‘Covid Toes’ Are Caused By Coronavirus Infecting The Lining Of Blood Vessels, Says New Study 11/14/20, 8:15 PM

EDITORS' PICK | 43,436 views | Jul 23, 2020, 03:11pm EDT

‘Covid Toes’ Are Caused By

Coronavirus Infecting The
Lining Of Blood Vessels, Says
New Study
Victoria Forster Contributor
Healthcare
Cancer research scientist and childhood cancer survivor.

Covid toes are one of the more strange symptoms associated with the coronavirus outbreak. Now
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‘Covid Toes’ Are Caused By Coronavirus Infecting The Lining Of Blood Vessels, Says New Study 11/14/20, 8:15 PM

Among one of the odder reported symptoms of Covid-19 has been the
mysterious “COVID toes.” People have been reporting that their toes are
red, sore, itchy and discolored, often with no or limited other symptoms
that would indicate they were sick with Covid-19. For many, the condition
feels and looks like chilblains, which can be experienced when toes and
feet get too cold, but shortly after the pandemic started, reports and even
tweets from people experiencing these symptoms started to roll in from all
over the world, including in warm places where this was unlikely to be the
cause.

Dermatologists have been puzzling over this for months, collecting more
information and cases and now they might have just found out why the
SARS-CoV2 seems to cause these rather unusual symptoms.

A new study from Spain recently published in the British Journal of

Dermatology looked at 7 children with painful chilblain-like symptoms on
their toes, taking a tiny biopsy sample from the toes to look at under a
specialized microscope, capable of seeing viruses. They found what looks
like coronavirus particles within the tiny blood vessel cells of the feet and
confirmed this by using a separate test. That the viral particles were there
does not 100% implicate them in causing COVID toes, but it provides
some of the strongest evidence yet that the virus may be directly
responsible for this symptom.

Despite the children having no respiratory symptoms, the next obvious

step was to see whether the virus could be detected using a nasal swab to
test for the genetic material of the virus, the standard method of testing
used to screen people around the world. The children were given the
swabs which were then sent for a PCR test, used to identify the virus. All

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‘Covid Toes’ Are Caused By Coronavirus Infecting The Lining Of Blood Vessels, Says New Study 11/14/20, 8:15 PM

of them were negative.

“The fact that all tested children were respiratory PCR-negative was
interesting, especially since the SARS-CoV-2 virus was visualized on the
biopsy specimens,” said Roxana Daneshjou, MD, PhD, Dermatologist and
Clinical Scholar at Stanford Dermatology. “An interesting question would
be whether these children end up developing antibodies. Though this was
a small case series, it is certainly a start in our understanding of the
chilblains-like skin eruption and its relationship with SARS-CoV-2,” she
added.

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That particular study didn’t test for antibodies, which indicate a previous
infection with the coronavirus. But shortly afterwards another larger study
from France looked at over 300 people including adults and children with
skin complaints that coincided with the Covid-19 outbreak in the country.
Two-thirds of the people in the study had chilblains, but of 121 people who
were tested via standard PCR for the virus only 7 were positive. Of 75
people who were tested for antibodies, only 5 were considered positive.

“We are still trying to figure out the exact relationship between "COVID
toes" and the virus with regards to whether a person is infectious or will
develop immunity as a result. Other causes of chilblains still exist, so we

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‘Covid Toes’ Are Caused By Coronavirus Infecting The Lining Of Blood Vessels, Says New Study 11/14/20, 8:15 PM

recommend a person see their primary care doctor or dermatologist if

they notice these skin findings,” said Daneshjou.

It was initially thought that COVID toes were just found in children and
younger adults, but as more data is collected this is turning out not to be
true. Esther Freeman, dermatologist and an assistant professor at
Harvard Medicine has been leading a worldwide effort to collect cases of
COVID toes and other skin complaints that may be associated with Covid-
19, in an attempt to learn more about how the disease affects the skin.

“Some of the early buzz suggested it was just in kids – but we are seeing it
across the whole age spectrum. Around three quarters of people who have
these symptoms in our registry are 22-59 years old,” said Freeman.

Freeman, who also has a background in infectious disease epidemiology,

explains that “COVID toes” are often a symptom of quite mild Covid-19,
with early data showing that only 16% of people who experience the
symptom are hospitalized with Covid-19. However, it is still a bit of a
mystery as to when people develop COVID toes in relation to when they
were actually infected with the coronavirus.

“Many of our patients, we don’t know when their infection actually was.
It’s a little hard to pin it down, some are actively shedding virus, but most
patients are PCR negative when tested,” said Freeman, noting that some
people develop COVID toes concurrently with other more typical Covid-19
symptoms, but that she’s also seen people come in weeks or months after
more traditional symptoms.

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“In our study – there are several other rashes we are seeing commonly.
For example, morbilliform rash – this is a non-specific rash seen with
many viruses such as measles – we see this commonly. If you’d asked a
dermatologist before Covid-19, what rash do you expect to see, it would be
this one,” said Freeman.

The rashes sometimes correlated with the severity of disease, with most

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‘Covid Toes’ Are Caused By Coronavirus Infecting The Lining Of Blood Vessels, Says New Study 11/14/20, 8:15 PM

people with “COVID toes” having mild disease, in contrast to a condition

called retiform purpura, where blood cells leak into the skin creating
purple, net-like patches and skin cell death. In the study, retiform
purpura, unlike COVID toes, was associated specifically in hospitalized
patients with severe disease.

“Covid-19 is causing so many different rashes. When you get chickenpox it

looks a certain way, but with COVID, there is no “COVID rash”, there’s
many different skin findings. We are seeing this with COVID in general,
many people have wildly different severity of lung symptoms, this is the
same as we’ve been seeing with skin,” said Freeman.

Although researchers are still learning about COVID skin rashes and their
exact relationship with coronavirus infection, including likelihood of a
positive result via PCR or antibody testing, Freeman urges physicians and
the public to be vigilant about this symptom.

“People who develop this should get tested for Covid-19, as some people
are still actively shedding virus. Our job is to stop the epidemic. We need
to stop people who are infectious from transmitting the virus. Identifying
people who are infectious but might not know it is extremely important,”
said Freeman.

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I am a postdoctoral research scientist focusing on childhood cancers and new,

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