Necrotic Plaques on the Ears of a Patient With COVID-19 | Critical Care Medicine | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Necrotic Plaques on the Ears of a Patient With COVID-19

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his 40s with a medical history of factor VII deficiency hemophilia presented with acute hypoxic respiratory failure secondary to COVID-19. Following admission, he was intubated with prone positioning, and treatment with tocilizumab and dexamethasone was started. He was also found to have Staphylococcus hemolyticus bacteremia, and treatment with cefepime was initiated. Three days after admission, the patient developed erythema and edematous necrotic plaques of the bilateral ears (Figure, A and B). No devices had been used on the ears. The necrosis progressed during the following days, primarily involving the earlobe of the right ear and a large portion of the helix of the left ear. A punch biopsy specimen was performed (Figure, C and D).

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

A. Pressure necrosis

Results of the biopsy specimen of the left ear revealed epidermal and dermal necrosis and ulceration; there was also necrosis of the eccrine glands (Figure, D). Although eccrine necrosis is not a specific finding, it is a consistent finding in pressure necrosis. The necrotic plaques improved and then resolved after prone positioning was discontinued and further pressure on the ears was avoided.

Pressure necrosis occurs from a lack of blood flow secondary to mechanical stress on the skin. Pressure necrosis in patients who are bedridden involves the sacral region. However, patients who are persistently hypoxemic often require prone positioning, subjecting other anatomic sites to prolonged pressures that exceed local capillary pressure.1 Prone positioning, often greater than 16 hours a day, is used as a therapy for moderate-to-severe cases of COVID-19 that require intubation. A retrospective cohort study highlighted the high incidence of facial pressure injuries in patients with severe COVID-19 who require prone positioning (47.6%), with a substantial association of duration of proning with ulcer development.2

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Kiran Motaparthi, MD, Department of Dermatology, University of Florida College of Medicine, 4037 NW 86 Terrace, 4th Floor, Gainesville, FL 32606 (kmotaparthi@dermatology.med.ufl.edu).

Published Online: April 13, 2022. doi:10.1001/jamadermatol.2022.0745

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Moore  ZE , Cowman  S .  Repositioning for treating pressure ulcers.   Cochrane Database Syst Rev. 2015;1(1):CD006898. Google Scholar
2.
Shearer  SC , Parsa  KM , Newark  A ,  et al.  Facial pressure injuries from prone positioning in the COVID-19 era.   Laryngoscope. 2021;131(7):E2139-E2142. doi:10.1002/lary.29374 PubMedGoogle ScholarCrossref
3.
Sayadi  L , Laub  D .  Levamisole-induced vasculitis.   Eplasty. 2018;18:ic5.Google Scholar
4.
Alonso  MN , Mata-Forte  T , García-León  N ,  et al.  Incidence, characteristics, laboratory findings and outcomes in acro-ischemia in COVID-19 patients.   Vasc Health Risk Manag. 2020;16:467-478. doi:10.2147/VHRM.S276530 Google ScholarCrossref
5.
Zhang  Y , Cao  W , Xiao  M ,  et al.  [Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acro-ischemia].  Article in Chinese.  Zhonghua Xue Ye Xue Za Zhi. 2020;41(0):E006. PubMedGoogle Scholar
6.
Vaiman  M , Lazarovitch  T , Heller  L , Lotan  G .  Ecthyma gangrenosum and ecthyma-like lesions: review article.   Eur J Clin Microbiol Infect Dis. 2015;34(4):633-639. doi:10.1007/s10096-014-2277-6 PubMedGoogle ScholarCrossref
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close