What do eyes, nose, and toes have to do with Covid-19?

Increasingly, we are finding out that the clinical manifestations of Covid-19 are not limited to the respiratory tract and that several other areas of the body, including the eyes, nose, and toes, may also be affected.

Eyes: In a study1 of 38 patients with Covid-19, 12 (32%) had eye manifestations consistent with conjunctivitis (or “pink eye”), including conjunctival hyperemia, chemosis, epiphora (watering eyes) and increased secretions; none had blurred vision. Most patients had more severe manifestations of Covid-19. Tears from 2 patients tested positive for Covid-19 virus (SARS-Co-V-2) by PCR.

Nose: Altered sense of smell was reported in 4 of 9 mild Covid-19 cases, 2 without rhinitis.2 Loss of sense of smell or anosmia has been reported in 30% or more of patients as their major presenting symptom of Covid-19 in otherwise mild cases by the British Rhinological Society (unpublished data).3  Another study found a 5% prevalence of hyposmia (unpublished).4 In addition to infecting mucosal surfaces inside the nose, the coronaviruses may infect nerve cells.5 Fortunately, sense of smell alterations appear temporary.

Toes: Findings that may mimic frostbite or chilblains with erythema or bluish/purplish discoloration of toes along with pain, itching or burning have been described in patients with Covid-19.6,7 Anecdotally, many cases been observed in relatively healthy or younger patients.  Whether these changes are due to known coagulation and/or endothelial derangements in Covid-19 or other causes is not clear.8,9

Bonus Pearl: Did you know that ACE2 receptors have reportedly been found in abundance in the testes (not ovaries)10 and testicular pain has also been reported in a Covid-19 patient seen without respiratory symptoms?11

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  1. Wu P, Duan F, Luo C, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei province, China. JAMA Ophthalmology 2020; March 31. https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2764083
  2. Wolfel R, Corman VM, Guggemos W, et al. Virological assessment of hospitalized patients with COVID-2019. Nature 2020;April 1. https://www.nature.com/articles/s41586-020-2196-x
  3. Hopkins C, Kumar N. Loss of sense of smell as marker of COVID-19 infection. https://www.entuk.org/sites/default/files/files/Loss%20of%20sense%20of%20smell%20as%20marker%20of%20COVID.pdf
  4. Mao L, Wang M, Chen S, et al. Neurological manifestations of hospitalized patients with COVID-19 in Wuhan, China: a retrospective case series study. https://www.medrxiv.org/content/10.1101/2020.02.22.20026500v1
  5. Perlman S, Jacobsen G, Afifi A. Spread of a neurotropic murine Coronavirus into the CNS via the trigeminal and olfactory nerves. Virology 1989;170:556-560 https://www.sciencedirect.com/science/article/pii/0042682289904467
  6. Mazzotta F, Troccoli T, Bonifazi E. A new vasculitis at the time of COVID-19. Eur J Ped Dermatol 2020. https://www.ejpd.com/images/nuova-vasculite-covid-ENG.pdf
  7. Lee YJ. “Covid toes” might be the latest unusual sign that people are infected with the novel coronavirus. April 23, 2020. https://www.businessinsider.com/covid-toes-frostbite-coronavirus-skin-lesion-discolored-swollen-feet-2020-4
  8. Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and antiphospholipid antibodies in patients with Covid-19. N Eng J Med 2020;382:e38. https://www.nejm.org/doi/full/10.1056/NEJMc2007575
  9. Varga Z, Flammer AJ, Steiger P, et al. Endothelial cell infection and endothelial cell infection and endotheliitis in COVID-19. Lancet 2020; April 17. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930937-5
  10. Kim J, Thomsen T, Sell N, et al. Abdominal and testicular pain: an atypical presentation of COVID-19. Am J Emerg Med 2020 https://doi.org/10.1016/j.ajem.2020.03.052
  11. Fan C, Li K, Ding Y, et al. ACE2 expression in kidney and testis may cause kidney and testis damage. medRxiv 2020. https://doi.org/10.1101/2020.02.12.20022418.t

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!



What do eyes, nose, and toes have to do with Covid-19?

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