November 29, 2022/COVID-19

New Onset Eosinophilic Fasciitis after COVID-19 Infection

Could the virus have caused the condition or triggered previously undiagnosed disease?

Eosinophilic Fasciitis

By Ambreesh Chawla, MD


Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

Eosinophilic fasciitis, also known as Shulman syndrome, is a rare autoimmune disorder that involves inflammation of the fascia overlying muscle, resulting in edema and deep induration of the extremities. It is typically symmetric and involves all four extremities. In contrast to scleroderma, the digits are typically spared and there is no association with Raynaud’s phenomenon or microscopic nailfold capillary changes. Eosinophilia is a characteristic laboratory finding in the early phase; however, it is not always present in early cases and is less prominent in later stages. Some cases of eosinophilic fasciitis can be associated with underlying hematologic disorders such as lymphoma, leukemia or aplastic anemia. Diagnosis is normally based on a deep excisional biopsy of the skin that includes the fascia.

Case report

A 46-year-old female with a recent diagnosis of COVID-19 presented to Cleveland Clinic’s rheumatology clinic with new-onset worsening distal upper and lower extremity pain and discomfort. She noted that shortly after her diagnosis of COVID-19, she began to experience severe allodynia to light touch over her forearms and shins.

Laboratory testing revealed 25% eosinophils on complete blood count with mildly elevated markers of inflammation and borderline positive rheumatoid factor. Because of worsening allodynia, polyarthralgia and polymyalgia with persistent eosinophilia, the patient underwent an aggressive workup for eosinophilic-related conditions, including parasitic infections/strongyloides, vasculitis/eosinophilic granulomatosis with polyangiitis, blood disorders/hypereosinophilic syndrome, and allergy testing.


On a follow-up rheumatology evaluation, a physical exam revealed skin thickening and deep induration of her distal extremities (sparing her hands and feet) with a peau d’orange appearance of the skin of her forearms and shins. Magnetic resonance imaging revealed fascial thickening and edema predominantly involving the deep peripheral fascia superficial to the muscles in the forearms and lower legs. The patient subsequently underwent a full thickness biopsy, consisting of skin, fascia and superficial muscle, which demonstrated perivascular infiltration of histiocytes, eosinophils, lymphocytes and plasma cells. Based on these findings, she was diagnosed with eosinophilic fasciitis. The patient was then started on high doses of oral prednisone (1mg/kg/day) in addition to methotrexate. Treatment led to normalization of the eosinophil count and skin softening on subsequent evaluation.

Clinical implications

While many autoimmune and rheumatologic conditions after viral infections have been described in the literature, to our knowledge this is the first case reported of eosinophilic fasciitis after primary COVID-19 infection. Development of new-onset autoimmune skin conditions has been reported following various vaccinations. Eosinophilic fasciitis has been documented after influenza vaccination and, more recently, has been described after a patient had received the COVID-19 mRNA vaccine. Other cutaneous disorders, such as morphea and discoid lupus, also have been described in the literature following various vaccinations.

The sequential association presented here between COVID-19 and newly diagnosed eosinophilic fasciitis could be coincidental. It is also possible that the COVID-19 primary infection triggered a phenotypic expression of a previously existing undiagnosed disease.


Patients with eosinophilic fasciitis typically respond with loosening of the skin to prolonged courses of high doses of steroids in conjunction with steroid-sparing agents such as methotrexate, mycophenolate mofetil and others. Treatment is typically required for several months to years. The condition overall caries a favorable prognosis, although joint contractures may persist if treatment is delayed.

Related Articles

Doctor talking with patient
March 21, 2024/Pulmonary/News & Insight
COVID-19: A Management Update

A review of IDSA and NIH guidelines

OCT scan showing dry AMD
Autoimmune Disease Linked With Higher Risk of Macular Degeneration

Early data shows risk is 73% higher in patients with lupus, 40% higher in patients with rheumatoid arthritis

ICU care
March 30, 2023/Digestive/Research
Vaccination Mitigates Increased Risk of COVID Hospitalization in Celiac Patients, Study Finds

Results from the large, single-center, retrospective study have multiple implications for preventive care

Tired patient
February 21, 2023/Pulmonary/News & Insight
Cleveland Clinic Joins NIH’s COVID-19 Recovery Research Consortium

Will enable patients with long COVID to enroll in national clinical trials

22-CHP-3415472 CQD-Kim-Association between COVID and New-Onset Type 1 Diabetes650x450
February 1, 2023/Pediatrics
COVID-19 and Diabetes in Pediatric Patients: What We Know

Evidence, clinical considerations, and why more research is still needed

23-CHP-3524808 CQD-MIS-C in Children with COVID-19-650×450
January 23, 2023/Pediatrics
Researchers Identify Potential Genetic Cause for MIS-C Complication

Team collaborates to explore effects of genetic mutations to proteins OAS and RNase L

January 13, 2023/COVID-19
Optimal Management of High Risk Immunocompromised Patients in the COVID-19 Era

As the pandemic evolves, rheumatologists must continue to be mindful of most vulnerable patients

covid-19 virus
January 12, 2023/COVID-19
Real World Experience with Tixagevimab/Cilgavimab in B-Cell-Depleted Patients

Early results suggest positive outcomes from COVID-19 PrEP treatment