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Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 58

Coumarin in COVID long-hauler

Department of Dermatology, AIIMS Raebareli, Raebareli, Uttar Pradesh, India

Date of Submission10-Mar-2021
Date of Decision04-Oct-2021
Date of Acceptance05-Dec-2021
Date of Web Publication25-Feb-2022

Correspondence Address:
K Geetha
Department of Dermatology, AIIMS Raebareli, Raebareli, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cdr.cdr_18_21

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How to cite this article:
Geetha K. Coumarin in COVID long-hauler. Clin Dermatol Rev 2022;6:58

How to cite this URL:
Geetha K. Coumarin in COVID long-hauler. Clin Dermatol Rev [serial online] 2022 [cited 2022 Sep 25];6:58. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/1/58/338591

Dear Editor,

Patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) who experience prolonged symptoms have been termed “long-haulers” or are said to have “long COVID.” Studies report that 66%–87% of patients continued to have one or more COVID-19 symptoms 60 days after polymerase chain reaction positivity.[1] The purpose of this case report is to bring attention to skin manifestations post-COVID-19 and the importance of anticoagulation therapy in the treatment of COVID manifestations.

The cutaneous manifestations seen in COVID-19 include six main clinical patterns, namely urticarial rash, confluent erythematous maculopapular morbilliform rash, papulovesicular exanthema, chilblain-like acral pattern, livedo reticularis–livedo racemosa-like pattern, and purpuric “vasculitic” pattern. Of all the manifestations, pernio/chilblains were long-haulers with toe symptoms lasting at least 60 days, with two laboratory-confirmed patients with COVID toes lasting longer than 130 days.[1]

A 65-year-old man with a personal history of diabetes mellitus and hypertension presented with swelling, discoloration, and pain over the right second toe for past 10 days. He had intermittent claudication pain of Stage IIA as per Fontaine classification for peripheral arterial disease. Previously, he was admitted and treated for SARS-CoV-2 pneumonia before 2 months. His blood tests showed elevation of inflammatory markers such as leukocytes, erythrocyte sedimentation rate, C-reactive protein, ferritin, and interleukin-6. He was treated with remdesivir and mechanical ventilation for 10 days.

He developed swelling and discoloration of the right second toe gradually after discharge [Figure 1]. Initially, he was treated with oral antibiotics and anti-inflammatory agents with very minimal response. Later, investigations were done to rule out arthritis which showed normal values with negative ANA report. He was treated with steroids, calcium dobesilate, bromelain, and rutoside supplements with no effect. His magnetic resonance imaging of the right foot and ankle showed diffuse soft tissue swelling with no evidence of osteomyelitis or Charcot joint. Venous Doppler study was normal. Arterial Doppler study of right lower limb showed peripheral arterial obstructive disease with arteriosclerosis and reduced volume and velocity of the triphasic flow pattern in posterior tibial, anterior tibial, and dorsalis pedis arteries. He was prescribed oral anticoagulant coumarin 200 mg twice daily with chymotrypsin for 2 weeks. The swelling and discoloration reduced with marked improvement in claudication pain.
Figure 1: Post-COVID-19 cutaneous manifestation

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COVID-19 disease causes mainly respiratory disease with reports of cardiovascular, gastrointestinal, neurologic, and hematologic manifestations. There are multiple reports of peripheral extremity arterial occlusion in COVID-19 patients. They are more commonly seen in those with other comorbid conditions such as diabetes, obesity, and hypertension with increased inflammatory markers.[2]

The hypercoagulable state and endothelial injury through the angiotensin-converting enzyme 2 receptor by the coronavirus causes a spectrum of clinical manifestations such as chilblains, acral cyanosis, bruising, hemorrhagic bulla, dry gangrene, and acute limb-threatening ischemia.[3] The severity of peripheral arterial disease is assessed using a functional classification system (Fontaine or Rutherford). Critical limb ischemia is the most severe grade, which requires rapid revascularization to avoid tissue loss and amputation.[4] If limb ischemia is suspected, use of thrombolytic therapies such as tissue plasminogen activator and heparin products has to be started. Therefore, higher doses of prophylactic anticoagulation have to be started for patients with severe COVID-19 in the absence of obvious contraindications such as ongoing bleeding.[5] This case report has shown the importance of COVID long-hauler and the role of anticoagulants in the treatment of cutaneous manifestations post-COVID 19 infections.

Informed consent

Informed consent was obtained from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Genovese G, Moltrasio C, Berti E, Marzano AV. Skin manifestations associated with COVID-19: Current knowledge and future perspectives. Dermatology 2021;237:1-12.  Back to cited text no. 1
Ogawa M, Doo FX, Somwaru AS, Roudenko A, Kamath A, Friedman B. Peripheral arterial occlusion due to COVID-19: CT angiography findings of nine patients. Clin Imaging 2021;73:43-7.  Back to cited text no. 2
Putko RM, Bedrin MD, Clark DM, Piscoya AS, Dunn JC, Nesti LJ. SARS-CoV-2 and limb ischemia: A systematic review. J Clin Orthop Trauma 2021;12:194-9.  Back to cited text no. 3
Sena G, Gallelli G. An increased severity of peripheral arterial disease in the COVID-19 era. J Vasc Surg 2020;72:758.  Back to cited text no. 4
Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res 2020;194:101-15.  Back to cited text no. 5


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