Discussion
The main target of the SARS-CoV2 is the respiratory system. Typical
manifestations include fever, sore throat, dry cough, fatigue, diarrhea,
hyposmia and hypogeusia7. Simultaneously, the
infection can be associated with multiorgan dysfunctions. The viruses
bind to angiotensin-converting enzyme 2 receptors, which are present in
all cells, including in endothelial cells leading to microvascular
dysfunction8. Upon entering host cells, the viruses
replicate and destroy them. This process induces organ damage, release
of proinflammatory cytokines, chemokines, and activation of the
complement system which all lead to the hyperinflammation state known as
“cytokine storm”2. Both microvascular dysfunction
and cytokine storm are involved in thrombotic and ischemic
manifestations3. Several studies have reported
different signs of acral ischemia such as pseudo-chilblains, livedo
reticularis and dry gangrene4–6. Chilblains occur
more commonly in young patients with mild or asymptomatic form of the
disease4,6. However, as in our case, the other
manifestations of acral ischemia, including gangrene and livedo
reticularis often occur in patients with severe disease, with a
mortality rate of 10%6. This group of patients may
present with a misleading form of the disease in a context of a
confusing hidden severity. Thus, they don’t always develop signs that
require hospitalization, like the case of our patient who did not
develop respiratory signs or asymptomatic hypoxemia.
The particularity of our case consists in the appearance of ischemic
skin manifestations of SARS-CoV2 infection and in the severe course of
the disease leading to death without any respiratory signs. Considering
the arteriopathy and the cholesterol embolization syndrome, the
infection precipitated the evolution of lesions that would heal towards
dry gangrene.