Novel Clinical Presentations of COVID-19

Contributed by Dr Rini Bandyopadhyay

Cutaneous manifestations

The skin manifestations of the novel coronavirus SARS-CoV-2 were recognized only in the later stages of the pandemic. Much like with HIV and syphilis, COVID-associated "rashes" seem to be a 'Great Mimicker'. The largest published study to date is a case series in Spain with 375 cases1 which identified five clinical patterns:

  1. Acral erythema with vesicles or pustules; so-called "pseudo-chilblains", also known as “COVID toes” or COVID-associated pernio (19%) - These lesions may resemble chilblains and have purpuric areas, affecting hands and feet. They were usually asymmetrical (Fig A & B).
  2. Vesicular (chicken pox-like) eruptions (9%) - small monomorphic vesicles (unlike polymorphic vesicles in chickenpox); may also affect the limbs, have haemorrhagic content, and become larger or diffuse (Fig C).
  3. Urticaria (19%) - mostly distributed in the trunk; may be palmar and dispersed (Fig D).
  4. Maculopapular eruptions (47%) - Some have perifollicular distribution and varying degrees of scaling (Fig E).
  5. Livedo or necrosis (6%) – varying degrees of lesions suggesting occlusive vascular disease, including areas of truncal or acral ischemia.

Neurologic manifestations

  1. Guillain–Barré Syndrome Associated with SARS-CoV-2
    • 5 to 10 days after mild to moderate COVID-19 respiratory disease.
    • SARS-CoV-2 PCR was positive in nasopharyngeal swabs while was PCR negative for SARS-CoV-2 in CSF with albuminocytologic dissociation2.
    • Flaccid tetraplegia or tetraparesis, with no autonomic dysfunction - most common clinical presentation.
    • EMG NCV - axonal variant of GBS.
  2. Acute Necrotising Encephalopathy associated with SARS-CoV2 infection
    • In a French case series evaluating CNS manifestation sof COVID 19, 40 (69%) patients were encephalopathic with agitation or confusion, including 39 (67%) with corticospinal tract signs.
    • Brain imaging showed haemorrhagic lesions consistent with acute necrotising encephalopathy (Figure 6).

    Figure 6. Magnetic resonance images demonstrate T2 Fluid-attenuated inversion recovery (FLAIR) hyperintensity within the bilateral medial temporal lobes and thalami (A, B, E, F) with evidence of haemorrhage indicated by hypointense signal intensity on susceptibility-weighted images (C, G) and rim enhancement on postcontrast images (D, H)

  3. Encephalitis associated with SARS-CoV2
    • A smaller proportion of patients present with headache, fatigue, fever and then sore throat, often presenting with seizures, reduced consciousness and neck stiffness.
    • CSF analysis showed predominantly lymphocytic pleocytosis, moderately elevated protein, with raised opening pressure.
    • Brain MRI showed hyperintensity in the right medial temporal lobe consistent with encephalitis (Figure 7)5.
    • Clinical response to high dose steroids has been documented.

    Figure 7. A: Diffusion weighted images (DWI) showed hyperintensity along the wall of inferior horn of right lateral ventricle. B,C: FLAIR images showed hyperintense signal changes in the right mesial temporal lobe and hippocampus with slight hippocampal atrophy. These findings indicated right lateral ventriculitis and encephalitis mainly on right mesial lobe and hippocampus

Other Manifestations

Ageusia and anosmia; visual impairment and nerve pain have also been described. Anosmia has been suggested as a useful diagnostic marker. Hyposmia and hypogeusia were both found to be strongly associated with COVID-19.


  1. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Galván Casas C, et al. Br J Dermatol. 2020 Apr 29
  2. Zhao H, Shen D, Zhou H, Liu J, Chen S. Guillain-Barre syndrome associated with SARS-CoV-2 infection: causality or coincidence? Lancet Neurol. 2020 May;19(5):383-384
  3. Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19-associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features. Radiology 2020; : 201187
  4. Moriguchi T, Harii N, Goto J, et al. A first Case of Meningitis/Encephalitis associated with SARS-Coronavirus-2. Int J Infect Dis 2020. DOI:10.1016/j.ijid.2020.03.062