What is “COVID Toe”? Strange sign of coronavirus infection confuses doctors

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Before the coronavirus epidemic, Dr. Lindy Fox, a dermatologist in San Francisco, saw four or five patients a year with frostbite – painful red or purple sores that usually appear on fingers or toes in winter.

In the past few weeks, she has seen dozens.

“All of a sudden we’re inundated with toes,” said Fox, who practices at the University of California, San Francisco. “I have clinics full of people who come with new toe injuries. And these are not people who had frostbite before – they have never had anything like it. “

It is also not the time of year for frostbite, which is caused by inflammation of the small blood vessels in response to cold or humidity. “Usually we see it in the dead of winter,” said Fox.

Fox is not the only one to be inundated with boxes. In Boston, Dr. Esther Freeman, director of global health dermatology at Massachusetts General Hospital, said her telemedicine clinic was also “completely filled with toes.” I had to add additional clinical sessions just to take care of the toe consultations. People are very worried. “

Lesions appear as another symptom of infection with the new coronavirus. The most prominent signs are a dry cough and shortness of breath, but the virus has been linked to a series of unusual and various effects, such as mental confusion and decreased sense of smell.

Federal health authorities don’t include toe damage in the list of coronavirus symptoms, but some dermatologists are pushing for a change, saying the so-called COVID toe should be reason enough for testing. (COVID-19 is the name of the disease caused by the coronavirus.)

Several medical documents from Spain, Belgium and Italy have described an increase in complaints of painful lesions on patients’ toes, Achilles heels and the soles of their feet; whether the patients were infected was not always clear, since they were otherwise healthy and testing 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 to the public is not to panic – most of the patients we see with these lesions are doing extremely well,” said Freeman.

“They have what we call a mild clinical course. They stay at home, they get better, the toe lesions disappear. “

Scientists are just starting to study the phenomenon, but so far, frost-like lesions seem, oddly enough, to signal a mild, even asymptomatic, infection. They can also develop several weeks after the acute phase of an infection has ended.

Patients who develop swollen toes and red and purple lesions should consult their primary care physician or dermatologist to rule out other possible causes. But experts say they shouldn’t run to the emergency room, where they risk being exposed to the coronavirus or exposing others if they become infected.

“The good news is that frostbite-like lesions usually mean you’re fine,” said Fox. “Usually, it’s a good sign that your body has seen COVID and is having a good immune response. “

Patients who suffer from painful lesions are often alarmed. They most often appear on the toes, often affecting multiple toes on one or both feet, and the sores can be extremely painful, causing a burning or itching sensation.

At first, the toes are swollen and take on a reddish tinge; sometimes part of the toe is swollen and individual lesions or bumps can be seen. Over time, the lesions turn purple.

Hannah Spitzer, 20, a second-year student at Lafayette College who is finishing the remote academic year at her home in Westchester County, New York, has lesions on all 10 of her toes that are uncomfortable – painful during day and itching at night – that she can’t 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 got worse and worse,” said Spitzer. “Most of my toes are red, swollen, almost shiny. It looks like frostbite. “

She used hydrocortisone and Benadryl to ease the discomfort, and ice is also helpful. Doctors say the lesions go away on their own within a few weeks.

To add to the mystery, some adolescents and young adults with lesions have given negative results for the coronavirus.

Spitzer got tested shortly after developing the lesions, and the result was negative, but she is convinced that the toe lesions are a delayed response to a previous infection that was so mild that she barely got it. Note.

“I have never had anything like it,” she said. “It is completely new. “

A recent article by Spanish doctors, published in the International Journal of Dermatology, described six cases of patients with toe damage and included photos of frostbite-like bumps that patients had emailed their doctors.

Most of the patients were adolescents or young adults, including a 15-year-old adolescent who discovered he had COVID-19 pneumonia when he went to the emergency room for toe care.

Another patient was a 91-year-old man who had been hospitalized with the coronavirus three weeks earlier and had recovered and returned home.

While dermatologists say it is not uncommon for skin rashes to appear with viral infections – like measles or chickenpox – the lesions of the toes have surprised them.

Other problems like hives have also been linked to the coronavirus, but COVID toes have been the most common and striking skin manifestation.

Patients with viral infections often get a pink bumpy rash called a morbilliformis, or hives, Fox said, but added that the toe damage was “unexpected.”

Toe cases account for half of all reports filed by dermatologists around the world in a new international registry launched by the American Academy of Dermatology, which tracks complications.

No one knows exactly why the new coronavirus can cause frostbite-like lesions. One hypothesis is that they are caused by inflammation, an important characteristic of COVID-19. Inflammation also causes one of the most serious syndromes associated with coronavirus, acute respiratory distress syndrome.

Other hypotheses are that the lesions are caused by inflammation in the walls of blood vessels or by small micro-clots in the blood. (Coagulation is another hallmark of the disease.)

The lesions seen in otherwise healthy people appear to be distinct from those seen by doctors in some critically ill COVID-19 patients in intensive care, who tend to develop blood clots.

Some of these clots can be very small and can block tiny vessels in the extremities, causing rashes on the toes, said Dr. Humberto Choi, pulmonologist and intensive care doctor at the Cleveland Clinic.

Some experts now believe that the COVID toe should be recognized as a sufficient reason for testing, even in the absence of other symptoms.

“This should be a test criteria, just like odor loss, shortness of breath, and chest pain,” said Fox.

Roni Caryn Rabin c. 2020 The New York Times Company

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