May 19, 2020

Skin manifestations of COVID-19 in young patients, environmental contamination by presymptomatic patients

By Denise Baez

NEW YORK -- May 19, 2020 -- In today’s DG Alert, we cover skin manifestations of coronavirus disease 2019 (COVID-19) in adolescents, and environmental contamination of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in a relatively short time by presymptomatic individuals.

In a small case series published in The Lancet Infectious Diseases, Emmanuele Venanzi Rullo, MD, University of Messina, Messina, Italy, and colleagues describe 3 young patients presenting with chilblain-like lesions who were diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Lesions involved the acral sites, especially the dorsum of the digits of the feet, beginning as erythematous-violaceous patches that slowly evolved to purpuric lesions and then to blisters and ulceronecrotic lesions, with final complete return to normal. Burning and itching were also present with some of the lesions.

The first patient was a boy aged 14 years who presented to the hospital with erythematous-violaceous lesions involving the dorsum of all digits of both feet. After 7 days, a few red macules and papules appeared on the lateral and plantar aspect of both feet and a small ulcer developed on the fifth digit of the left foot. Because a family member had tested positive for SARS-CoV-2, the patient underwent nasopharyngeal swab and was found positive for SARS-CoV-2. The lesions disappeared in the following 7 days.

The second patient was a boy aged 14 years with no known exposure to COVID-19. He had small erythematous-violaceous lesions on the dorsum of almost all digits of the feet. The lesions lasted 20 days, with complete healing. Nasopharyngeal swab taken by the family’s paediatrician 2 days after the skin manifestations appeared was positive for SARS-CoV-2.

The third patient was a male aged 18 years whose grandfather had COVID-19 pneumonia. Chilblain-like lesions involving the distal part of all digits of the feet appeared 2 days after fever onset, remained unchanged for 10 days, and then suddenly disappeared without treatment. Nasopharyngeal swab taken 4 days after the skin manifestations appeared was positive for SARS-CoV-2.

“Acute acro-ischaemic manifestations along the course of SARS-CoV-2 infection seem to be different from classic acrocyanosis, erythema pernio, and vasculitis; however, they could represent a cutaneous expression of the typical thrombotic pattern of COVID-19 due to hyperinflammation and altered coagulation and endothelial damage,” the authors wrote. “During this time, children and adolescents with chilblain-like lesions who are otherwise asymptomatic should undergo SARS-CoV-2 testing, which could help early detection of silent carriers.

Another study, published in Emerging Infectious Diseases, found extensive environmental contamination of SARS-CoV-2 RNA in a relatively short time (<24 hours) in occupied rooms of 2 persons who were presymptomatic.

The researchers found high levels of SARS-CoV-2 RNA on surface swab samples of the pillow cover, duvet cover, and sheets, highlighting the importance of proper handling procedures when changing or laundering used linens of patients with SARS-CoV-2.

Fa-Chun Jiang, Qingdao Municipal Center for Disease Control and Prevention, Qingdao, China, and colleagues examined the presence of SARS-CoV-2 RNA in collected environmental surface swab specimens from 2 rooms of a centralised quarantine hotel where 2 presymptomatic patients had stayed after returning home to China in March. Neither patient had fever or clinical symptoms. On the morning of the second day of quarantine, throat swab samples were collected at the same time that temperatures were taken, and both individuals tested positive for SARS-CoV-2 RNA. They were then transferred to a local hospital for treatment. At admission, they remained presymptomatic, but nasopharyngeal swab, sputum, and fecal samples were positive for SARS-CoV-2 RNA with high viral loads. Fever and cough developed in patient A on day 2 of hospitalisation. Patient B developed fever and cough on day 6 along with ground-glass opacities on chest CT scan.

The researchers sampled the surfaces of the rooms about 3 hours after the patients tested positive for SARS-CoV-2. Surfaces included the door handle, light switch, faucet handle, thermometer, television remote, pillow cover, duvet cover, sheet, towel, bathroom door handle, toilet seat, and toilet flushing button. Swab samples were also collected from 1 unoccupied room as a control measure. The researchers interpreted cycle threshold (Ct) <40 as positive for SARS-CoV-2 RNA and Ct ≥40 as negative.

Of the 22 samples collected, 8 (36%) were positive for SARS-CoV-2 RNA, with Ct values ranging from 28.75 to 37.59.

In patient A’s room, surface samples collected from the sheet, duvet cover, pillow cover, and towel tested positive for SARS-CoV-2 RNA. Ct from the pillow cover was 28.97 and Ct from the sheet was 30.58. Interestingly, the Ct values of these 2 samples correlated with the patient’s nasopharyngeal (24.73) and fecal (33.12) swab samples at hospital admission. In patient B’s room, one surface sample from the faucet was positive for SARS-CoV-2 RNA, with a Ct of 28.75, and surface samples of the pillow cover were positive with a Ct of 34.57. All control swab samples were negative for SARS-CoV-2 RNA.

“In our study, we demonstrate high viral load shedding in presymptomatic patients, which is consistent with previous studies, providing further evidence for the presymptomatic transmission of the virus,” the authors wrote. “In addition, presymptomatic patients with high viral load shedding can easily contaminate the environment in a short period. Our results also indicate a higher viral load detected after prolonged contact with sheets and pillow covers than with intermittent contact with the door handle and light switch. To minimise the possibility of dispersing virus through the air, we recommend that used linens not be shaken upon removal and that laundered items be thoroughly cleaned and dried to prevent additional spread.”

SOURCE: The Lancet Infectious Diseases, Emerging Infectious Diseases