Original ArticlesSpectrum of Clinicopathologic Findings in COVID-19-induced Skin Lesions Demonstration of Direct Viral Infection of the Endothelial CellsGarrido Ruiz, Maria C. MD, PhD*; Santos-Briz, Ángel MD, PhD†,‡; Santos-Briz, Ángel MD, PhD†,‡; Sánchez, Alba MD§; Alonso-Riaño, Marina MD*; Burgos, Juan MD*; Medina-Miguelañez, Mario MD∥; Puebla, Laura MD∥; Román-Curto, Concepción MD, PhD∥; Roncero-Riesco, Mónica MD, PhD∥; Garcia, Rosa PhD*; Ortiz, Pablo L. MD, PhD§; Rodriguez-Peralto, Jose-Luis PhD* Author Information Departments of *Pathology §Dermatology, 12 de Octubre University Hospital, Complutense University of Madrid, Investigation Instutute I+12, CIBERONC, Madrid Departments of †Pathology ∥Dermatology, University Hospital of Salamanca ‡Institute for Biomedical Research (IBSAL), Salamanca, Spain Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Maria C. Garrido Ruiz, MD, PhD, Department of Pathology, 12 de Octubre University Hospital, Avda de Córdoba s/n, Madrid 28041, Spain (e-mail: [email protected]). The American Journal of Surgical Pathology: March 2021 - Volume 45 - Issue 3 - p 293-303 doi: 10.1097/PAS.0000000000001634 Buy Metrics Abstract The novel coronavirus disease (COVID-19) is a rapidly spreading pandemic, secondary to severe acute respiratory syndrome coronavirus 2. The severity and the little knowledge that we have of the disease have made us focus mostly on the respiratory symptoms. As we bend the curve, other findings reported in association with COVID-19 become of importance for specialists to recognize. We describe the spectrum of clinicopathologic lesions in the skin that can be the only symptom or the first manifestation of COVID-19 and demonstrate the origin of the virus. We collected 25 patients with skin lesions in this context. We recognized 5 types of cutaneous manifestations including acute acroischemic or chilblain-like lesions (11), purpura palpable (2), exanthemas (9), urticarial eruptions (1), and other lesions (2) that might appear with more unspecific pictures. Chilblain-like lesions were the most common form of presentation, which tend to appear as self-healing, erythematous-necrotic plaques mostly on the feet, in young patients with no systemic symptoms associated. Importantly, we visualized viral particles with electron microscopy in 5 of 13 cases analyzed. In this study, we seek to draw a picture of the spectrum of clinicopathologic lesions that may appear in the skin in the context of COVID-19. Although apparently skin lesions are not correlated with disease severity, it may help in some cases to recognize and control the spread of the infection sooner. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.