnostic consideration; however, in this case the rash preceded the initiation of lopinavir-ritonavir and hydroxychloroquine.

Sharing the images of this case may benefit physicians dealing with similar rashes in undiagnosed patients during this pandemic. We hope that, in the upcoming months, skin rashes associated with COVID-19 will be better understood.

Corresponding Author: Borja Diaz-Guimaraens, MD, Dermatology Department, Ramon y Cajal University Hospital, Carretera Colmenar Viejo km 9.100, 28034 Madrid, Spain (borja.diazg@edu.uah.es).

Published Online: April 30, 2020. doi:10.1001/jamadermatol.2020.1741

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We also thank Carmen Moreno García del Real, MD, PhD (Department of Pathology, Ramon y Cajal University Hospital), for the histopathologic analysis and all of her kind support during the redaction of the manuscript.