Concomitant calciphylaxis and COVID-19 associated thrombotic retiform purpura
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CASE REPORT
Concomitant calciphylaxis and COVID-19 associated thrombotic retiform purpura Jessica A. Rotman 1,2 & Kathryn E. Dean 1,2 & Cynthia Magro 1,3 & Gerard Nuovo 4 & Roger J. Bartolotta 1,2 Received: 20 May 2020 / Revised: 1 August 2020 / Accepted: 9 August 2020 # ISS 2020
Abstract While initial reports regarding coronavirus disease 2019 (COVID-19) focused on its pulmonary manifestations, more recent literature describes multisystem abnormalities related to its associated microvascular angiopathy. Calciphylaxis is a rare systemic condition characterized by tissue necrosis in the setting of systemic microvascular calcifications. Both COVID-19 and calciphylaxis are procoagulant diagnoses associated with vascular-mediated cutaneous findings. To our knowledge, this is the first report to document the coexistence of COVID-19 associated retiform thrombotic purpura and calciphylaxis in a single patient, to link the pathologic etiologies of the two entities, and to describe the concomitant diagnoses’ associated radiologic findings. Keywords COVID-19 . Calciphylaxis . CT . Ultrasound . Panniculitis
Introduction In addition to diffuse alveolar damage, which can be seen in the setting of viral pneumonia, complement-mediated microvascular injury and thrombosis play a critical role in the pathogenesis of acute respiratory distress syndrome associated with COVID19 [1]. Microangiopathy also plays a crucial part in the * Jessica A. Rotman [email protected] Kathryn E. Dean [email protected] Cynthia Magro [email protected] Gerard Nuovo [email protected] Roger J. Bartolotta [email protected] 1
Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
2
Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, New York, NY 10065, USA
3
Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, USA
4
OSU Comprehensive Cancer Center, Columbus, Ohio 43210, USA
development of extrapulmonary manifestations associated with COVID-19, including cutaneous retiform purpura, stroke, myocardial insufficiency, and acute renal failure [1]. Calciphylaxis (calcific uremic arteriolopathy) is a rare systemic condition that predominantly manifests as skin necrosis attributable to subcutaneous thrombotic calcific arteriopathy and microangiopathy. In the pathogenesis of calciphylaxis, there is a critical role for a bone-forming phenotype within the vasculature as well as a procoagulant state for triggering arterial intimal and microvascular adluminal calcification [1–4]. We report a case of an ischemic dermopathy syndrome developing in the setting of COVID-19 exhibiting hybrid overlapping features of retiform thrombotic purpura and calciphylaxis. The pathophysiology that underlies this distinctive presentation along with the associated radiologic findings is presented. By recognizing the ultrasound and CT appearance of the vasculopathy-mediated cutaneous manifestations of these systemic disorders, radiologists can play an essential role in
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