A case of COVID-19 accompanied by cherry angiomas

[pattismith]

SciELO - Brazil - A case of COVID-19 with papulovesicular rash that progressed to retiform purpura, accompanied by cherry angiomas A case of COVID-19 with papulovesicular rash that progressed to retiform purpura, accompanied by cherry angiomas

Cherry angiomas are generally seen on the trunk in middle-aged adults. Their pathogenesis is not well understood. It has been suggested that immune dysregulation of the skin could be a predisposing factor for the development of eruptive cherry angiomas.9 Cherry angiomas in COVID-19 cases have only been rarely reported in the literature. Eruptive cherry angioma of the back has been reported.7 Cherry angiomas were noticed in the case of our patient when the lesions gained reticular purpuric characteristics. The simultaneous occurrence of two types of lesions may indicate a common etiopathogenesis. In a previous study, it was determined histopathologically that angiotensin-converting enzyme 2 (ACE2) receptors were secreted from endothelial cells and that the virus caused endotheliitis through this receptor.10 Retiform purpura and eruptive cherry angioma formation in the patient could be caused by endotheliitis. The occurrences of lesions on the patient’s extremities made it easier to recognize and monitor them.

Endothelial cell involvement in COVID-19 patients was recently observed. It was demonstrated histologically that these cells express ACE2 receptors, through which SARS-CoV-2 manages to infect the host, accompanied by viral elements and inflammatory cells. These findings suggest that SARS-CoV-2 infection may produce endotheliitis in different organs, including the skin, as a direct effect from the presence of the virus and host’s inflammatory response.10 Maculopapular rash, one of the skin manifestations associated with coronavirus, is the most frequently reported skin manifestation, although cases of retiform purpura and, rarely, cherry angioma have also been reported

 

[pattismith]

HHV8 already suspected in some cherry angioma eruptions:

Detection of human herpesvirus 8 sequences in cutaneous cherry angiomas - PubMed (nih.gov)

P403 : A case of hemangioma with expression of human herpes virus 8 < 논문상세 < 페이퍼서치 (papersearch.net)

In this good article:

Cherry Hemangioma Article (statpearls.com)

Etiology


There is no well-known cause of cherry angiomas. Some of the associations and possible etiologies of these lesions are as follows.

1. Aging: Since these lesions are seen mostly in old age, the aging process can be a cause of their development.[3]
2. Genetic mutation: Some studies have seen somatic missense mutations in GNAQ (Q209H, Q209R, R183G) and GNA11 (Q209H) genes in these lesions.[4]
3. Pregnancy

Eruptive cherry angiomas: This term indicates the sudden development of multiple and extensive cherry angiomas. They may be seen in the following conditions:

1. A side effect of topical nitrogen mustard used for the treatment of vitiligo[5]
2. A side effect of cyclosporine[6]
3. Chronic graft-host disease[7]
4. Lymphoproliferative diseases and multicentric Castleman disease (MCD): The possible mechanism is hypersecretion of vascular endothelial growth factor in response to elevated interleukin 6 levels. Therefore, it is suggested that if the patient presents with sudden multiple cherry angiomas along with systemic symptoms and lymphadenopathy, the patient should be evaluated for multicentric Castleman disease (MCD) and other lymphoproliferative disorders.[8]
5. A side effect of ramucirumab: The underlying mechanism for this is ramucirumab-induced somatic activating VEGFR2 mutation.[9]
6. Human herpesvirus-8 (HHV8): It is frequently found in eruptive cherry hemangiomas (52.9%)[10]

I also found cherry angioma to be common in diabetic patients

 

[Booble]

Very interesting.
I did not check antibodies to see if my virus of Dec 2019 was in fact COVID-19. It seemed to early on the timeline and there were many other virus possibilities. I did get some of the hallmarks of the early version of COVID in that I got conjunctivitis (eyes) and I was dry coughing so hard I pulled many muscles in my chest. But it never went into my lungs as far as I know and my breathing was never impacted. I happened to have had a pulse oximeter and my O2 was generally between 96 - 97. The cherry angiomas and petechiae came on in what I call phase 2 of the illness once the typical cold symptoms diminished at about the 3-4 week point. That's when things moved to heavy fatigue, loss of appetite, and petechiae and cherry angiomas. I'm still getting way more new ones than normally a year and a half later.

 

[Pyrrhus]

HHV8 already suspected in some cherry angioma eruptions:

Detection of human herpesvirus 8 sequences in cutaneous cherry angiomas - PubMed (nih.gov)

Very interesting!
Thanks for sharing @pattismith

I wonder if COVID causes a re-activation of Herpesvirus 8 (HHV8)?

 

[Martin aka paused||M.E.]

It's also common in several autoimmune diseases
like psoriasis (have them too)

 

[Booble]

"Lastly, acute GvHD (aGvHD) develops as a consequence of the activation of the immune system. Antigen‐presenting cells become activated by endothelial and tissue damage derived from direct toxicity of the conditioning regimen, thus initiating an alloreactive T‐cell response directed against recipient tissues. 41 As a result, SDC‐1 is commonly elevated in the serum of patients with GvHD and correlates with disease severity. 42 In addition to cell‐mediated cytotoxic damage, the cytokine storm generated in response to T‐cell activation and proliferation causes targeted organ damage involving mainly the skin, liver and gut. 43 It has recently been suggested that endothelial vulnerability and pro‐thrombotic shift precedes clinically evident aGvHD and that angiogenesis driven by early endothelial activation is an initiating event. 44 Indeed, increased plasma levels of VWF, 45 Ang‐2 46 and TNF receptor 1 47 have been detected in patients prior to development of aGvHD, correlating with response to therapy."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014053/

 

[pattismith]

It's also common in several autoimmune diseases
like psoriasis (have them too)

yes, cherry angioma is a very common finding, actually most people get it, it's just a question of time;

I think it's something intriguing when it comes suddenly with an eruptive form.

I have some CA for years, but can't remember if they come all at the same time, and even can't remember when exactly I noticed it

 

[Zebra]

Hi, @pattismith

How kind of you to alert me to this thread you started. Thank you!

I am grateful to now know the term "eruptive cherry angiomas," and I will use that terminology with doctors going forward.

As my illness began in 2014, I know the trigger wasn't COVID-19. And, I tested negative for HHV8 (PCR) a few years later.

However, I'm going to carefully read the articles you cited and consider revisiting with my dermatologist. Thank you!

Z

 

[Booble]

yes, cherry angioma is a very common finding, actually most people get it, it's just a question of time;

I think it's something intriguing when it comes suddenly with an eruptive form.

I have some CA for years, but can't remember if they come all at the same time, and even can't remember when exactly I noticed it

What do you mean by "eruptive form?"

 

[Booble]

Hi, @pattismith

How kind of you to alert me to this thread you started. Thank you!

I am grateful to now know the term "eruptive cherry angiomas," and I will use that terminology with doctors going forward.

As my illness began in 2014, I know the trigger wasn't COVID-19. And, I tested negative for HHV8 (PCR) a few years later.

However, I'm going to carefully read the articles you cited and consider revisiting with my dermatologist. Thank you!

Z

Keep in mind that most dermatologists don't know much about petechiae, pupura and cherry angiomas. They are vascular related not skin related.

 

[pattismith]

What do you mean by "eruptive form?"

This eruptive form is described in medical articles

"Eruptive cherry angiomas: This term indicates the sudden development of multiple and extensive cherry angiomas. "

Cherry angioma itself is a common benign vascular tumour that doesn't need any special attention unless in its eruptive form.

There is an another entity that looks a bit like eruptive cherry angioma and is associated to many virus, but it seems to resolve within weeks or months

Eruptive pseudoangiomatosis = transient eruptive cherry angioma with white perilesional halo

Eruptive Pseudoangiomatosis in Adult Associated to Parvovirus B19 (biomedres.us)

Eruptive pseudoangiomatosis - cherry angiomas with perilesio (plexusmd.com)

EP is a rarely reported entity, and the precise cause of the vascular changes is still unclear. Previous studies have suggested it to be a “dermal hypersensitivity reaction” to viral infection or a direct viral effect on the vascular endothelium. EP is a rare disease characterized by initial prodrome of mild fever, sore throat, or gastrointestinal symptoms, followed by the appearance of hemangiomata like cutaneous lesions, resolving in a few days. The etiology of this eruption is still unknown. Association with insect bites, infection with ECHO virus E25 and E32, coxsackie B, Epstein Barr virus, and cytomegalovirus have been described in patients in whom eruption occurred after prodromal symptoms.

 

[Booble]

Ok, thank you.
So there is some sort of number of them appearing at once that they would consider "eruptive."

The photos appear to be of the "pseudo" kind that go away within weeks or months so I guess it's unclear how many appear in the eruptive format.
For me I went from getting one every once in awhile to getting about 4-5 on each part of my body -- lower leg, upper leg, lower arm, upper arm, trunk. And new ones come much more often than they used to.

 

[Gingergrrl]

I developed cherry angiomas and extensive bruising right after having severe Mono (from EBV) in 2012. My PCP at that time was so concerned that she referred me to see a hematologist. I really don’t know what role (if any?) that played in the course of my illness?

 

[JadeD]

I have them all over my torso and they seem to be popping up in other new places like my legs etc. It’s definitely hereditary in my case as my mum has them. But the speed at which I’ve got them is quite interesting over the last 5 years I’ve been severe/moderate and I’m only 33. There must be some vascular connection since my exertion intolerance is shocking. Maybe due to endothelial dysfunction who knows.

 

[Booble]

I developed cherry angiomas and extensive bruising right after having severe Mono (from EBV) in 2012. My PCP at that time was so concerned that she referred me to see a hematologist. I really don’t know what role (if any?) that played in the course of my illness?

Viral infections can cause platelet loss or destruction. Do you recall if your hematologist prescribed any treatment or if your body rebuilt platelets on its own?

Did you have any similar side effects from your COVID-19 vaccine?

 

[Woof!]

As far as I know, cherry adenomas don't itch (at least mine don't). They just suddenly crop up as little red dots.

As opposed to chigger bites or another kind of insect bite, which do itch and itch and itch and itch... (says the person with lots of chigger bites from walking in a pine forest)

Those "pseudo" pictures look a lot like chigger bites!

 

[Booble]

As far as I know, cherry adenomas don't itch (at least mine don't). They just suddenly crop up as little red dots.

As opposed to chigger bites or another kind of insect bite, which do itch and itch and itch and itch... (says the person with lots of chigger bites from walking in a pine forest)

Those "pseudo" pictures look a lot like chigger bites!

I've noticed I feel them when they first crop up, like a slight itch. I'll find my self rubbing that area thinking I might have a bite and then I look down and there is a new cherry angioma. And then after that they stay forever but don't itch.

 

[Gingergrrl]

Viral infections can cause platelet loss or destruction. Do you recall if your hematologist prescribed any treatment or if your body rebuilt platelets on its own? Did you have any similar side effects from your COVID-19 vaccine?

The hematologist that I saw at that time (2012) did not prescribe any treatment. She felt that the vascular issues would eventually improve with time as I got further away from the Mono. I did not get the COVID vaccine b/c it is medically contraindicated for me and I have now discussed it with three doctors. I don't want to take this thread off-track re: vaccines but feel free to PM me if you want to discuss further.

As far as I know, cherry adenomas don't itch (at least mine don't). They just suddenly crop up as little red dots.

The cherry angiomas that I developed in 2012 after the severe Mono looked like the photos in the first post in this thread (but did not look like the photos in post #11). What I experienced did not itch or hurt whatsoever and were tiny red raised dots like you described.

 

[Booble]

Oh sorry, Gingergrrl. I was confusing you with someone else who got the vaccine. My mistake.