A 59-year-old woman was referred to the emergency department due to dyspnea with respiratory insufficiency and productive cough.Approximately 1 month prior to admission she contracted an infection from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with subsequent occurrence of a painful, swollen and reddened ankle.A postinfection arthritis was suspected by an external hospital and she was started on a high-dose methylprednisolone treatment.At our clinic, physical examination was remarkable for cyanosis of the fingertips and ankle edema.Laboratory tests revealed a significant decrease in hemoglobin to 7.6 g/dL, a substantially elevated C-reactive protein (CRP) level of 312 mg/L and a nephritic sediment in the urinalysis.A chest computed tomography (CT) scan showed bilateral pulmonary infiltrates (Fig. 1a).Positive antineutrophil cytoplasmic antibodies (c-ANCA) staining by indirect immunofluorescence and PR3-ANCA detection by enzyme-linked immunosorbent assay, together with a renal biopsy showing pauci-immune rapidly progressive glomerulonephritis, provided the diagnosis of granulomatosis with polyangiitis.Immunosuppressive induction therapy with high dose prednisone, cyclophosphamide, rituximab and plasmapheresis was started.During the first few days of treatment, the patient developed splinter hemorrhages with scattered necroses of the fingertips (Fig. 1b).Endocarditis as the cause of these splinter hemorrhages was excluded by transesophageal echocardiography and a source of thromboembolic spread
Ribitsch et al. (Thu,) studied this question.