SARS-CoV-2 PCR testing of skin for COVID-19 diagnostics: a case report – The Lancet

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SARS-CoV-2 PCR testing of skin for COVID-19 diagnostics: a case report – The Lancet


Understanding the disease course and prevalence of COVID-19 is important not only for medical, but also for socioeconomic reasons. So far, COVID-19 has been understood as a multisystem disease, mainly affecting the lungs, kidneys, and heart.

  • Menter T
  • Haslbauer JD
  • Nienhold R
  • et al.

Postmortem examination of COVID-19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings in lungs and other organs suggesting vascular dysfunction.

In the past few months, different cutaneous manifestations, such as chilblain-like, vasculitis-like, or urticaria-like lesions, have been described in patients with COVID-19.

  • Recalcati S

Cutaneous manifestations in COVID-19: a first perspective.

Colmenero and colleagues

  • Colmenero I
  • Santonja C
  • Alonso-Riaño M
  • et al.

SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases.

detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in endothelial cells of cutaneous chilblain lesions via immunohistochemistry methods in seven paediatric patients with negative nasopharyngeal swabs.

  • Colmenero I
  • Santonja C
  • Alonso-Riaño M
  • et al.

SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases.

Here, we report the case of an 81-year-old woman who presented at the Department of Dermatology at the University Hospital of Basel, Basel, Switzerland, with a temperature of up to 39°C and a generalised macular eruption with partial vasculitis-like patterns and palmoplantar accentuation (

appendix pp 1–2

). Infection with SARS-CoV-2 was suspected and laboratory assessments of blood samples showed increased C-reactive protein (248 mg/L), decreased lymphocyte count (7·7%), and negative

Treponema pallidum

serology. A SARS-CoV-2 PCR (nasopharyngeal swab, Cobas SARS-CoV-2 Test, Roche Diagnostics, Rotkreuz, Switzerland) was negative. 2 days later, a lesional whole skin 4 mm punch biopsy sample was taken from the left flank, which showed a subacute lichenoid interface dermatitis with vacuolisation of the basal epidermal keratinocytes and scant lymphohistiocytic perivascular infiltration in the upper dermis. No leukocytoclastic vasculitis or microthrombosis was present (

appendix pp 1–2

). Over the next 2 weeks, the patient’s rash gradually improved. 6 weeks later, serology tests against anti-SARS-CoV-2 antibodies (Elecsys Anti-SARS-CoV-2, Roche Diagnostics, Rotkreuz, Switzerland) were negative. However, PCR testing of the skin using established methods

  • Menter T
  • Haslbauer JD
  • Nienhold R
  • et al.

Postmortem examination of COVID-19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings in lungs and other organs suggesting vascular dysfunction.

detected SARS-CoV-2 at low copy numbers (37 per 1 × 10

6

human

RPPH1

copies).

This case is important because it highlights the shortcomings of currently available testing methods for SARS-CoV-2 infection. Although the sensitivity and specificity of currently available PCR and serology tests are high, swab samples that are taken incorrectly are known drivers of the relatively large number of false negative tests for SARS-CoV-2.

  • Wang W
  • Xu Y
  • Gao R
  • et al.

Detection of SARS-CoV-2 in different types of clinical specimens.

Our finding that the patient’s serology remained negative is compatible with the hypothesis that some patients with COVID-19 might not establish humoral immunity; an observation that has also been made for other coronaviruses.

  • Randolph HE
  • Barreiro LB

Herd immunity: understanding COVID-19.

In summary, this case emphasises the use of SARS-CoV-2 PCR testing of skin biopsy samples as an additional diagnostic tool, helping to shed light on the actual prevalence of COVID-19 in the general population. Additionally, further studies are needed to understand to what extent and at what point during their disease course patients with COVID-19 actually develop immunity—a question of uttermost importance, especially with regards to the currently ongoing efforts to develop a vaccine to SARS-CoV-2, and the concept of herd immunity generation.

We declare no competing interests. AT has been supported by the Botnar Research Centre for Child Health. ER thanks the Filling the Gap Grant of the University of Zurich, Zurich, Switzerland, for their support. Patient approval for publication of clinical data and pictures was acquired according to international ethics standards.

Supplementary Material

References

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    • Menter T
    • Haslbauer JD
    • Nienhold R
    • et al.

    Postmortem examination of COVID-19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings in lungs and other organs suggesting vascular dysfunction.

    Histopathology.2020;()

  2. 2.
    • Recalcati S

    Cutaneous manifestations in COVID-19: a first perspective.

    J Eur Acad Dermatol Venereol.2020;34:e212-e213

  3. 3.
    • Colmenero I
    • Santonja C
    • Alonso-Riaño M
    • et al.

    SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases.

    Br J Dermatol.2020;()

  4. 4.
    • Wang W
    • Xu Y
    • Gao R
    • et al.

    Detection of SARS-CoV-2 in different types of clinical specimens.

    JAMA.2020;323:1843-1844

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    • Randolph HE
    • Barreiro LB

    Herd immunity: understanding COVID-19.

    Immunity.2020;52:737-741

Article Info

Publication History

Published: August 13, 2020

Identification

DOI:https://doi.org/10.1016/S0140-6736(20)31754-2

Copyright

© 2020 Elsevier Ltd. All rights reserved.

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