In this issue, we will discuss a case report of COVID-19.
In this case, the patient developed thrombosis after COVID-19 infection, causing ischemia of the legs and other symptoms.
Case
A 72-year-old Caucasian male.
No relevant medical history or medication.
Respiratory failure, shock, and multiple organ failure occurred, and he was admitted to the intensive care unit.On admission, physical examination did not show any abnormalities in the extremities and the values related to coagulation were normal.
Three weeks later, the patient was extubated, and although there were no alterations and no dialysis, he needed to be reintubated two days later due to progressive respiratory failure.The ECG showed sinus rhythm with signs of ischemia but no acute myocardial infarction.Therefore, aspirin medication was started.Supplemental diagnostic CT thoracic angiography showed bilateral frosted lungs as seen in severe COVID-19, without signs of pulmonary embolism.In addition, CT angiography showed an arch of the ascending aorta and a floating thrombus within the distal thoracic aorta.Additionally, atherosclerotic plaques were seen in the descending aorta and not at the site of the aortic thrombus.Treatment with unfractionated heparin was initiated in the therapeutic target range.Physical examination the next day revealed blue toe syndrome.It became more severe in the right leg than in the left leg, and additional CT angiography of the peripheral vasculature of the leg revealed occlusion of the right posterior tibial artery without any sign of significant atherosclerosis.Computed tomography brain showed no signs of cerebral vascular ischemia.Computed tomography angiography of the abdomen revealed intact renal and mesenteric perfusion.
Follow-up CT aorta after one week showed stabilization of thrombus in the vessel wall and resolution of floating thrombus.Despite the reduced thrombus load in the aorta and the prevention of new thrombi by one week of heparin therapy, the first three toes of the right foot became necrotic and the left lower extremity recovered.This reduction in blood supply to the right leg was probably caused by distal embolization of most of the floating thrombus in the thoracic aorta.During these processes, the patient had persistently positive tests for SARS-CoV-2.Two weeks after admission, the renal function improved and eventually returned to normal.In addition, one blood culture was positive for Enterococcusfaecium, which was sensitive to vancomycin treatment.A blood culture taken one day later showed no microbial growth.Additional echocardiography showed no signs of endocarditis.
After the second weaning from the ventilator after 5 days, during rehabilitation, the patient was scheduled for follow-up CT aortic to anticoagulation with coumarin for at least 3 months.Over the next few weeks, the patient's cognitive function improved and he was transferred to a rehabilitation facility where full cognitive and substantial physical recovery was expected.Amputation of the first three toes of the right foot was performed three months after discharge.
Jan W Buikema, Folkert W Asselbergs, Janneke Tekstra, COVID-19 related thrombi in ascending and descending thoracic aorta with peripheral embolization: a case report, European Heart Journal - Case Reports, Volume 5, Issue 2, February 2021, ytaa525, https://doi.org/10.1093/ehjcr/ytaa 525
Learning points
Prophylactic anticoagulants are necessary for hospitalized patients.
D-dimer levels measured on admission in infected patients can help in the selection of therapeutic anticoagulants.
Conclusion
This was a case of COVID-19 infection that led to necrosis of the toes.
With cases like this, it may be important to investigate what happens in the event of infection.
