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Eruptive pseudoangiomatosis: An outbreak in the third wave of COVID-19

 Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India

Date of Submission07-Aug-2022
Date of Decision31-Aug-2022
Date of Acceptance09-Sep-2022
Date of Web Publication21-Nov-2022

Correspondence Address:
Bhavni Oberoi,
Department of Dermatology, INHS Asvini, Near RC Church, Colaba, Mumbai - 400 005, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_129_22


A range of skin manifestations has been reported since the beginning of the COVID-19 pandemic. These findings earlier thought to be due to direct cytopathic effects of the virus are now predominantly known to be paraviral eruptions due to an immune reaction to the virus. Eruptive pseudoangiomatosis is one such paraviral eruption which has been scarcely reported to be associated with COVID-19 vaccination or infection. We did not find any such association during the first two waves of COVID; however, we found a phenomenal increase in cases of eruptive pseudoangiomatosis with the third wave of COVID-19 in India which coincided with the spread of the Omicron variant. Hereby, we report a case series of ten such cases. All these cases had a temporal correlation with COVID-19 infection and resolved spontaneously without recurrence within 14 days.

Keywords: COVID-19, eruptive pseudoangiomatosis, paraviral eruption, third wave

How to cite this URL:
Oberoi B, Agarwal R, Rajput GR. Eruptive pseudoangiomatosis: An outbreak in the third wave of COVID-19. J Mar Med Soc [Epub ahead of print] [cited 2023 Mar 21]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=361666

  Introduction Top

The COVID-19 pandemic has constantly intrigued physicians across the globe. Along with systemic manifestations, a range of cutaneous manifestations has been described having correlation with the severity and prognosis of the disease. Most of these cutaneous findings are now predominantly considered to be paraviral eruptions which are not directly related to the cytopathic effects of the virus.[1] Eruptive angiomatosis is one such paraviral eruption. Throughout the COVID-19 pandemic, we were constantly scrutinizing these patients for skin findings. We noticed a number of patients presenting with lesions of eruptive pseudoangiomatosis with the third wave which coincided with the Omicron variant in India. Despite having a daily admission state of over 250 patients during the peak COVID times, we did not notice such lesions during the previous two waves and hereby report a case series of ten such cases.

  Case Series Top

Ten patients presented to us during the peak of the third wave of COVID in India (December 2021 and January 2022) with a history of multiple eruptive erythematous lesions ranging in size from 2 to 5 mm. All these patients gave a consistent history of the development of symptoms within 15 days of being diagnosed with COVID-19 infection or symptoms of the same. Six of these patients had symptomatic pruritus while four were asymptomatic. All the lesions were branchable on diascopy with a few occasional red dots and most of the lesions had a characteristic distinct perilesional pale halo [Figure 1].
Figure 1: 36-year-old male with multiple erythematous papules having a characteristic pale halo (blue star) on the trunk

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A detailed description of these patients is provided in [Table 1]. All the patients were real time reverse transcription–polymerase chain reaction positive and were symptomatic with only fever (n = 4) or fever with sore throat (n = 6). The mean duration between the onset of fever and the appearance of symptoms was 10.8 days. The most common site of distribution was acral (n = 6), followed by generalized (n = 3) and one had only truncal involvement. The baseline investigations of all ten patients including complete blood count, liver, and renal function tests turned out to be normal. Erythrocyte sedimentation rate was found to be raised in four out of ten patients. Dermoscopy (Dermlite DL4, ×10 magnification) of the lesions revealed a reddish structureless area with a few red dots in the center with a brownish peripheral pigmentary network [Figure 2]. Histopathological examination revealed endothelial cell swelling, lymphomononuclear infiltrate around the vessel walls, and extravasation of red blood cells with no definite features of vasculitis [Figure 3]. All the patients were treated symptomatically with emollients and antihistamines if pruritus was present, and the lesions resolved spontaneously with no recurrence. The median duration of the resolution was 11 days with most of the lesions resolving between 6 and 14 days with one outlier value (resolution after 35 days).
Figure 2: Polarized dermoscopy of a lesion on the extremity showing few red dots (blue arrow), a reddish structureless area (yellow arrow) and a peripheral pigmentary network (red arrow); (Dermlite DL4 Dermoscope at ×10)

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Figure 3: Dilated vessels in the upper dermis with plump endothelial cells and surrounding mononuclear infiltrate (black star) and few extravasated RBCs (red star) with no definite features of vasculitis; (H and E, ×40)

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Table 1: Detailed clinical presentation of the cases

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  Discussion Top

Eruptive pseudoangiomatosis was originally reported to be predominantly associated with echovirus infection.[2] These lesions clinically resemble angiomata or cherry angiomas, however, on histopathology, there is no evidence of vasculitis or vascular proliferation and hence it has been given the term “pseudoangiomata.”

There has been a vigorous search for cutaneous manifestations of COVID which mainly included maculopapular rash, urticaria, chilblain like lesions, and vascular lesions such as livedo reticularis and vasculitis among many others. However, this entity of eruptive pseudoangiomatosis has been infrequently reported and that too more with COVID-19 vaccination in some case series[3],[4],[5] and rarely with infection[6] in a few reports. In one of the case series, all five patients were asymptomatic within 10 days, whereas the time to resolution in our patients was slightly longer with most resolving within 14 days which was similar to the resolution time previously described with the echovirus correlation. Our dermoscopy and histopathology findings were similar to the ones described earlier with an additional finding of peripheral pigmentary network on dermoscopy. The blanching seen on dermoscopy was due to the transitory dermal blood vessel dilatation which can be seen as the reddish structureless area. The few red dots in the center over that explain the extravasated RBCs. In this correspondence, we aim to bring to light further emphasis on this rare paraviral exanthem and its association with COVID-19 and it would be interesting to know if some other researchers or physicians also found a similar increase in these cases with the third wave or Omicron variant.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Lipsker D. Paraviral eruptions in the era of COVID-19: Do some skin manifestations point to a natural resistance to SARS-CoV-2? Clin Dermatol 2020;38:757-61.  Back to cited text no. 1
Cherry JD, Bobinski JE, Horvath FL, Comerci GD. Acute hemangioma-like lesions associated with ECHO viral infections. Pediatrics 1969;44:498-502.  Back to cited text no. 2
Mohta A, Jain SK, Mehta RD, Arora A. Development of eruptive pseudoangiomatosis following COVID-19 immunization – Apropos of 5 cases. J Eur Acad Dermatol Venereol 2021;35:e722-5.  Back to cited text no. 3
Moya-Martinez C, Berná-Rico ED, Melian-Olivera A, Moreno-Garcia Del Real C, Fernández-Nieto D. Comment on 'development of eruptive pseudoangiomatosis following COVID-19 inmunization-apropos of 5 cases': Could eruptive pseudoangiomatosis represent a paraviral eruption associated with SARS-CoV-2? J Eur Acad Dermatol Venereol 2022;36:e95-7.  Back to cited text no. 4
Mohta A, Sharma MK, Ghiya BC, Mehta RD. Clinical, histopathological, and dermatoscopic characterization of eruptive pseudoangioma developing after COVID-19 vaccination-A case-series. J Cosmet Dermatol 2022;21:1799-801.  Back to cited text no. 5
Alonzo Caldarelli A, Barba P, Hurtado M. Eruptive pseudoangiomatosis and SARS-CoV-2 (COVID-19) infection. Int J Dermatol 2021;60:1028-9.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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