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Dermatology

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

JAMA Dermatology

Published Online: April 13, 2022

JAMA Dermatology Clinicopathological Challenge

Article Information and Disclosures

Erika Tvedten, BS¹;

Tyler Marion, MD, MBA²;

Kiran Motaparthi, MD²

Author Affiliations

¹Michigan State University College of Osteopathic Medicine, East Lansing
²Department of Dermatology, University of Florida College of Medicine, Gainesville

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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).

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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

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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

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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. PubMed Google Scholar

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 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.