ABSTRACT
SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: As the coronavirus pandemic continues to burden the global health care system, strong associations have emerged with hypercoagulability. Recent reports of Covid-19 support both venous and arterial thromboembolism, thus coagulopathy emerging as one of the most severe sequelae of the disease, which has also been associated with poorer outcomes. CASE PRESENTATION: A 71-year-old female with a past medical history of hypertension, type 2 diabetes, and obesity presented with progressively worsening shortness of breath and cough. She was found to be hypoxic to 80% on arrival and tested positive for COVID-19. She was subsequently intubated and admitted to the ICU. Her D-dimer was noted to be 9.04mcg/mLFEU (0-0.55mcg/mLFEU), ferritin 256ng/mL(10-291ng/mL), LDH 707 U/L(130-270U/L), CRP 138mg/L (< 10mg/L). She was treated with a ten-day course of dexamethasone and a five-day course of Remdesivir. On Day 7, purple discoloration was noted in the second to fifth digits of the left hand, concerning acute ischemia. Left upper extremity ultrasound revealed intraluminal heterogeneous echogenicity likely occlusive ulnar arterial thrombus with no flow to mid or distal segment and normal flow in the radial artery into a complete palmar arch. This was seen to be classical for micro-embolic phenomenon attributable to the hypercoagulable state associated with Covid-19 infection. Treatment with Heparin drip was initiated along with the local application of nitro paste. The patient was subsequently discharged home but re-presented a month later for gastrointestinal bleeding. At this admission, her left second digit was noted to express purulent drainage. Imaging confirmed osteomyelitis in the second through fifth digits and was referred to a tertiary center for definitive treatment. DISCUSSION: Covid-19 has been shown to provoke catastrophic inflammatory responses by triggering a dysfunctional cascade of thrombosis in the pulmonary vasculature leading to both micro and macroangiopathic manifestations. The quick progression of ischemia to digital gangrene, despite collateral circulation and early intervention, indicates severe microangiopathy. CONCLUSIONS: Thus physicians must always have a high index of suspicion for thromboembolic complications in patients with Covid-19. The development of severe complications despite prompt anticoagulation highlights the need for alternative or newer therapies like targeted immunotherapy that would effectively manage these complications of SARS-CoV-2. Reference #1: Digital Gangrene as a Sign of Catastrophic Coronavirus Disease 2019-related Microangiopathy Jessica S. Wang, MD,* Helena B. Pasieka, MD, MS,† Vesna Petronic-Rosic, MD, MSc, MBA,† Banafsheh Sharif-Askary, MD,* and Karen Kim Evans, MDcorresponding author Reference #2: Galván Casas C, Català A, Carretero Hernández G, Rodríguez-Jiménez P, Fernández-Nieto D, Rodríguez-Villa Lario A, Navarro Fernández I, Ruiz-Villaverde R, Falkenhain-López D, Llamas Velasco M, García-Gavín J, Baniandrés O, González-Cruz C, Morillas-Lahuerta V, Cubiró X, Figueras Nart I, Selda-Enriquez G, Romaní J, Fustà-Novell X, Melian-Olivera A, Roncero Riesco M, Burgos-Blasco P, Sola Ortigosa J, Feito Rodriguez M, García-Doval. Classifications of the cutaneous manifestations of Covid-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. 2020 Jul;183(1):71-77. doi: 10.1111/bjd.19163. Epub 2020 Jun 10. Reference #3: Mouhamed Yazan Abou-Ismail 1, Akiva Diamond 2, Sargam Kapoor 3, Yasmin Arafah 2, Lalitha Nayak 4.The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management Thromb Res. 2020 Oct;194:101-115. doi: 10.1016/j.thromres.2020.06.029. Epub 2020 Jun 20. DISCLOSURES: No relevant relationships by Navyamani Kagita No relevant relationships by ABHIGNA KULKARNI No relevant relationships by Rajesh Thirumaran
ABSTRACT
Background: Coronavirus disease 2019 (COVID19) evolved into a worldwide pandemic leading to devastating complications. In healthcare, significant changes were made to reallocate resources to cater to an increasing number of hospital admissions and prevent infection spread. Reallocation of the health care staff led to the scarcity of care in outpatient facilities, including infusion centers, until the widespread adoption of Telehealth. Treating lung cancer patients with immunochemotherapy and radiotherapy has been incredibly challenging due to the pandemic, especially in regard to balancing malignancy treatment with limiting exposure of vulnerable patients to acute lifethreatening infection. In addition, being unable to provide appropriate treatment to cancer patients can result in decreased functional capacity, loss of treatment window, and increased mortality. A multidisciplinary approach can prevent these outcomes by anticipating challenges early and streamlining resources appropriately to provide better patient care. In this study, we aimed to assess the adherence of NCCN guidelines for lung cancer at a community hospital in Philadelphia during the pandemic. Methods: A retrospective chart review was performed of patients diagnosed and receiving active treatment for primary lung cancer between March 1, 2020, and December 31, 2020, at Mercy Catholic Medical Center. Fifty cases of primary lung cancer undergoing active treatment were identified. Type and staging of lung cancer, NCCN guidelines' adherence, COVID-19 exposure, and missed treatments were reviewed and analyzed. Results: Of the 50 cases reviewed, 92% had non-small cell lung cancer (NSCLC), and 8% had small cell lung cancer (SCLC). Among NSCLC, 72% had adenocarcinoma, 12% had squamous cell carcinoma, and 8% had large cell carcinoma. Stage IV lung cancer consisted of 46%, followed by 34% of stage I, 14% of stage III, and 6% of stage II. NCCN guideline-directed treatment was initiated in 88% (44/50) of the total patients, with the remaining 12% of the patients either refusing treatment (8%) or were lost to followup (4%). COVID-19 infection was diagnosed in 35% of the patients, of which 60% missed less than two chemotherapy sessions and 40% of COVID-19 positive patients who required hospitalization missed more than two cycles. 28% of patients missed treatment sessions due to other factors. This resulted in 61% (27/44) of patients having a disruption in NCCN guidelinedirected treatment at some point during the pandemic. Conclusions: Our study results reflect upon the need for developing effective strategies in managing cancer patients. When possible, switching to oral regimens, redefining regimen administration intervals, postponing invasive investigations for asymptomatic patients, and utilizing telemedicine as appropriate should be considered.
ABSTRACT
INTRODUCTION: Arterial and venous thromboses secondary to Coronavirus disease 2019 (COVID-19) infection in critically ill patients is well-known. We present a unique case of devastating thrombosis in an otherwise stable patient as a result of COVID-19. METHODS: A 66-year-old female with history of hypertension and type 2 diabetes presented with suddenonset bilateral lower extremity pain after being discharged 6 days prior in a healthy state following admission for COVID-19 pneumonia. On presentation, examination revealed absent femoral pulses and loss of motor function in the right lower extremity (RLE) with decreased sensation in the left lower extremity. Bloodwork was significant for white count 12,300/μL, D-dimer 20μg/dL, and creatinine kinase 12383μ/L. CT Aorta with runoff revealed multiple acute thrombi in the pulmonary artery, infrarenal abdominal aorta, and bilateral popliteal arteries. Heparin drip was initiated, and emergent thrombectomies of the involved arteries and compartment fasciotomies of bilateral lower extremities were performed. RLE ischemia worsened despite revascularization with hospitalization complicated by severe sepsis secondary to Serratia sp. bacteremia and tissue necrosis of the RLE requiring above-knee amputation. RESULTS: Hypercoagulability in COVID-19 infection is presumed to be secondary to a cytokine storm precipitating an acute systemic inflammatory response and activation of the coagulation cascade. While many cases of critically ill patients with venous thromboembolism (VTE) have been reported, our patient is unique in that she was hemodynamically stable upon presentation. Most hospitalized patients receive VTE prophylaxis due to pre-existing guidelines. Initiating prophylaxis in COVID-19 patients is more critical as the coagulopathy from COVID-19 appears to be pro-thrombotic rather than hemorrhagic, and a higher than expected number of patients with COVID-19 limb ischemia are requiring amputation despite revascularization efforts. Currently, there are no clear guidelines on intensifying anticoagulation to therapeutic dosages in critically ill patients based on elevated biomarkers alone. We emphasize the need for conducting systematic trials to provide protocols specific for COVID-19 to decrease the incidence of catastrophic outcomes, as seen in our case.