Isolated “puffy hands” following COVID-19: clue to a long-term capillary leakage syndrome?

Abstract

Post-acute sequelae of SARS-CoV-2 infection (post-acute COVID-19 syndrome (PACS)) represent a novel challenge for physicians dealing with individuals recovering from COVID-19. However, the entire spectrum of long-term consequences of COVID-19 is still far to be fully elucidated [1]. Although persistent cutaneous and musculoskeletal complaints have been described in long-hauler patients [2], literature about the manifestations of potential rheumatological interest developing weeks to months after COVID-19 is still limited. Here we share the cases of two female patients aged, respectively, 28 and 33 years, attending our rheumatology clinic between March and April 2021 with a history of recent-onset, painful, bilateral swelling of the hands. At the time of the first evaluation, the patients reported no other medical conditions and in particular no history of symptoms consistent with Raynaud’s phenomenon, were not taking any medication and had no known allergies. Both patients reported a positive SARS-CoV-2 real-time PCR on nasopharyngeal swab, respectively, 6 and 8 weeks before the onset of symptoms. The course of COVID-19 was mild, characterized by headache and myalgia in one case and dry cough with low-grade fever in the other. Notably, hand swelling was not present during the acute phase of the infection. After resolution of symptoms, a second nasopharyngeal swab was obtained, testing negative. Clinical examination revealed a moderate bilateral, nonpitting oedema of the hands and fingers, with erythematous skin, fissures over the interphalangeal joints and tenderness on palpation (patient 1, Fig. 1A). Skin thickening, fingertip lesions and telangiectasia were absent; no urticarial eruptions or pernio was present. Radial and brachial pulses were symmetrical. Complete blood count, liver, kidney and thyroid function were normal, as were acute phase reactants and levels of complement fractions. Furthermore, antinuclear antibodies, antineutrophil cytoplasmic antibodies, cryoglobulins, anticyclic citrullinated peptide antibodies and rheumatoid factor were absent. Nailfold videocapillaroscopy was performed in both patients, demonstrating mild pericapillary oedema but wellpreserved capillary distribution, arrangement and morphology (patient 1, Fig. 1B). Ultrasound of hands and wrists confirmed the oedematous thickening of subcutaneous layer with no evidence of synovitis, joint effusion or tenosynovitis. Finally, arterial and venous Doppler sonography of the upper limbs was normal. Empirically, a short course of glucocorticoids was prescribed, resulting in only minor improvement. Besides the well-known dermatological sequelae of COVID-19 [2], our cases highlight the possibility of a * Jacopo Ciaffi [email protected]