Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 297-299

Atypical presentation of Covid-19 – Peripheral arterial thrombosis


Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India

Date of Submission25-May-2020
Date of Decision31-May-2020
Date of Acceptance03-Jun-2020
Date of Web Publication12-Sep-2020

Correspondence Address:
Vivek Wadhawa
Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_67_20

Rights and Permissions
  Abstract 


The present ongoing pandemic of Coronavirus Disease 2019 (COVID-19) has been viewed to be typically affecting the respiratory system chiefly the lungs parenchyma, but it has been more and more evident that severe acute respiratory syndrome coronavirus-2 is not exclusive to his single system. Here, we report a rare case of a 55-year-old female presented with the left brachial thrombus as an atypical presentation of COVID-19.

Keywords: Acute respiratory distress syndrome, coronavirus disease 2019, severe acute respiratory syndrome coronavirus-2


How to cite this article:
Gohil I, Patel D, Wadhawa V. Atypical presentation of Covid-19 – Peripheral arterial thrombosis. Indian J Vasc Endovasc Surg 2020;7:297-9

How to cite this URL:
Gohil I, Patel D, Wadhawa V. Atypical presentation of Covid-19 – Peripheral arterial thrombosis. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Sep 21];7:297-9. Available from: http://www.indjvascsurg.org/text.asp?2020/7/3/297/294909




  Introduction Top


The global pandemic caused by coronavirus disease 2019 (COVID-19) has affected more than 880,000 people in over 180 countries or regions worldwide.[1] COVID-19 is the clinical manifestation of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and most frequently presents with respiratory symptoms that can progress to pneumonia and in severe cases, acute respiratory distress syndrome and shock. It is a well-known fact that a significant quantity of the infected patients remain asymptomatic, and hence generating a carrier reserve for the virus to spread as a pandemic. However, there is increasing awareness of the cardiovascular manifestations of COVID-19 disease and the adverse impact that cardiovascular involvement has on prognosis.[2] COVID-19 may predispose to both venous and arterial thromboembolic disease due to excessive inflammation, hypoxia, and immobilization and diffuse intravascular coagulation.[3],[4] This is a case report of a patient who presented with peripheral arterial thrombosis.


  Case Report Top


A 55-year-old female was admitted with pain over the left forearm and hand for past 1 day. After taking consent from the patient, further history was taken and, it was known that patient has been transferred from a secondary government hospital with the diagnosis of acute limb ischemia. The patient had no history of venous thrombosis or spontaneous thromboembolism in the family. The patient had a history of exposure to suspected Covid positive patient before 1 week who eventually deemed positive on real time polymerase chain reaction (PCR) testing. On physical examination, the patient has sensory and motor movements present of the left limb, but a continuous pain was present over the forearm which was aggravated on doing work but not completely relieved on rest. The patient was investigated and Doppler ultrasonography showed acute thrombus in the left brachial artery. The venous system washaving a normal flow on the Doppler study. Electrocardiogram was done which showed that the patient was in sinus rhythm but the QRS complex was wide (>12 ms) [Figure 1]. TTE was done with no significant findings and no source of clot. Among the coagulation profile tests, all were within normal range except D-dimer which was raised reaching up to 3800. Other tests to rule out hypercoagulable state such as homocysteine level, protein C, protein S, and factor V Leiden deficiency test were done which came out to be normal. Due to the present COVID pandemic as per institute protocol high-resolution computed tomography of the thorax was done of the patient preoperatively which was normal without any significant lung pathology. The patient was taken into emergency surgery bearing proper precautions left brachial embolectomy was done under local anesthesia. Clots were removed and adequate proximal flow and distal runoff were ensured before the closure of the vessel. In the postoperative period, Covid PCR test was done for the patient which yielded to be positive. The patient had a smooth postoperative course. No adverse events such as rethrombosis or bleeding were seen in the immediate postoperative period. Postoperatively, the patient was given heparin infusion for 24 h such that activated clotting time was maintained between 150 and 200 and consequently with enoxaparin 0.6 mg BD for 2 more days. Above anticoagulants were overlapped with aspirin 150 mg OD for day 1 postoperatively and was advised to continue for at least 6 months. Tablet warfarin was started on the postoperative day 1 for 3 months keeping the INR between 1.5 and 2 Serial chest X-rays were done which showed no detrimental effect in the subsequent days. Supportive treatment for Covid is given as per protocol and the patient is stable.
Figure 1: 12-lead electrocardiogram showing sinus rhythm and broad QRS complex

Click here to view



  Discussion Top


COVID-19 though being a pandemic is a relatively newer disease whose pathophysiology is yet to be completely understood. The most important clinical symptoms in COVID–19 patients are fever, dry cough, and shortness of breath. However, various reports have been cited all over the globe presenting atypically and affecting neurology and circulation at various levels. Increase in incidence of myocardial ischemia, stroke, pulmonary embolism, and deep vein thrombosis in patients suffering from COVID-19 has been noted in every place geographically with no definitive testing methods to prove either it is just a coincidence or had a causal. However, this unusual rise in these atypical findings should not stray away from the fact that precise and complete pathophysiology of COVID-19 is yet to be understood, and till then this grey area needs to be more and more explored. It has been proven that when virus activates in a human host it increases various complement regulatory factors mutations and coagulation pathway mutations which could promote susceptibility to enhanced complement activation and thrombosis [Figure 2].[6] This information might further enhance the pathophysiology of the disease and help in explaining the atypical presentations. This patient had a known exposure to Covid positive patient before a week after which she started developing symptoms and eventually had thrombosis of the brachial artery. Moreover, D-dimer was also positive in this case which is sensitive enough to say that possibility of Covid cannot be ruled out. The pathophysiology related to this case can be explained by thus created hypercoagulable state in the body and formation of thrombus in a major peripheral artery. As no source of embolism was found in this case it can be safely said that patient had neo-thrombus formation in the artery itself. It cannot be proved by the routine testing methodology that Covid infection is directly related to thrombosis in this patient but ruling out other obvious causes and the timeline leading to symptoms show a pretty good causal relationship between the two. Furthermore, the patient was not a known case off coronary artery disease or any other inflammatory disease did no precede this event, this thrombotic event can be attributed to the COVID-19 positive status of the patient.
Figure 2: Model for compliment activation by severe acute respiratory syndrome coronavirus-2 and its interaction with coagulation cascade[5]

Click here to view



  Conclusion Top


We can fairly conclude that keeping an open mind and accepting the newer researches of SARS CoV-2 we can know in detail about the various atypical disease presentations, and hence can be properly treated. Here, the patient had an atypical presentation of peripheral arterial thrombosis which is attributed to COVD-19 and was successfully managed by surgical intervention for thrombus and supportive management for COVID-19 itself.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

U.N. Mehta Institute of Cardiology and Research Centre.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020;20:533-4.  Back to cited text no. 1
    
2.
Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol 2020. [doi: 10.1001/jamacardio. 2020.0950].  Back to cited text no. 2
    
3.
Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: Retrospective study. BMJ 2020;368:m1091.  Back to cited text no. 3
    
4.
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20. [doi.org/10.1056/NEJMoa2002032].  Back to cited text no. 4
    
5.
Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, et al. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases. Transl Res 2020;220:1-3. Published online 2020 Apr 15. doi: 10.1016/j.trsl.2020.04.007.  Back to cited text no. 5
    
6.
Fremeaux-Bacchi V, Fakhouri F, Garnier A, Bienaimé F, Dragon-Durey MA, Ngo S, et al. Genetics and outcome of atypical hemolytic uremic syndrome: A nationwide French series comparing children and adults. Clin J Am Soc Nephrol 2013;8:554-62.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed34    
    Printed0    
    Emailed0    
    PDF Downloaded6    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]