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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