Glans penile necrosis in a patient with SARS-CoV-2 and leprosy infection 

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Indonesian physicians from the Universitas Syiah Kuala and the Dr. Hasan Sadikin General Hospital at Universitas Padjajaran have presented a case study involving a patient with leprosy contracting SARS-CoV-2 in which it was found that the co-infection escalated the necrosis of the glans of the penis.

The case report was published on a preprint server and is pending peer review. https://f1000research.com/articles/11-142

At the beginning of 2020, the World Health Organization declared novel coronavirus disease-2019 (COVID-19) infection as a pandemic which caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) that has led to a global health crisis due to acute respiratory distress syndrome (ARDS).1 

Most cases have mild-to-moderate symptoms, with approximately 15% developing severe pneumonia, while about 5% developing ARDS and organ failure.2 Other serious complications related to SARS-CoV-19 infection include hypercoagulability and thrombotic vasculopathy with clinical manifestations such as coronary syndrome, deep vein thrombosis, ischemic stroke, and pulmonary embolism.3,4 

Recently, other serious clinical manifestations associated with genitalia condition were reported in patients with SARS-CoV-2 infection with penile ischemia.5 

In patients infected by SARS-CoV-2, penile priapism has also been reported.6,7 Some authors have speculated that these conditions related to COVID-19 may be due to severe hypercoagulability and thrombotic tendency observed in patients with COVID-19.5,8

On the other hand, penile involvement in leprosy is uncommon.9 Leprosy (also known as Hansen’s disease) is an infection caused by Mycobacterium leprae (M. leprae) that can damage the peripheral nerves and bone absorption. Leprosy has two distinct phases: direct infection of macrophages and Schwann cells and reactional episodes.

Approximately 50% of patients with leprosy are affected by a reactional episode,10 which occurs because of endothelial inflammation leading to necrotizing pan-vasculitis. This condition, in severe cases, progresses to necrotic hemorrhagic lesions of the extremities and trunk, as well as Lucio’s phenomenon.11,12

Penile ischemia or necrosis is rare due to its abundant blood circulations. Usually, penile necrosis is associated with thrombotic phenomena and calcium deposits in patients on dialysis.13 However, no previous cases of penile ischemia in a COVID-19 patient who concomitantly infected with leprosy have ever been reported.

Here, we presented a unique case of penile necrosis in acute COVID-19 and leprosy infection following the CARE guidelines.14 To the best of our knowledge, this case is the first case presenting penile glans necrosis in COVID-19 patient concomitant leprosy. We also described the potential pathophysiology of glans penis necrosis in this case through a literature review.

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Figure B. Pelvic Computerized Tomography Angiography showed no occlusion that obstructed blood flow in the right and left internal pudendal arteries was observed.

Conclusions

In our perspective, microthrombus formation, diffuse capillary occlusion and tissue necrosis are the basis of the etiology penile glans necrosis in our patient. It is likely associated with SARS-CoV-2 and leprosy co-infection. This hypothesis makes this case an interesting report. In addition, from what we know at the time of writing this manuscript, this is the first case report of glans penile necrosis in a patient with SARS-CoV-2 and leprosy co-infection.

Recently, other serious clinical manifestations associated with genitalia condition were reported in patients with SARS-CoV-2 infection with penile ischemia. https://pubmed.ncbi.nlm.nih.gov/33866610/
 
In patients infected by SARS-CoV-2, penile priapism has also been reported. https://www.sciencedirect.com/science/article/pii/S0735675720305143
 
https://pubmed.ncbi.nlm.nih.gov/33868634/
 
Some researchers have speculated that these conditions related to COVID-19 may be due to severe hypercoagulability and thrombotic tendency observed in patients with COVID-19. https://pubmed.ncbi.nlm.nih.gov/32557889/
 
Typically, penile necrosis is linked to thrombotic events and calcium deposits in dialysis patients. https://pubmed.ncbi.nlm.nih.gov/1878296/
 
A study in Japan described fifteen patients with penile necrosis due to calciphylaxis and a long history of diabetes. https://pubmed.ncbi.nlm.nih.gov/17603238/
 
In this condition, it is clearly understood that diabetic vasculopathy and calcium deposits can become a thrombus which causes impaired blood flow to penis.

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