Purplish Discoloration of the Legs: An Unusual Long-COVID Symptom

A rare case of a British man with long COVID whose legs turned blue raises concerns over unknown symptoms of the disease. University of Leeds

The Lancet’s Clinical Picture published a paper in August detailing a rare case of a 33-year-old man in the United Kingdom with long COVID who developed a peculiar bluish discoloration in his legs. The case report has since raised concerns over unknown symptoms of the disease.

About six months ago, the individual noticed that after a minute of standing, his legs would start to darken and progressively turn purple, and his veins became more prominent. After about 10 minutes, the discoloration became even more pronounced. According to the patient, his legs would feel heavy, tingly, and itchy. However, upon lying down, his leg color would return to normal, and the other symptoms would subside.

The patient had previously contracted COVID-19 twice. In the year following his recovery, he grappled with unrelenting, treatment-resistant insomnia and fatigue. Other symptoms included muscle pain, sleep disruptions, visual challenges, sexual dysfunction, and brain fog. Two months before the case report, he was diagnosed with postural orthostatic tachycardia syndrome (POTS), characterized by an abnormal increase in heart rate upon standing, while blood pressure remained unchanged.

According to the UK National Health Service, patients with POTS may experience symptoms such as dizziness or lightheadedness, heart palpitations or chest pain, shortness of breath or fainting, shaking and sweating, digestive issues, headaches, vision problems, and purple discoloration in the hands and feet, fatigue, and brain fog.

Prior to contracting COVID-19, this patient’s medical history included irritable bowel syndrome diagnosed at the age of 18, pelvic pain since 21, attention-deficit hyperactivity disorder (ADHD), and joint hypermobility at 31. Considering the patient’s medical history and clinical indicators, the diagnosis pointed toward secondary autonomic dysfunction associated with SARS-CoV-2 infection and linked to long COVID. The discoloration of the legs is attributed to venous stasis and skin ischemia.

According to the Stanford University School of Medicine, autonomic dysfunction occurs when the autonomic nervous system (responsible for regulating well-being and maintaining balance) fails to function properly. Autonomic dysfunction can affect heart rate, blood pressure, body temperature, sweat glands, and digestive, urinary, and sexual functions.

Dr. Manoj Sivan, associate clinical professor and honorary consultant in rehabilitation medicine at the University of Leeds School of Medicine, told SciTechDaily: “This was a striking case of acrocyanosis in a patient who had not experienced it before his COVID-19 infection. ... Clinicians may not be aware of the link between acrocyanosis and Long Covid.”

Long COVID is a multisystem syndrome with a range of symptoms that can affect patients’ quality of life. In addition to the common symptoms of long COVID, Dr. Janet Diaz, the technical lead of the World Health Organization’s (WHO) Severe Acute Respiratory Infection (SARI) Critical Care Training project, said that there have been over 200 symptoms of long COVID reported.

Increasing evidence suggests a connection between long COVID and POTS, as well as autonomic dysfunction. Additionally, acrocyanosis has previously been observed in children with autonomic dysfunction.

A study conducted in Spain in 2022 indicated that 2.5 percent of patients with long COVID would experience late dysautonomia (autonomic dysfunction), with POTS being a more common autonomic phenotype among these patients.

Methods for Alleviating POTS Symptoms

The paper suggested increasing fluid and salt intake for this patient, along with engaging in muscle-strengthening exercises.

A study published in the Journal of the American College of Cardiology (JACC) in 2021 indicated that consuming a slightly higher amount of salt can lower plasma norepinephrine levels, reduce heart rate variability, and improve clinical symptoms.

Researchers conducted a six-day study involving 14 POTS patients (experimental group) and 13 healthy individuals (control group) with ages ranging from 23 to 49. The experimental group consumed a high-sodium diet of 300 milliequivalent (mEq) daily, while the control group consumed a low-sodium diet of 10 mEq daily. The supine and standing heart rate, blood pressure, serum aldosterone, blood volume, plasma renin activity, and plasma norepinephrine and epinephrine of the participants were measured.

The results revealed that compared to a low-sodium diet, a high-sodium diet led to an increase in blood volume, a decrease in standing heart rate variability, and a reduction in plasma norepinephrine levels. Moreover, patients on the high-sodium diet experienced significant improvements in their well-being, including reduced lightheadedness and relief from headaches.

POTS can lead to sleep disruption; therefore, it is crucial to focus on sleep management. The Cleveland Clinic recommends raising the head of one’s bed by 6 to 10 inches to help alleviate symptoms. Additionally, it suggests establishing a consistent sleep schedule, avoiding excessive daytime napping, and refraining from excessive television viewing or using a smartphone or computer in bed, as these electronic devices can impact sleep quality.

Diet and nutrition are other crucial aspects for improving POTS. Doctors advise developing the following habits:

• Increase daily sodium intake from 3,000 milligrams to 10,000 milligrams.
• Consume 2 to 2.5 liters of water per day.
• Opt for frequent and smaller meals.
• Follow a diet rich in fiber and complex carbohydrates to help reduce blood sugar spikes and alleviate symptoms.
• Maintain nutritional balance with protein, vegetables, dairy products, and fruits.
• Opt for salty snacks such as broth, pickles, sardines, olives, anchovies, and nuts. Choose healthier options and avoid relying on chips and crackers for salt intake.