The Association between COVID-19 Infection and Gabrin Sign: A Case-Control Study

Abstract: Letter to the Editor The Association between COVID‑19 Infection and Gabrin Sign: A Case‑Control Study nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 02/20/2024 Dear Editor, The COVID‑19 pandemic has claimed countless lives, including that of Dr. Frank Gabrin, who battled bilateral testicular cancer and androgenetic alopecia before succumbing to the virus. In his memory, Wambier et al. conducted a study highlighting a novel symptom of COVID‑19: the Gabrin sign.[1] Recent research has shown that the SARS‑CoV‑2 virus primarily infects type II pneumocytes through binding with their angiotensin converting enzyme (ACE)-2 receptors, which is facilitated by the proteolytic priming of viral spike proteins by TMPRSS2. Studies of SARS‑CoV‑1 have suggested that inhibiting serine proteases can decrease the likelihood of virus attachment to ACE‑2 receptors. Furthermore, TMPRSS2 gene transcription is regulated by androgenic promoters.[2] Studies show that COVID‑19 patients have a higher incidence of androgenetic alopecia (AGA), making it critical to investigate AGA in both male and female patients as a potential risk factor.[3,4] The aim of this prospective case‑control study was to explore the potential correlation between COVID‑19 severity and androgenic alopecia in hospitalized male and female patients. We conducted this case‑control study at our tertiary care centre between March 2021 and August 2021, with institutional ethical committee approval (F/SPMC/IERB/0904) and informed consent from participants. Hospitalized males and females with COVID‑19 infection requiring oxygen support were included, and the virus was detected using real‑time reverse transcription‑polymerase chain reaction (RT‑qPCR) and COVID‑19 rapid antigen test (RAT). Cases included subjects with androgenic alopecia. This group was further divided into ‘positive Gabrin sign’ including Hamilton–Norwood scale (HNS) graded from 3 to 7 for men and Ludwig scale (LS) grade from 2 to 3 for women; and ‘negative Gabrin sign’ including HNS 1‑2 and LS‑1. Controls were recruited for this case‑control study by selecting individuals without androgenic alopecia who had been diagnosed with lab‑proven COVID‑19 from the same ward as the cases. Controls were also matched to cases on important variables that may affect the risk of COVID‑19 severity, such as age, gender, ethnicity, and comorbidities. Matching controls to cases helped to reduce the effects of confounding variables that may have impacted the study results. In our study, patients were categorized into three groups according to type of oxygen assistance required, namely those who needed simple oxygen masks (non‑severe), those who required high‑flow devices such as continuous positive airway pressure or high‑flow nasal cannulas (severe), and those who needed mechanical ventilation (critical). The outcomes were: survivor and non‑survivor. To further assess the effect of androgens on infection’s severity, for males, we noted the presence or absence of any prostate disease or history of consuming antiandrogens, while for females, we recorded the history of hormone replacement therapy and signs of hyperandrogenism, such as polycystic ovarian disease and virilization. The sample size calculation assumed a prevalence of 50% and an odds ratio of 1.7 according to previous studies, a power of 80%, and a significance level of..