Case Report:
The patient was a 21-old-year male referred to the emergency department
with three days of fever, myalgia, shortness of breath, and dry cough,
five days after close contact with a patient with Covid-19. He also
complained of abdominal pain and hematuria for two days. Physical
examination revealed a blood pressure of 92/55 mmHg, a pulse rate of 128
beats per minute, a respiratory rate of 28 per minute, an oral
temperature of 38.6 °C, and O2 saturation of 88%. He also had crackles
in both lungs and a mild diffuse abdominal tenderness. The pulmonary
computed tomography showed diffusely scattered ground-glass opacities.
The lab tests showed a white cell count of 5300 per cubic millimeter
(consisting 83% of polymorphonuclears, 13% lymphocytes, and 4%
monocytes), a hemoglobin level of 11.4 mg/dl, a platelet count = 314,000
per cubic millimeter, and a creatinine level of 1.1 mg/dl. The
first-hour erythrocyte sedimentation rate level was 89, and the
C-reactive protein level was 68 mg per liter. Urine analysis showed mild
proteinuria, and 20–25 red blood cells in a 40x magnification field,
30% Dysmorphic. The nasopharyngeal swab for the SARS
Coronavirus-2 polymerase chain reaction (PCR) was positive.
We started treatment with parenteral ceftriaxone and pantoprazole, oral
azithromycin and lopinavir/ ritonavir, and oxygen supplement. We also
asked for a nephrology consultation and complete abdominopelvic
ultrasound. The pulmonary symptoms recovered gradually during the
following days, but abdominal pain and malaise continued. The ultrasound
study was unremarkable. Other laboratory tests showed a urine protein
level of 565 mg in a day, a negative HBs antigen, HCV antibody,
anti-nuclear antibody, HLA-B5, HLA-B51, and a positive HLA-B27. The
serum complements level was in the normal range. On day 8, a purpuric
rash appeared on the back and lower extremities and extended for five
days (Figure 1). We asked for dermatology and rheumatology consultations
and performed a skin punch biopsy. After that, we started intravenous
dexamethasone four mg three times a day, which improved his condition
during the next days. The histopathology study revealed superficial
lymphocytic infiltrate and small-vessel vasculitis in the dermis (Figure
2). We diagnosed HSP based on clinical presentation and
histopathological findings. Finally, we discharged the patient on day 18
of admission with oral prednisolone and ferrous sulfate supplement.
Discussion :
HSP is a small-vessel vasculitis, which mainly affects the skin and
mucous membrane. It may develop after upper respiratory tract infections
such as Streptococci , Adenovirus , andcoxsackievirus (6). In our case, HSP occurs after SARS
Coronavirus-2 infection. The most common dermal presentation in
Covid-19 is viral exanthemas. Other cutaneous manifestations of Covid
-19 with distinct histopathology, also reported (Table 1). Unlike
cardiac or pulmonary involvement of Covid-19, skin involvement usually
leaves a good outcome, such as our patient. We recommend further studies
to investigate the immunological disturbance in Covid -19 and systematic
efforts to control it in parallel activities for vaccine development and
antiviral drugs.
Conclusion : SARS Coronavirus-2 is a viral respiratory
infection with prodromal symptoms at its early course. However, many
unpredictable syndromes may occur after that, related to the
immunological phenomenon. We used to predicate Tuberculosis orBrucellosis as the disease of a thousand faces. However, now, the
Covid-19 must also be considered as the third disease with this title.
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