Medical history

Female, Chinese, 27/01/1978, rapidly vanishing, asymptomatic varicella-like rash (duration of 5-6 days), involving trunk and upper extremities, in patient with Covid 19 bilateral interstitial pneumonia.

Histopathology: mild lymphomonocytic perivascular and periadnexal infiltrate, with perinuclear vacuolation of the keratinocytes of the superficial layers of the epidermis, that appear “uninhabitated” by the nucleus, similarly to what happens in hairy cell leucoplakia.

Medical history

Male, Italian, 07/02/1950, ex football player, in November bilateral acrocyanosis with livedoid lesions evolved in bilateral gangrene, concomitant with severe Covid 19 bilateral interstitial pneumonia. The patient had a previous diagnosis (2007) of positivity to antiphospholipid antibodies, never followed by arterial or venous thrombotic events.

February 2021: death.

Medical history

A 59-year-old man was admitted to hospital for a severe respiratory failure and then intubated due to worsening of his respiratory condition. During his hospital stay, he received multiple empirical broad spectrum antibiotics (cefepime, piperacillin/tazobactam, linezolid, gentamicin and meropenem plus amikacin). The patient had no known history of drug allergies. A test to detect SARS-CoV-2 by real-time reverse-transcription-polymerase-chain-reaction (RT-PCR) assay of a throat swab was positive. Blood cell count showed severe eosinophilia (from 1,3 to 4.60 x 10) that decreased abruptly to 0.47 x 10 after introduction of methylprednisolone 1 mg/kg/day. On day 35 post admission, while on therapy only with corticosteroids, he developed a symmetrically distributed maculopapular purpuric exanthema on the face, trunk and extremities . Mucous membranes were spared. No lymphadenopathies were present. Laboratory data including liver function, cryoglobulins, antinuclear antibody, anti-neutrophil cytoplasmic antibodies test results were all normal. A skin biopsy found a superficial and deep perivascular neutrophilic infiltrate with sparse leukocytoclasis, red blood cell extravasation and fibrinoid necrosis of vessel walls. The patient’s conditions worsened and he died for neurological complications  due to acute cerebrovascular disease.

Drug reaction with eosinophilia and systemic symptoms syndrome (DRESS) was considered in our patient for skin eruption and blood eosinophilia that integrate two criteria for the diagnosis ; however, histopathology showing a classical picture of leucocytoclastic vasculitis was not consistent with DRESS. In fact, different histopathologic patterns were described in DRESS including spongiotic, erythema multiforme-like, or lichenoid but no vasculitis . Despite an antibiotic allergy was considered, it is known that severe COVID-19 induces endothelial damage and vasculopathic changes .