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.