CASE REPORT

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Periorbital erythema as a presenting sign of 57
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4 COVID-19 Q1 59
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6 Q5 Q2 61
Samantha Kalner, and Irene J. Vergilis, MD
7 New York, New York 62
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11 66
12 INTRODUCTION 67
13 Abbreviation used: 68
Reports in literature of the presence of cutaneous
14 findings in patients who have tested positive for COVID-19: coronavirus disease 2019 69
15 Q3 SARS-CoV2, which causes coronavirus disease 2019 70
16 (COVID-19), have ranged from 20.4%1 to 0.2% of 71
17 cases.2 Reported cutaneous manifestations span had developed fever, cough, sore throat, muscle 72
18 from nonpruritic to pruritic erythematous morbilli- weakness, myalgias, and shortness of breath. She 73
19 form eruptions involving the trunk, to localized or was prescribed alclometasone dipropionate 0.05% 74
20 widespread urticaria, to chickenpox-like vesicles.1 ointment. She was followed via telemedicine en- 75
21 Petechial rash has also been described at the initial counters and reported that she subsequently tested 76
22 presentation of the COVID-19 disease,3 along with positive for the SARS-CoV2. She reported that she 77
23 confluent erythematous-yellowish papules on heels was using prescribed ointment twice a day and her 78
24 bilaterally that presented 13 days after the onset of rash completely resolved within a few days of using 79
25 COVID-19 and which progressed to pruritic, hard, the ointment, along with improvement in her sys- 80
26 erythematous plaques.4 The timing of the reported temic symptoms. After this initial improvement in the 81
27 cutaneous manifestations observed has also varied, systemic symptoms, and approximately 10 days after 82
28 with some patients presenting with cutaneous find- she developed initial periorbital dyschromia, she 83
29 ings at the onset of the COVID-19 symptoms, again developed the periorbital changes. As before, 84
30 whereas others develop cutaneous involvement 2 days after developing periorbital dyschromia, she 85
31 after infection has progressed and they have been again became febrile, with worsening cough, myal- 86
32 hospitalized.1 Herein, we present a novel cutaneous gias, and shortness of breath, in what appeared to be 87
33 finding, a dusky red, nonpruritic, nonblanching, the second phases of COVID-19 that have been 88
34 periorbital dyschromia that we have observed in reported in the literature. She requested another 89
35 several patients who have received a diagnosis of telemedicine consultation when the periorbital 90
36 COVID-19. This rash appeared before the develop- changes reappeared (Fig 2) and was told to use 91
37 ment of any of the systemic symptoms of COVID-19, alclometasone dipropionate 0.05% ointment, which 92
38 and we believe that it can potentially serve as an led to complete resolution of periorbital dyschromia 93
39 early sign of patients’ developing COVID-19. (Fig 3). She completely recovered from COVID-19 94
40 and no further periorbital dyschromia was observed. 95
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CASE REPORT Patient 2 was an otherwise healthy 50-year-old
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Patient 1, an otherwise heathy 43-year-old man who developed similar periorbital dyschromia,
43 without any ocular changes, 2 days before onset of 98
woman, presented with dusky red, nonpruritic,
44 systemic symptoms including fever, shortness of 99
nonblanching periorbital dyschromia (Fig 1). There
45 breath, myalgias, and syncope. No images were 100
was no conjunctivitis, other ocular symptoms, or any
46 obtained because he was hospitalized for his sys- 101
systemic findings of COVID-19 reported when the
47 temic symptoms of COVID-19 and tested positive for 102
periorbital dyschromia appeared. Two days after the
48 the SARS-CoV2 while he was in the hospital. No 103
appearance of the rash, the patient reported that she
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51 From Dermatology and Skin Surgery, New York. 2352-5126 106
52 Funding sources: None. Ó 2020 by the American Academy of Dermatology, Inc. Published 107
Conflicts of interest: None disclosed. by Elsevier, Inc. This is an open access article under the CC BY-
53 Correspondence to: Irene J. Vergilis, MD, 262 Central Park West, NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
108
54 Ste 1D, New York, NY 10024. E-mail: drvergilis@gmail.com. 4.0/). 109
55 JAAD Case Reports 2020;jj:j-j. https://doi.org/10.1016/j.jdcr.2020.05.001 110

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111 reappearance of the periorbital dyschromia. 166

112 Periorbital dyschromia once again resolved, with 167
113 the resolution of systemic symptoms of COVID-19. 168
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116 DISCUSSION 171
117 COVID-19, a disease caused by SARS-CoV2, has 172
118 afflicted millions of people worldwide during the 173
119 past several months. Although there are multiple 174
120 reports of systemic findings observed in patients with 175
121 COVID-19, cutaneous manifestations of this disease 176
122 Fig 1. At initial presentation of periorbital dyschromia. have not been as widely described. Anecdotal and 177
123 (The photograph was obtained via telemedicine visits with 178
incidental cutaneous findings associated with
consent of the patient.)
124 COVID-19 have appeared in the literature, but no 179
125 systematic review of the cutaneous manifestation of 180
126 COVID-19 has been composed to date, to our 181
127 knowledge. Some of the cutaneous manifestations 182
128 of COVID-19 that have been described in the 183
129 literature have ranged from erythematous eruptions 184
130 involving the trunk, to widespread erythema and 185
131 chickenpox-like vesicles,1 to rash with petechia,3 to 186
132 confluent erythematous-yellowish papules on heels 187
133 bilaterally that progressed to hard erythematous 188
134 plaques.4 189
135 Furthermore, COVID-19 patients seem to be 190
Fig 2. At recurrence of periorbital dyschromia. (The
136 prone to coagulation dysfunction with signs of small 191
photograph was obtained via telemedicine visits with
137 blood vessel occlusion, as is evident by systemic, as 192
consent of the patient.)
138 well as cutaneous, findings of ischemia in the limbs. 193
139 These cutaneous manifestations of microcirculation 194
140 disorder that patients with COVID-19 may be devel- 195
141 oping can clinically present as findings ranging from 196
142 petechiae or tiny bruises, to nonpruritic blanching 197
143 livedoid vascular eruptions on extremities, to plantar 198
144 plaques, plantar vesicles, dry gangrene, or just 199
145 bruising in the fingers and toes.5 Perhaps the 200
146 periocular dyschromia that we have noticed is a 201
147 part of the coagulation dysfunction affecting the 202
148 periocular vasculature. Although much more 203
149 research is needed to evaluate the cutaneous man- 204
150 ifestations that accompany COVID-19, herein we 205
151 present our findings of periorbital dyschromia that 206
152 presents a few days before the onset of systemic 207
153 Fig 3. At resolution of periorbital dyschromia. (The manifestations of COVID-19 and does not have any 208
154 photograph was obtained via telemedicine visits with ocular findings, unlike in other reported studies.6 We 209
consent of the patient.)
155 believe that appearance of periorbital dyschromia 210
156 may serve as an early cutaneous manifestation of 211
157 creams or ointments were applied for his periorbital COVID-19 and as a precursor of the systemic 212
158 dyschromia during his hospitalization, and he re- symptoms that seem to follow this presentation. 213
159 ported that the rash resolved on its own, with 214
160 improvement in the systemic symptoms of COVID- REFERENCES 215
161 19. As with patient 1, patient 2 reported that he again 1. Recalcati S. Cutaneous manifestations in COVID-19: a first 216
perspective. J Eur Acad Dermatol Venereol. 2020. https://doi.org/
162 noticed periorbital dyschromia 2 days before wors- 10.1111/jdv.16387. Q4 217
163 ening of the systemic symptoms, with recurrence of 2. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus 218
164 fever, worsening cough, and shortness of breath after disease 2019 in China. N Engl J Med. 2020;382:1708-1720. 219
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221 3. Joob B, Wiwanitkit V. COVID-19 can present with a rash 5. Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and antiphos- 276
222 and be mistaken for dengue. J Am Acad Dermatol. 2020;82(5): pholipid antibodies in patients with Covid-19. N Engl J Med. 277
e177. 2020;382(17):e38.
223 278
4. Est
ebanez A, Perez-Santiago L, Silva E, et al. Cutaneous 6. Wu P, Duan F, Luo C, et al. Characteristics of ocular findings of
224 manifestations in COVID-19: a new contribution. J Eur patients with coronavirus disease 2019 (COVID-19) in Hubei 279
225 Acad Dermatol Venereol. 2020. https://doi.org/10.1111/jdv. Province, China. JAMA Ophthalmol. 2020. https://doi.org/ 280
226 16474. 10.1001/jamaophthalmol.2020.1291. 281
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