ABSTRACT
Introduction: •COVID-19 is a thrombotic state (hypercoagulable) •Incidence of thromboembolic complications: •DVT: 25%. •Combined DVT, PE, and arterial thrombosis: 31%. •Anticoagulation therapy is recommended to prevent thrombotic complications. •Rare case of extensive thrombosis of abdominal arteries - multiorgan infarct being reported first time even after giving anticoagulation prophylaxis. Materials and methods: Case •A 60-year-old male, k/c/o hypertension on medication, diagnosed to have COVID-19 pneumonia, with SpO2 of 85% on 15 L/minute O2 through a face mask. •Fully conscious, with normal vitals admitted in ICU. Results: Treatment given: •Azithromycin 500 mg od •Dexamethasone 6 mg IV od •Remdesivir 100 mg IV od •LMWH 0.4 mL SC bd COURSE IN ICU: DAY 5: Developed severe, constant abdominal pain. •P/A: Soft, tender in umbilical, hypogastric area •CECT Abdomen: Superior mesentric artery (SMA) thrombus, edematous wall bowel loops, caecum, colon. •Thrombolysis with streptokinase done, Heparin therapeutic bolus dose followed by infusion given, aPTT targeted for 3 times normal. DAY 6,7 : Abdominal pain improved, passed stools. Oral liquid started DAY and: Pain increased, whole abdomen tender, gaurding. Emergency laparotomy done and bowels excised. CECT Abdomen: Massive infarct in spleen, Multiple Massive infarct in both kidneys, ischaemic bowel loops. Celieac artery, bilateral renal artery, splenic artery occluded Emergency Laparotomy and ischaemic bowel loops excised. POD1: He developed refractory hypoxemia, shock and cardiac arrest and died on POD 1. Course in ICU: Day 5: Developed severe, constant abdominal pain. •P/A: Soft, tender in umbilical, hypogastric area. •CECT Abdomen: Discussions: Pathophysiology of COVID-19 Induced Hypercoagulopathy: •Multifactorial. •Acute inflammatory response: cytokine stromea activation of platelet, endothelial cells, tissue factor, changes in levels of thrombomodulin, proteins C and S. •Binding of SARS-CoV-2 to angiotensin-converting enzyme a endothelial activation. •Bedridden. •Presence of large vascular catheters. Conclusion: •COVID-19 patients can develop thromboembolism even after adequate thromboprophylaxis. •Thromboprophylaxis to be started either with LMWH, heparin. •Point of care ultrasound (POCUS) screening should be done for early diagnosis of any thrombotic complication. •PT/INR, aPTT, D-dimer to be monitored every 48 hours.
ABSTRACT
Aims & Objectives: The 2019 novel coronavirus (2019-nCoV) or the severe acute respiratory syndrome corona virus 2 (SARS-CoV- 2), originated in Wuhan City of Hubei Province of China. In India, first confirmed case of coronavirus disease (COVID-19) was reported on January 30, 2020 and since then the virus has spread across the country. More than 7.9 million cases of COVID-19 and more than 1.19 lakh deaths have been reported in India. The pathobiology of the disease is poorly known, and significant efforts have been made to understand the disease process worldwide. Clinical autopsies are known to have a vital role in developing an understanding of the disease process. The aim of the present study was to evaluate bone marrow findings of COVID-19 by minimally invasive autopsies. Patients/Materials & Methods: This prospective study was conducted at All India Institute of Medical Sciences, Jodhpur. After obtaining approval from Institute's ethics committee and consent from next of kins, minimally invasive autopsies were conducted within an hour after the death. Procedures were done with all biosafety measures. The tissue specimens were kept in neutral buffered formalin for 48 h and then processed with standard biosafety measures. Electronic medical records were reviewed retrospectively and patients' clinical details and results of laboratory investigations were noted. Results: In this prospective study, bone marrow biopsy procedures were done in 37 COVID-19 minimally invasive autopsies. Mean age of these cases was 61.8 years (Range, 28-85 years) and male: female ratio was 2.36. Comorbidities were observed in 25(67.5%) of all cases. Histopathological analysis revealed hypercellular, normocellular and hypocellular marrow in 5, 25 and 5 cases respectively (two biopsies were inadequate). There was marked interstitial prominence of histiocytes in 24(68.5%) cases. Out of these, evidence of haemophagocytosis (Figure 1) was observed in 14(40%) cases, marked increase of haemosiderin laden macrophages in 20(57.1%) cases. There was prominence of plasma cells in 28 (80%) cases. Discussion & Conclusion: Incorporation of minimally invasive autopsies provides an effective method to study the pathological findings in COVID-19 deaths in resource constrained settings. Histopathological findings in bone marrow suggest indirect insult to bone marrow, presumably related to circulatory and/or hyperinflammatory response to viral infections.