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SESSION TITLE: Rare Cases of Nervous System and Thrombotic Complication Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Covid 19 virus has impacted nearly 450 million people across the globe;ranging from an asymptomatic carrier state to respiratory symptoms, cardiovascular symptoms, hematologic manifestations and multiorgan failure to death. Thrombotic events are one of its devastating complications. CASE PRESENTATION: A 66 year old man with a history of diabetes mellitus, hypertension and 30 pack years smoking history presented to the emergency room with hypoxia and altered mental status. On exam, his GCS was 8/15 and oxygen saturation was 85% on room air. He was subsequently intubated. CTA chest demonstrated bilateral diffuse ground glass opacities and left pulmonary embolism (PE). CT abdomen and pelvis showed multifocal infarcts in the right kidney with findings suggestive of renal artery thrombosis. Initial platelet count was 80,000/ul with creatinine of 3.9 mg/dl and creatine kinase (CK) of 3977 u/l. His INR was 1.4. Patient was not a candidate for thrombolysis given his thrombocytopenia. He was started on intravenous (IV) heparin and given IV hydration. On day 3 of his admission, he developed dry gangrene of the toes. Ankle brachial index of the right lower extremity (LE) was 1.16 and left LE was 0. Duplex ultrasonography of left LE showed mid to distal popliteal artery thrombus occluding below knee popliteal and tibial arteries. Echocardiogram showed ejection fraction of 55% and bubble study was negative for any intra atrial or pulmonary shunting. On day 4 of his admission, he developed oliguria and his gangrene got worse. His platelet counts decreased to 36,000/ul. Other pertinent labs showed INR 1.2, PT 15.3, PTT 34, D dimer 14.82, fibrinogen 498, CK 6434 mg/dl, hemoglobin 13.2 g/dl, haptoglobin 243 mg/dl and LDH 1041 U/l. Given his poor prognosis in the setting of ventilator dependent respiratory failure, multiple thrombosis and kidney failure requiring hemodialysis, the family decided to withdraw care. DISCUSSION: There are multiple hypotheses of thrombus formation in Covid 19 infection such as interleukin 6 and other cytokines induced endothelial injury, angiogenesis and elevated prothrombotic factors such as factor VIII and fibrinogen. Our patient had PE, renal artery thrombosis and popliteal artery thrombosis. Despite being on full dose anticoagulation, he developed gangrene of the toes. His lab results were not consistent with disseminated intravascular coagulation, thrombotic thrombocytopenic purpura and he was not known to have any baseline hypercoagulable disorder. He did not have any intra cardiac shunts. Hence, it is most likely Covid 19 induced multiple arterial and venous thrombosis. CONCLUSIONS: The treatment of Covid 19 related thrombosis has become very challenging especially in the setting of multiple clots. It is crucial to have large multicenter studies to investigate vascular complications of Covid-19 and to formulate management strategies to ensure good patient outcomes. Reference #1: https://www.nejm.org/doi/full/10.1056/nejmoa2015432 Reference #2: https://journal.chestnet.org/article/S0012-3692(21)01126-0/fulltext DISCLOSURES: No relevant relationships by Devashish Desai No relevant relationships by Swe Swe Hlaing no disclosure on file for Jean Marie Koka;No relevant relationships by Hui Chong Lau No relevant relationships by Subha Saeed No relevant relationships by Anupam Sharma No relevant relationships by Muhammad Moiz Tahir
ABSTRACT
SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Dieulafoy lesions are abnormally dilated submucosal vessels remain uncommon cause of upper gastrointestinal bleeding, accounting for approximately 1.5% of all GI bleeds [1]. Although the exact etiology remains unknown, multiple co-morbid conditions have been attributed to this condition, including heart diseases, hypertension, chronic kidney disease, diabetes, or excessive alcohol use [2].In our case, it was identified as a cause of lower GI bleed in a critically ill Covid patient. CASE PRESENTATION: A 49-year-old male with a history of diabetes, internal hemorrhoids, and diverticulosis was admitted to the hospital due to hypoxic respiratory failure from COVID pneumonia with characteristic CT findings of bilateral ground-glass opacification. On admission, the patient was afebrile, normotensive, tachypneic with a respiratory rate of 34.The physical examination was unremarkable except for coarse crackles in upper and middle lung zones. We treated patient with Dexamethasone and Remdesivir. His hypoxia deteriorated, and he was eventually intubated. On admission patient hemoglobin was within normal range. During the patient's hospital course, he had a significant drop in hemoglobin, requiring multiple blood transfusions. Blood clots were found on perianal examination. Flexible sigmoidoscopy revealed blood in the rectosigmoid colon. A visible vessel without apparent ulcer was seen in the rectum, which was actively oozing blood. It was determined to be a Dieulafoy lesion. The affected area was injected with epinephrine for hemostasis, and subsequently, hemostatic clips were placed. After the procedure patient did not have any repeat episodes of hematochezia or drop in hemoglobin. DISCUSSION: Dieulafoy lesions are an uncommon cause of GI bleeding and are usually present in the upper gastrointestinal tract. Furthermore, they caused hemodynamically significant bleeding from the lower gastrointestinal tract in our case. Dieulafoy lesions can be asymptomatic or may bleed intermittently to cause severe hemodynamic compromise. They may be missed on endoscopy due to the small size and intermittent bleeding [2]. In up to 9-40% of the cases, these lesions tend to rebleed. Therefore the patients need close monitoring [3]. In our case, after the intervention with the clips, the patient's bleeding stopped, and he had no further blood loss from the lesion. CONCLUSIONS: Dieulafoy's lesion is an infrequent cause of gastrointestinal bleeding, and it is challenging to diagnose [3]. It is a rare cause of GI bleeding, and even in those instances, it is found chiefly in upper GI bleed cases but can also be the cause of lower GI bleeding. Knowing that GI bleeding in Covid patients leads to worse outcomes, it is prudent to account for rare causes of GI bleed during the work-up. Reference #1: Van Zanten SV, Bartelsman J, Schipper M, Tytgat G. Recurrent massive haematemesis from Dieulafoy vascular malformations–a review of 101 cases. Gut. 1986;27(2):213. Reference #2: Shin HJ, Ju JS, Kim KD, et al. Risk factors for Dieulafoy lesions in the upper gastrointestinal tract. Clinical Endoscopy. 2015;48(3):228. Reference #3: Baettig B, Haecki W, Lammer F, Jost R. Dieulafoy's disease: endoscopic treatment and follow up. Gut. 1993;34(10):1418-1421. DISCLOSURES: No relevant relationships by Swe Swe Hlaing No relevant relationships by Joyann Kroser No relevant relationships by Hui Chong Lau No relevant relationships by Sze Jia Ng No relevant relationships by Subha Saeed No relevant relationships by Muhammad Moiz Tahir