Cold Weather Injuries: Initial Evaluation and Management.

ABSTRACT: As more people take to extreme sporting activities and hobbies, the sports medicine physician should be proficient in early identification and initial sideline or field management of cold weather injuries. There is significant mortality and morbidity associated with these conditions. The most severe of these are hypothermia and frostbite, which have limited evidence for their field management. Nonfreezing cold injuries and chilblains are much rarer, although appropriate prevention and treatment strategies can be used to minimize harm to athletes. This article will provide the most updated recommendations for field or sideline evaluation and initial management of hypothermia, frostbite, nonfreezing cold injury, and chilblains.

Patient characteristics in tardive COVID-19 pseudoperniosis: a case series of 16 patients.

BACKGROUND: Acute pseudoperniosis (PP) has a recognized association with COVID-19 and tends to occur without cold precipitation in young, healthy patients, often without a clear history of COVID-19. These lesions usually resolve within 2 weeks and without long-term sequelae. In the early months of 2021, patients with delayed and protracted PP began to emerge. We have called this presentation 'tardive COVID-19 PP (TCPP)'. AIM: To consolidate and expand knowledge on TCPP, we describe the clinical characteristics, treatments and outcomes of 16 patients with TCPP who were reviewed by our outpatient dermatology service. RESULTS: The initial clinical manifestations were erythema, swelling and PP of the fingers in 56.2%, and of the toes in 31.2%, desquamation in 56.2% and acrocyanosis in 12.5%. Ten patients had eventual involvement of all acral sites. The median duration of symptoms was 191 days. Six patients reported close contact with a confirmed or suspected case of COVID-19, but only two had positive COVID-19 tests. Four patients experienced complete or almost complete resolution of symptoms, while the rest remain under active treatment. CONCLUSION: Unlike acute PP, TCPP has a protracted and delayed presentation that is typically associated with profound acrocyanosis. Patients with TCPP represent a new phenomenon that is part of the post-COVID-19 syndrome, with risk factors and pathophysiology that are not yet fully understood. Our data indicate that likely predisposing factors for developing TCPP include young age, a preceding history of cold intolerance and an arachnodactyloid phenotype. Anorexia, connective tissue disorders or sickle cell trait may also predispose to TCPP. In addition, low titre antinuclear antibody positivity, the presence of cryoglobulins, or low complement levels may represent further risk factors. Finally, prolonged low temperatures are also likely to be contributing to the symptoms.

What Are COVID Toes? A Case Study.

BACKGROUND: COVID-19 symptoms mimic many other common conditions, making it difficult to identify patients infected with COVID-19. Adult patients may exhibit what is called "COVID toes" later in their course of illness. Noteworthy is that COVID toes may be the only symptom in otherwise asymptomatic young adults and children. CASE: We present experience with an adult female patient residing in the United States with presumed COVID-19 infection who was self-isolating with illness not severe enough to require hospitalization. COVID toes were one symptom experienced as a part of her illness. Because COVID toes are usually seen in the recovery phase of COVID-19, and often in patients with less severe cases, many providers are unfamiliar with this new symptom. CONCLUSION: Familiarity with COVID toes will help foot care providers to identify patients who may not have been diagnosed with COVID-19 but could still be infectious and need to be isolated. COVID toe signs may be subtle and often mimic other conditions such as chilblains/pernio, thus a thorough history and physical examination are required.

Management of pernio-like cutaneous manifestations in children during the outbreak of COVID-19.

During the outbreak of COVID-19 many pernio-like lesions have been increasingly reported. The aim of the study is to describe our management of these skin manifestations and to evaluate a possible correlation to SARS-CoV-2 infection. All patients underwent clinical and laboratory tests to detect a possible underlying connective disease and also to specific SARS-CoV-2 investigations such as oropharyngeal swab and IgG-IgM serology. Nine patients aged between 5 and 15 years old were evaluated. Skin lesions observed were purplish, erythematous and oedematous, in some cases painful and itchy. Six out of nine had respiratory and systemic symptoms (cough, nasal congestion, chills, fever, and asthenia) that preceded cutaneous findings of approximately 2 weeks. Concerning blood exams, three out of nine had D-dimer weakly increased, four had ANA positivity: two with a title 1:160, one with 1:320, and one with 1:5120 and a speckled pattern. The latter patient had also ENA SS-A positive and RF positivity, confirmed at a second check, so as to allow us to make a diagnosis of connective tissue disease. Four out of nine had aPL positivity (IgM). Reactants acute phase were all negative. Oropharyngeal swabs and serology tests for SARS-CoV-2 was negative (borderline in one patient for IgM). No treatment was needed. Even if we do not have enough data to prove it, we hypothesize a correlation between pernio-like lesions and SARS-CoV-2 infection for an increased number of these lesions described during the pandemic and also because such manifestations appeared when temperatures were mild and patients were at home in isolation for the lockdown. Many questions remain open about interaction host-virus.

Clustered cases of acral perniosis: Clinical features, histopathology, and relationship to COVID-19.

BACKGROUND/OBJECTIVES: A recent marked increase in pediatric and adult patients presenting with purpuric acral lesions concerning for ischemia, thrombosis and necrosis has been observed in COVID-19 prevalent regions worldwide. The clinical and histopathological features and relationship to COVID-19 have not been well described. The objective of this case series is to describe the clinical features and determine the histopathologic findings and clinical implications of the clusters of acral perniosis cases identified in pediatric patients. METHODS: We describe six otherwise healthy adolescents-three siblings per family from two unrelated families-presented within a 48-hour period in April, 2020, with acral perniosis-like lesions in the context of over 30 similar patients who were evaluated within the same week. RESULTS: Affected patients had mild symptoms of viral upper respiratory infection (URI) or contact with symptomatic persons 1-2 weeks preceding the rash. They all presented with red to violaceous macules and dusky, purpuric plaques scattered on the mid and distal aspects of the toes. Skin biopsies performed on each of the six patients demonstrated near identical histopathologic findings to those of idiopathic perniosis, with a lymphocytic inflammatory infiltrate without evidence of thromboembolism or immune complex vasculitis. While SARS-CoV-2 polymerase chain reaction was negative, testing was performed 1-2 weeks after URI symptoms or sick contact exposure. CONCLUSION: We offer a clinical approach to evaluation of patients with this presentation and discuss the possibility that these skin findings represent a convalescent-phase cutaneous reaction to SARS-CoV-2 infection.

Chilblains in children in the setting of COVID-19 pandemic.

BACKGROUND: Different skin manifestations of COVID-19 are being reported. Acral lesions on the hands and feet, closely resembling chilblains, have been recognized during the peak incidence of the COVID-19 pandemic. MATERIAL AND METHODS: A retrospective review of 22 children and adolescents with chilblain-like lesions seen over a short period of time in the Emergency Department of a children's hospital during the peak incidence of COVID-19 in Madrid, Spain. RESULTS: All patients had lesions clinically consistent with chilblains of the toes or feet, with three also having lesions of the fingers. Pruritus and mild pain were the only skin symptoms elicited, and only 10 had mild respiratory and/or GI symptoms. None had fever. Coagulation tests, hemogram, serum chemistry, and lupus anticoagulant were normal in all patients tested. One out of 16 tested cases had elevated D-dimer results, but without systemic symptoms or other laboratory anomalies. SARS-CoV-2 PCR tested in 19 cases was positive in just one case. Skin biopsies obtained in six patients were consistent with chilblains. On follow-up, all cases showed spontaneous marked improvement or complete healing. CONCLUSION: Acute chilblains were observed during COVID-19 pandemic in children and teenagers. It is a mildly symptomatic condition with an excellent prognosis, usually requiring no therapy. Etiopathogenesis remains unknown.

Hypothermia and Cold Weather Injuries.

Hypothermia, frostbite, and nonfreezing cold injuries predominantly affect older adults, homeless or intoxicated people, adventurers, and military personnel. Prevention begins with clothing that is clean, layered, and loose to promote circulation. Base layers made of moisture-wicking materials are favored over wool or cotton. Wool or fleece garments are ideal for middle layers, whereas outer layers should repel moisture. Hypothermia occurs when core body temperature drops below 95°F and can be staged by clinical symptoms when core temperature measurement is unavailable. Initial treatment includes external and internal rewarming. Warmed normal saline is favored over lactated Ringer solution. Frostbite is a freezing injury that usually affects the extremities. After rapid rewarming, prognosis is best determined with technetium 99mTc pyrophosphate scintigraphy or magnetic resonance angiography. Initial treatment includes protecting tissue from further trauma, preventing refreezing, and avoiding dry heat sources. Ideally, patients should be transported to facilities where rapid rewarming, imaging, and thrombolytic treatment are available. Tissue plasminogen activator significantly decreases amputation rates for severe injuries if started within 24 hours of rewarming. Immersion foot occurs during damp nonfreezing conditions. Rapid rewarming should be avoided, and amitriptyline should be considered for pain control.

Clinical characteristics, etiologic associations, laboratory findings, treatment, and proposal of diagnostic criteria of pernio (chilblains) in a series of 104 patients at Mayo Clinic, 2000 to 2011.

OBJECTIVE: To further characterize the clinical features, etiologic associations, laboratory findings, and treatment of pernio. PATIENTS AND METHODS: This is a retrospective review of patients with pernio seen at our institution between January 1, 2000, and December 31, 2011. RESULTS: Of 104 patients with pernio (mean age at diagnosis, 38.3 years), 82 (79%) were women. Pernio affected the toes in 85 patients (82%) and the fingers in 31 (30%). Thirty-eight patients (37%) had at least 1 abnormal laboratory test result, and test results were positive for cold agglutinins in 11 (55%) of 20 tested patients. Results were negative for cryoglobulins in all tested patients (n=53). Four patients (4%) had connective tissue disease (nonlupus) associated with pernio; 3 patients (3%) had an associated hematologic malignant disease. Conservative treatments (eg, warming, drying, and smoking cessation) provided complete response in 23 (82%) of 28 patients with follow-up data. CONCLUSION: To our knowledge, this study represents one of the largest single-center case series of pernio to date. Most of the patients did not have an underlying systemic association with pernio, although a few patients had pernio in association with connective tissue disease or hematologic malignant disease.

[Hypothermia, chilblain and frostbite].

Many factors such as the environmental conditions (temperature and humidity etc.), a nutritional status, the degree of fatigue, a moisturizing state of the body, clothes, the sensitivity to coldness are involved in an outbreak of hypothermia. Children, aged persons and the presence of an underlying disease are also risk factors related to the occurrence of hypothermia. The dysfunction of the respiratory system, the circulatory system and the central nervous system is caused by a decrease in body temperature. Finally, death is brought about at 25 degrees C of body temperature or lower. Frostbite develops when tissue is exposed to -4 degrees C of coldness or lower. The extent of injury is determined by the magnitude of coldness.

Nonfreezing cold-induced injuries.

Non-freezing cold injury (NFCI) is the Cinderella of thermal injuries and is a clinical syndrome that occurs when tissues are exposed to cold temperatures close to freezing point for sustained periods. NFCI is insidious in onset, often difficult to recognize and problematic to treat, and yet the condition accounts for significant morbidity in both military and civilians who work in cold conditions. Consequently recognition of those at risk, limiting their exposure and the appropriate and timely use of suitable protective equipment are essential steps in trying to reduce the impact of the condition. This review addresses the issues surrounding NFCI.

A retrospective study of cases presenting with chilblains (Perniosis) in Out Patient Department Of Dermatology, Nepal Medical College and Teaching Hospital (NMCTH).

Chilblains (Perniosis/Pernio) is characterized by painful red-to-purple papular lesions involving the fingers or toes due to non-freezing damp cold that resolves with symptomatic treatment. As in winters, cold is moderate to severe in Kathmandu, this retrospective study was undertaken to find out the incidence of chilblains cases, seeking health care in the Out Patient Department of Dermatology, Nepal Medical College and Teaching Hospital. Cases of chilblains were noted in the months of October to December 2009, January to March 2010, October to December 2010 and January to March 2011. Out of total 49 cases maximum patients (n=25; male 10, female 15) were in the age group of 7-20 years. Rest of them (n=18; male 7, female 11) were in the age group of 21-40 years and only 6 (male 2, female 4) were in the age group of 41-65 years. Amongst all the cases 30 patients were females (61.2%) and 19 were males (38.8%). Most of (79.6%) the chilblain victims sought health care during the months of December to February -- coldest time of the years. The patients were advised to protect their acral parts from cold exposure as far as practicable by wearing shocks and gloves. They were advised not to warm their extremities all on a sudden, after exposure to cold, as this causes vasospasm and makes the condition worse. Extremities should be warmed gradually. Assessing the severity of the condition topical allocation of steroid ointment and/or anti allergic drugs was prescribed, when felt needed.

[Chilblains, differential diagnosis and risk factors]. / Les engelures, stigmates des affres climatiques.

Chilblain results from environmental nonfreezing cold exposure. It is a localized inflammatory lesion most frequently localized on the toes and fingers. Chilblains are often idiopathic, but they may be part of lupus erythematosus.

Idiopathic chilblains.

BACKGROUND: Chilblains is a benign condition infrequently encountered in clinical practice; its resemblance to vasculitis or peripheral thromboemboli can often result in an extensive and unnecessary diagnostic work-up. METHOD: Three cases of chilblains seen by our Rheumatology service, along with 113 documented cases, were reviewed. RESULTS: Chilblains is characterized by painful red-to-purple papular lesions involving the acral surface of fingers or toes that resolves with symptomatic treatment. Female sex and low body mass index are risk factors. CONCLUSION: Distinct clinical features of chilblains can be used for early recognition and management, thus avoiding unnecessary diagnostic testing and delays in patient care.