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What Is ‘Covid Toe’? Maybe a Strange Sign of Coronavirus Infection What Is ‘Covid Toe’? Maybe a Strange Sign of Coronavirus Infection
(3 days later)
Before the coronavirus outbreak, Dr. Lindy Fox, a dermatologist in San Francisco, used to see four or five patients a year with chilblains — painful red or purple lesions that typically emerge on fingers or toes in the winter.Before the coronavirus outbreak, Dr. Lindy Fox, a dermatologist in San Francisco, used to see four or five patients a year with chilblains — painful red or purple lesions that typically emerge on fingers or toes in the winter.
Over the past few weeks, she has seen dozens.Over the past few weeks, she has seen dozens.
“All of a sudden, we are inundated with toes,” said Dr. Fox, who practices at the University of California, San Francisco. “I’ve got clinics filled with people coming in with new toe lesions. And it’s not people who had chilblains before — they’ve never had anything like this.”“All of a sudden, we are inundated with toes,” said Dr. Fox, who practices at the University of California, San Francisco. “I’ve got clinics filled with people coming in with new toe lesions. And it’s not people who had chilblains before — they’ve never had anything like this.”
It’s also not the time of year for chilblains, which are caused by inflammation in small blood vessels in reaction to cold or damp conditions. “Usually, we see it in the dead of winter,” Dr. Fox said.It’s also not the time of year for chilblains, which are caused by inflammation in small blood vessels in reaction to cold or damp conditions. “Usually, we see it in the dead of winter,” Dr. Fox said.
Dr. Fox is not the only one deluged with cases. In Boston, Dr. Esther Freeman, director of global health dermatology at the Massachusetts General Hospital, said her telemedicine clinic is also “completely full of toes. I had to add extra clinical sessions, just to take care of toe consults. People are very concerned.”Dr. Fox is not the only one deluged with cases. In Boston, Dr. Esther Freeman, director of global health dermatology at the Massachusetts General Hospital, said her telemedicine clinic is also “completely full of toes. I had to add extra clinical sessions, just to take care of toe consults. People are very concerned.”
The lesions are emerging as yet another telltale symptom of infection with the new coronavirus. The most prominent signs are a dry cough and shortness of breath, but the virus has been linked to a string of unusual and diverse effects, like mental confusion and a diminished sense of smell.The lesions are emerging as yet another telltale symptom of infection with the new coronavirus. The most prominent signs are a dry cough and shortness of breath, but the virus has been linked to a string of unusual and diverse effects, like mental confusion and a diminished sense of smell.
Federal health officials do not include toe lesions in the list of coronavirus symptoms, but some dermatologists are pushing for a change, saying so-called Covid toe should be sufficient grounds for testing. (Covid-19 is the name of the illness caused by the coronavirus.)Federal health officials do not include toe lesions in the list of coronavirus symptoms, but some dermatologists are pushing for a change, saying so-called Covid toe should be sufficient grounds for testing. (Covid-19 is the name of the illness caused by the coronavirus.)
Several medical papers from Spain, Belgium and Italy described a surge in complaints about painful lesions on patients’ toes, Achilles’ heels and soles of the feet; whether the patients were infected was not always clear, because they were otherwise healthy and testing was limited.Several medical papers from Spain, Belgium and Italy described a surge in complaints about painful lesions on patients’ toes, Achilles’ heels and soles of the feet; whether the patients were infected was not always clear, because they were otherwise healthy and testing was limited.
Most cases have been reported in children, teens and young adults, and some experts say they may reflect a healthy immune response to the virus.Most cases have been reported in children, teens and young adults, and some experts say they may reflect a healthy immune response to the virus.
“The most important message to the public is not to panic — most of the patients we are seeing with these lesions are doing extremely well,” Dr. Freeman said.“The most important message to the public is not to panic — most of the patients we are seeing with these lesions are doing extremely well,” Dr. Freeman said.
“They’re having what we call a benign clinical course. They’re staying home, they’re getting better, the toe lesions are going away.”“They’re having what we call a benign clinical course. They’re staying home, they’re getting better, the toe lesions are going away.”
Scientists are just beginning to study the phenomenon, but so far chilblain-like lesions appear to signal, curiously enough, a mild or even asymptomatic infection. They may also develop several weeks after the acute phase of an infection is over.Scientists are just beginning to study the phenomenon, but so far chilblain-like lesions appear to signal, curiously enough, a mild or even asymptomatic infection. They may also develop several weeks after the acute phase of an infection is over.
Patients who develop swollen toes and red and purple lesions should consult their primary care doctor or a dermatologist to rule out other possible causes. But, experts said, they should not run to the emergency room, where they risk being exposed to the coronavirus or exposing others if they are infected.Patients who develop swollen toes and red and purple lesions should consult their primary care doctor or a dermatologist to rule out other possible causes. But, experts said, they should not run to the emergency room, where they risk being exposed to the coronavirus or exposing others if they are infected.
“The good news is that the chilblain-like lesions usually mean you’re going to be fine,” Dr. Fox said. “Usually it’s a good sign your body has seen Covid and is making a good immune reaction to it.”“The good news is that the chilblain-like lesions usually mean you’re going to be fine,” Dr. Fox said. “Usually it’s a good sign your body has seen Covid and is making a good immune reaction to it.”
Patients who get the painful lesions are often alarmed. They appear most frequently on the toes, often affecting several toes on one or both feet, and the sores can be extremely painful, causing a burning or itching sensation.Patients who get the painful lesions are often alarmed. They appear most frequently on the toes, often affecting several toes on one or both feet, and the sores can be extremely painful, causing a burning or itching sensation.
At first, the toes look swollen and take on a reddish tint; sometimes a part of the toe is swollen, and individual lesions or bumps can be seen. Over time, the lesions become purple in color.At first, the toes look swollen and take on a reddish tint; sometimes a part of the toe is swollen, and individual lesions or bumps can be seen. Over time, the lesions become purple in color.
Hannah Spitzer, 20, a sophomore at Lafayette College who is finishing the academic year remotely at her home in Westchester County, has lesions on all 10 of her toes, so uncomfortable — painful during the day, and itchy at night — that she can’t put anything on her feet, not even socks.Hannah Spitzer, 20, a sophomore at Lafayette College who is finishing the academic year remotely at her home in Westchester County, has lesions on all 10 of her toes, so uncomfortable — painful during the day, and itchy at night — that she can’t put anything on her feet, not even socks.
Walking is difficult, and she has trouble sleeping. “At first I thought it was my shoes, but it got worse and worse,” Ms. Spitzer said. “Most of my toes are red, swollen, almost shiny. It looks like frostbite.”Walking is difficult, and she has trouble sleeping. “At first I thought it was my shoes, but it got worse and worse,” Ms. Spitzer said. “Most of my toes are red, swollen, almost shiny. It looks like frostbite.”
She has used hydrocortisone and Benadryl to alleviate the discomfort, and said ice is also helpful. Doctors say the lesions disappear on their own within a few weeks.She has used hydrocortisone and Benadryl to alleviate the discomfort, and said ice is also helpful. Doctors say the lesions disappear on their own within a few weeks.
Adding to the mystery is that some teens and young adults with the lesions have tested negative for the coronavirus.Adding to the mystery is that some teens and young adults with the lesions have tested negative for the coronavirus.
Dr. Amy Paller, chair of the department of dermatology at Northwestern University Feinberg School of Medicine, said one possible explanation is that these patients had such a mild disease and that viral replication was limited, making the virus undetectable.Dr. Amy Paller, chair of the department of dermatology at Northwestern University Feinberg School of Medicine, said one possible explanation is that these patients had such a mild disease and that viral replication was limited, making the virus undetectable.
Another possibility, she said, is that the lesions are what is called an epiphenomenon — a symptom may accompany a disease without being causally related. For instance, perhaps more people are developing the lesions because they are staying inside and walking around barefoot more than usual.Another possibility, she said, is that the lesions are what is called an epiphenomenon — a symptom may accompany a disease without being causally related. For instance, perhaps more people are developing the lesions because they are staying inside and walking around barefoot more than usual.
But she also dismissed that idea as highly unlikely. “I don’t think that’s it — I think it’s a mild inflammatory process manifesting in this way,” Dr. Paller said. “It’s a real phenomenon. We don’t really understand it at all.”But she also dismissed that idea as highly unlikely. “I don’t think that’s it — I think it’s a mild inflammatory process manifesting in this way,” Dr. Paller said. “It’s a real phenomenon. We don’t really understand it at all.”
Ms. Spitzer had a test shortly after developing the lesions, and the result was negative, but she is convinced the toe lesions are a delayed response to an earlier infection that was so mild she barely noticed it.Ms. Spitzer had a test shortly after developing the lesions, and the result was negative, but she is convinced the toe lesions are a delayed response to an earlier infection that was so mild she barely noticed it.
“I’ve never had anything like this,” she said. “It’s completely new.”“I’ve never had anything like this,” she said. “It’s completely new.”
A recent paper by doctors in Spain, published in the International Journal of Dermatology, described six cases of patients with toe lesions and included pictures of the chilblain-like bumps that patients had emailed to their physicians.A recent paper by doctors in Spain, published in the International Journal of Dermatology, described six cases of patients with toe lesions and included pictures of the chilblain-like bumps that patients had emailed to their physicians.
Most of the patients were teens or young adults, including one 15-year-old who found out he had Covid-19 pneumonia when he went to the emergency room seeking medical attention for his toes.Most of the patients were teens or young adults, including one 15-year-old who found out he had Covid-19 pneumonia when he went to the emergency room seeking medical attention for his toes.
Another patient was a 91-year-old man who had been hospitalized with the coronavirus three weeks earlier, and had recovered and returned home.Another patient was a 91-year-old man who had been hospitalized with the coronavirus three weeks earlier, and had recovered and returned home.
Updated June 12, 2020Updated June 12, 2020
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.
Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.
The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
While dermatologists say it’s not unusual for rashes to appear along with viral infections — like measles or chickenpox — the toe lesions surprised them.While dermatologists say it’s not unusual for rashes to appear along with viral infections — like measles or chickenpox — the toe lesions surprised them.
Other problems like hives have also been linked to the coronavirus, but Covid toes have been the most common and striking skin manifestation.Other problems like hives have also been linked to the coronavirus, but Covid toes have been the most common and striking skin manifestation.
Patients with viral infections often get a pink bumpy rash called morbilliform, or hives, Dr. Fox said, but added that the toe lesions were “unexpected.”Patients with viral infections often get a pink bumpy rash called morbilliform, or hives, Dr. Fox said, but added that the toe lesions were “unexpected.”
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The toe cases make up half of all reports filed by skin doctors around the world to a new international registry started by the American Academy of Dermatology, which is tracking the complications.The toe cases make up half of all reports filed by skin doctors around the world to a new international registry started by the American Academy of Dermatology, which is tracking the complications.
No one knows exactly why the new coronavirus might cause chilblain-like lesions. One hypothesis is that they are caused by inflammation, a prominent feature of Covid-19. Inflammation also causes one of the most serious syndromes associated with the coronavirus, acute respiratory distress syndrome.No one knows exactly why the new coronavirus might cause chilblain-like lesions. One hypothesis is that they are caused by inflammation, a prominent feature of Covid-19. Inflammation also causes one of the most serious syndromes associated with the coronavirus, acute respiratory distress syndrome.
Other hypotheses are that the lesions are caused by inflammation in the walls of blood vessels, or by small micro clots in the blood. (Clotting has been another feature of the disease.)Other hypotheses are that the lesions are caused by inflammation in the walls of blood vessels, or by small micro clots in the blood. (Clotting has been another feature of the disease.)
The lesions seen in otherwise healthy people appear to be distinct from those that doctors are seeing in some critically ill Covid-19 patients in intensive care, who are prone to developing blood clots.The lesions seen in otherwise healthy people appear to be distinct from those that doctors are seeing in some critically ill Covid-19 patients in intensive care, who are prone to developing blood clots.
Some of these clots may be very small and can block the tiny vessels in the extremities, causing rashes on the toes, said Dr. Humberto Choi, a pulmonologist and critical care physician at the Cleveland Clinic.Some of these clots may be very small and can block the tiny vessels in the extremities, causing rashes on the toes, said Dr. Humberto Choi, a pulmonologist and critical care physician at the Cleveland Clinic.
Some experts now believe Covid toe should be recognized as sufficient grounds for testing, even in the absence of other symptoms.Some experts now believe Covid toe should be recognized as sufficient grounds for testing, even in the absence of other symptoms.
“This should be a criteria for testing, just like loss of smell, and shortness of breath and chest pain,” Dr. Fox said.“This should be a criteria for testing, just like loss of smell, and shortness of breath and chest pain,” Dr. Fox said.