Venous insufficiency and acrocyanosis in long COVID: dysautonomia A 33-year-old man was referred to our specialist clinic with a 6-month history of a rapid purple discolouration of his legs on standing; he reported that his legs would progressively feel heavy, tingly, itchy, and become dusky in colour. Additionally, he said a petechial rash would occasionally appear over his feet (figure). The patient said his legs would return to their usual colour and the other symptoms would abate if he lay down. Taken from The Lancet Picture Quiz Gallery (not research) https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01461-7/fulltext
(UK) Professor draws attention to lesser-known sign in the legs of Long Covid A discolouration in your legs after standing could be a warning sign of Long Covid, according to a new study. https://www.express.co.uk/life-style/health/1801149/long-covid-symptoms-blue-legs
He had a mild SARS-CoV-2 infection, confirmed by PCR, 18 months before we saw him, with a suspected further SARS-CoV-2 infection 6 months later. He had been diagnosed with post-COVID-19 condition (also known as long COVID) in a specialist clinic 3 months before we saw him—reporting a 12-month history of disabling and delayed post-exertional exhaustion, disproportionate to the effort made; he also reported muscular pain, sleep disturbance, visual difficulties, sexual dysfunction, and brain fog. The patient had been diagnosed with postural orthostatic tachycardia syndrome (POTS) 2 months before we saw him, by a cardiologist. Regarding his medical history, he had been diagnosed with irritable bowel syndrome aged 18 years and attention-deficit hyperactivity disorder aged 31 years. He also had joint hypermobility—he scored 7 out of 9 on the Beighton Score after being assessed by a rheumatologist at age 32 years. He reported pelvic pain since the age of 21 years. He was prescribed sertraline and an oral solution of amitriptyline. On examination when lying down, his pulse was 68 beats per min and blood pressure was 138/85 mm Hg; on standing for 8 min, his pulse increased to a maximum of 127 beats per min and his blood pressure remained stable at 125/97 mm Hg. He reported accompanying symptoms of feeling foggy and shaky, having tingling, itchiness, and heaviness in his legs: findings consistent with a diagnosis of POTS. Laboratory investigations showed normal C-reactive protein concentration, normal erythrocyte sedimentation rate, and negative antinuclear antibodies, anti-neutrophil cytoplasm autoantibody, anti-cyclic citrullinated peptide antibodies, and normal immunoglobulin levels. Considering the patient's signs and symptoms, we diagnosed dysautonomia secondary to SARS-CoV-2 infection and associated with long COVID. We explained that the leg discolouration was due to venous pooling and cutaneous ischaemia; we recommended he increase his fluid intake, increase his salt intake, and do muscle strengthening exercises. Dysautonomia is a diverse group of disorders affecting either the central or peripheral autonomic nervous system or both. Dysautonomia can be primary, due to a disease of the autonomic nervous system, or secondary, due to a disease that causes secondary damage to the autonomic nervous system. POTS is a dysautonomia syndrome where patients have orthostatic intolerance with an excessive increase in heart rate and symptoms of light-headedness, non-vertiginous dizziness, and palpitations when standing, but they maintain their blood pressure. They may also report low energy, headache, cognitive impairment, muscle fatigue, chest pain, non-specific weakness, and gastrointestinal symptoms. Onset of POTS may be precipitated by a viral infection, physical trauma, menarche, pregnancy, or surgery; it may co-occur with other conditions, including migraine, hypermobile Ehlers-Danlos syndrome, and chronic fatigue syndrome. Long COVID is a multisystem syndrome with an array of symptoms and disabilities in daily activities; evidence is growing of a link between long COVID and POTS dysautonomia. In children with long COVID, Bier anaemic spots—not obvious in our patient—and cyanosis with urticarial-like eruption (known as BASCULE) syndrome has been reported. Contributors We both provided care for the patient. NI wrote the original draft. We both reviewed and edited the paper. Written consent for publication was obtained from the patient, who also reviewed the final draft. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01461-7/fulltext https://www.thelancet.com/action/showPdf?pii=S0140-6736(23)01461-7
Would be funny to see, if in a couple of years, we'll see all the pictures that Long-Covid patients on social media had previously posted of "Covid-toes" and other visbile abnormalities, reappear in medical journals and quizzes that will leave medical students wondering what these things could be, which patients have been talking about for years.
Incredible. The authors bother to write a paper about this, but don't seem to have noticed the narrowing of pulse pressure on standing. A pulse pressure (difference between systolic and diastolic blood pressure) of 28 is not normal. This man's blood pressure did not remain stable.
My son (pre-Covid ME/CFS) gets this. There have also been times when half of his foot is completely white and the rest is this puce red. He was getting this from the earliest of times when he was still very fit and strong, so muscle strength was not the problem or the solution. I got ME/CFS at the same time, but I don't think I get this particular symptom in my feet, not regularly anyway. At times my palms will go really red; my extremities will go cold in a way that isn't normal; I get numbness and pins and needles in my hands and feet too easily. I get pains in my fingers with a blue knot of a vein at the point of the pain. And of course there is the cardiovascular issues - the high heart rate combined with low pulse pressure. What I don't understand is, does this indicate a permanent problem e.g. nerve damage? If so, why are things okay one day, but not okay the next? Or is it a downstream result of something, some chemical, resulting from previous activity?
"He reported accompanying symptoms of feeling foggy and shaky, having tingling, itchiness, and heaviness in his legs: findings consistent with a diagnosis of POTS". I have/had neurally mediated hypotension, my blood pools to my feet, legs turn blotchy purple and I felt shaky during the early years of M.E. I don't experience this all the time.
"Lesser-known". Uh, not to patients. It's been reported for decades and systematically dismissed. The LC community was very quick to notice and report it. I get that we need not to antagonize MDs but seriously they have a huge amount of work to do on themselves when it comes to accountability and taking responsibility for their mistakes.
