Rheumatic and Dermatological Manifestations in Paucisymptomatic COVID-19 Patients
https://doi.org/10.46856/grp.10.e068
Cite as:
Solis Cartas U, Valdés González JL, Hernandez Perdomo W, Martinez Larrarte JP. Rheumatic and Dermatological Manifestations in Paucisymptomatic COVID-19 Patients [Internet]. Global Rheumatology. Vol 2 / Ene - Jun [2021]. Available from: https://doi.org/10.46856/grp.10.e068
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Rheumatic and Dermatological Manifestations in Paucisymptomatic COVID-19 Patients
Introduction
COVID-19 patients exhibit a wide range of symptoms, including both respiratory and non-respiratory manifestations. Among the latter, general, dermatological, and rheumatic manifestations stand out, although the exact prevalence of these symptoms is not yet clearly established.
Objective
To identify the frequency of rheumatic and dermatological manifestations in patients with COVID-19.
Methodology
A descriptive, cross-sectional cohort study was conducted. The sample consisted of 387 patients with confirmed COVID-19 diagnoses who were hospitalized in public and private healthcare centers in the city of Riobamba, Chimborazo Province, Ecuador, during the months of June, July, and August 2020. Directed observation and document review were used as research techniques to identify the presence of dermatological and rheumatic manifestations.
Results
The average age of participants was 56.23 years, with a predominance of male patients (55.04%) and patients without associated comorbidities (36.44%). Dermatological manifestations were observed in 33.33% of cases, with maculopapular lesions being the most common (53.49%). Rheumatic manifestations occurred in 46.77% of cases, with arthralgia (51.93%) and myalgia (50.28%) being the most frequent.
Conclusion
Dermatological and rheumatic manifestations occur with relative frequency in patients with confirmed COVID-19 diagnoses and are part of the clinical presentation of the disease.
COVID-19 has become the focus of global medical attention. The rapid spread of the disease and the high number of infections and deaths have forced the scientific community to work intensively to respond to a situation that began in December 2019 and still persists today. (1)
The increase in infections is largely due to the high proportion of paucisymptomatic patients, who present clinical manifestations not initially attributed to COVID-19. In other words, the disease is not detected in its early stages in these patients, making them sources of transmission and increasing the risk of respiratory complications that can endanger their lives. (1,2)
The main health challenge lies in identifying certain non-respiratory clinical manifestations that may serve as early indicators of the disease, even before any respiratory involvement appears. In many cases, respiratory symptoms never develop, and the patient remains unaware of having had the disease, continuing to be an "asymptomatic" source of transmission. (3)
Various extrapulmonary manifestations have been described in patients with COVID-19. Among these, dermatological and rheumatic manifestations have been noted as some of the most clinically significant in different stages of the disease, even in paucisymptomatic patients. It is estimated that approximately 50% of patients with COVID-19 present rheumatic and 7% present dermatological manifestations as part of the systemic expression of the disease. (4–7)
Among rheumatic manifestations, muscular disorders such as fibromyalgia, and articular disorders such as reactive arthritis, are the most frequently reported. Both show an unusual course with a poor response to standard therapeutic approaches. (7,8)
Regarding dermatological manifestations, several patterns have been described, including: acral lesions resembling chilblains, vesicular eruptions, acute urticaria, maculopapular exanthems, and lesions suggestive of vascular obstruction, such as livedo reticularis, among others. These currently represent the main patterns identified and reported. (9)
In light of the current global epidemiological situation regarding COVID-19, it is essential to identify factors that could aid in the clinical suspicion of the disease in paucisymptomatic patients, while also analyzing international evidence that highlights the high frequency of rheumatic and dermatological manifestations in patients with COVID-19.
In this context, this study was conducted with the aim of identifying the frequency of rheumatic and dermatological manifestations in patients with confirmed COVID-19 who were treated in public and private health facilities in the city of Riobamba, Chimborazo Province, Ecuador.
A descriptive, cross-sectional cohort study was conducted. The sample consisted of 387 patients with confirmed COVID-19 diagnoses, hospitalized in public and private healthcare centers in the city of Riobamba, Chimborazo Province, Ecuador, during the months of June, July, and August 2020. All patients diagnosed with COVID-19 were included.
Directed observation and document review were used as research techniques. The document review involved a search for up-to-date information on general and specific elements related to the clinical behavior of COVID-19, including the presence and types of extrapulmonary manifestations, such as dermatological and rheumatic conditions.
Patient medical records were also reviewed to identify reports of rheumatic and dermatological manifestations, along with their various clinical patterns.
To identify fibromyalgia, the 1990 diagnostic criteria of the American College of Rheumatology (ACR) were used, which have a sensitivity of 88.4% and specificity of 81.1% (10). For the diagnosis of reactive arthritis, the guidelines of the 4th International Workshop on Reactive Arthritis were followed, confirming the diagnosis in cases of post-infectious arthritis that met the criteria for seronegative spondyloarthropathy (11).
A database was created in Excel to standardize all collected data. The information was processed using SPSS version 20.5 for Windows. Measures of central tendency and dispersion were calculated for quantitative variables, and absolute frequencies and percentages for qualitative variables. The results were presented in statistical tables to facilitate understanding.
Throughout the study, the standards and protocols set out in the Declaration of Helsinki for research involving human subjects were followed (12). Each patient was informed, prior to inclusion in the study, about the research objectives and methods. Participation was voluntary, and informed consent was signed and properly documented.
The study incurred no economic cost for patients or their families. The data were used exclusively for research and educational purposes. All information was treated with strict confidentiality—names, ID numbers, medical record numbers, home addresses, workplaces, or any other identifying information were not included. Only alphanumeric codes were used in very specific cases. All collected data was stored securely with password protection, accessible only to the principal investigator. Once data processing was complete, the database was deleted as the research objectives had been fulfilled, and retention was deemed unnecessary.
The analysis of the general characteristics of patients confirmed with COVID-19 is shown in Table 1, which reports an average age of 56.23 years, with a predominance of patients aged 40 to 60 years (42.38%), followed by those aged 60 years or older (35.40%). In terms of sex, there was a predominance of male patients (55.04%) compared to females.
36.44% of patients reported other comorbidities, the most frequent being arterial hypertension (44.68%) and hypothyroidism (24.11%). Other reported conditions included diabetes mellitus (21.98%), ischemic heart disease (19.86%), and bronchial asthma (10.64%). Additionally, 6.38% of patients reported chronic kidney disease, and only 2.13% had a history of rheumatoid arthritis (Table 1).
Table 2 shows that 33.33% of COVID-19 patients exhibited dermatological manifestations. Upon analyzing the predominant types, it was found to be statistically significant that 53.49% presented maculopapular lesions, 32.56% had acral lesions resembling chilblains, and 29.46% were diagnosed with acute urticaria.
As shown in Table 3, 46.77% of patients with confirmed COVID-19 presented rheumatic manifestations during the course of the disease. The most frequent symptoms were arthralgia (51.93%) and myalgia (50.28%), both statistically significant. Also reported were reactive arthritis (38.12%), fibromyalgia (29.28%), and muscle contractures (17.68%).
Table 4 displays the distribution of patients based on the studied general characteristics and the presence of dermatological and rheumatic manifestations. Notably, dermatological manifestations occurred more frequently in younger patients, with the highest percentage found in COVID-19 patients under 20 years of age, where 60.71% were affected. In contrast, rheumatic manifestations appeared most frequently in patients aged 60 years or older, reaching 60.58% in this group.
Although there was a predominance of male patients, dermatological and rheumatic manifestations were more frequently recorded in female patients. Dermatological signs were observed in 42.52% of women and only 25.82% of men. Regarding rheumatic manifestations, 59.19% of women presented these conditions (Table 4). Patients with associated comorbidities had the highest percentage of rheumatic manifestations (58.16%), whereas dermatological manifestations were more commonly found in patients without comorbidities (33.33%) (Table 4).
COVID-19 is a novel disease in which, despite the numerous studies conducted, many details remain to be understood, defined, and mastered. Therefore, it is urgent to investigate the elements that can reduce infection rates and enable early diagnosis of the disease. (1)
In this regard, it is important to understand the frequency of extrapulmonary manifestations during the clinical course of COVID-19, as this will provide a broader and more comprehensive picture of the disease. Such knowledge can aid in identifying early signs that may precede respiratory involvement.
Dermatological and rheumatic manifestations clearly stand out as part of the immune system involvement caused by the virus. A key element is the systemic involvement of the disease, which affects the functioning of various vital organs, increases hemostatic imbalance, and, consequently, leads to a higher number of complications that, in advanced cases, can result in death.
Muscle and joint involvement has also been observed and reported in other viral illnesses such as dengue, Zika, and chikungunya (13–15). These manifestations were likewise reported during previous SARS and MERS outbreaks (16,17). One possible explanation for this phenomenon lies in the formation of immune complexes resulting from toxins released during viral infection (15,16). Authors such as Ciaffi et al. (18) and Parisi et al. (19) have reported that myalgia and arthralgia are commonly described signs and symptoms in the early stages of COVID-19.
Several authors have reported the presence of dermatological manifestations during the course of COVID-19 (9). The extent and severity of these skin manifestations vary and are linked to different patterns of dermatological involvement (20,21). A finding highlighted in this study—and in other research—is the higher prevalence of skin manifestations among younger patients (22). This may be due to the relative immaturity of the skin layers, which are more reactive to immune disturbances triggered by COVID-19 at younger ages (23).
The maculopapular pattern was the most frequently observed manifestation, a result also reported in the study by Maqueda et al. (9). Bender del Busto et al. (24) also describe maculopapular lesions, acute urticaria, and vesicular eruptions as the most common dermatological presentations. An important contribution is made by Mirza et al. (25), who reported chilblain-like lesions and maculopapular erythematous rashes as the most frequently identified dermatological manifestations.
Undoubtedly, COVID-19 is characterized by a wide array of clinical presentations. Among these, rheumatic manifestations are noted for muscle and joint involvement, and various patterns of skin involvement have also been recorded. Understanding these types of symptoms allows for a faster and more accurate diagnosis of the disease.
The limitations of this study included restricted access to patients and incomplete information on the disease’s progression, as well as strict biosafety protocols that occasionally posed challenges to the research team. Other limitations included the absence of established classification criteria for rheumatic and/or dermatological manifestations. Therefore, the criteria used to identify the different manifestations relied primarily on their clinical features and semiological elements.
The research team considers it important to point out two characteristics of this study: first, it did not aim to establish causal relationships between COVID-19 and any specific type of rheumatic and/or dermatological manifestation. Achieving this would require more in-depth studies using different research methodologies. Second, no modifications or manipulations of research variables were made, and no direct actions were taken with patients that could have posed harm, injury, or risk. For this reason, although reasonable, approval by a research ethics committee was not deemed necessary.
It is concluded that dermatological (Photo 1) and rheumatic (Photo 2) manifestations occur with relative frequency in patients with a confirmed diagnosis of COVID-19 as part of the clinical presentation of the disease.
Dermatological manifestations appear more frequently in patients under 40 years of age, female, and without associated comorbidities.
Rheumatic manifestations are more commonly found in patients over 40 years of age, female, and with associated comorbidities.
The authors declare no conflicts of interest.
No funding was received for the conduct of this research. All expenses were covered by the authors.
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