Multisystem Inflammatory Syndrome in Children Requiring ECMO: Anticoagulation strategies and Lessons Learned

Intro: Multisystem Inflammatory Syndrome in Children (MIS-C) is a post-infectious inflammatory response after exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which can cause acute cardiac dysfunction requiring mechanical circulatory support (MCS). MCS utilization for MIS-C is complicated by a propensity for thrombosis, which threatens circuit integrity. This study describes a cohort of MIS-C patients requiring MCS, their outcomes, and the anticoagulation strategies utilized. Method(s): A retrospective case series of patients diagnosed with MIS-C needing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) at Children's Healthcare of Atlanta from March 1, 2020 to June 30, 2022. VA-ECMO variables, laboratory data, complications, and outcomes were collected. Result(s): Seven patients (all male) with severe MIS-C required VA-ECMO for acute cardiac dysfunction. Median age was 13 years (range 4-15 years). Median ICU stay was 13 days (range 6-17 days) with a median ECMO duration of 7 days (IQR 3-8 days) and median mechanical ventilation duration of 8 days (IQR 5-11 days). All seven patients survived to hospital discharge with good neurologic outcomes. Median time to qualitatively normal ventricular function by echocardiogram was 9.5 days (IQR 3-21 days). Heparin was initially used in 6 patients, bivalrudin initially used in 1 patient, and 1 patient converted from heparin to bivalirudin for refractory systemic thrombosis. Median heparin dose was 206u/kg/d (IQR 192-276u/kg/d) with median anti-Xa levels of 0.75 (IQR 0.1-1.1) and median daily PTT 102 seconds (IQR 83-107 seconds). Median daily PTT of patients receiving bivalirudin was 86 seconds (80-93 seconds). Median R-values by thromboelastography were 38 seconds (IQR 25-55 seconds). Two patients required catheter directed thrombolysis with tissue plasminogen activator (t-PA) for refractory intracardiac thrombi, both were initially started on heparin. Significant cannula thrombosis occurred in 2 patients, 1 initially started on heparin and 1 initially on bivalrudin. Bleeding resulting in compartment syndrome occurred in one patient on heparin requiring fasciotomy of the upper extremities, this patient was not receiving t-PA. Conclusion(s): Anticoagulation management for MIS-C patients requiring ECMO is fraught with challenges. A successful management strategy may necessitate higher heparin assay levels, the use of direct thrombin inhibitors for refractory thrombosis, and the deployment of catheter directed thrombolysis. In this case series, CDT was safely and successfully used in two patients. Further studies are required to understand the optimal anticoagulation strategy for these patients to minimize complications.

Spontaneous Hematoma of Upper Extremities in a Patient with Antiphospholipid Antibody Syndrome: A Case Report

A 44-year-old woman with underlying systemic lupus erythematosus and antiphospholipid antibody syndrome presented with nausea and vomiting after her 2nd vaccination for coronavirus disease 2019 (COVID-19). Thirteen days after warfarin injection was administered along with steroid therapy, the patient suffered sudden right shoulder pain, paresthesia, and swelling, suggesting acute compartment syndrome. The warfarin regimen was bridged to low molecular weight heparin and fasciotomy was performed. Multiple hematoma evacuation after fasciotomy was done and the patient was referred for skin necrosis. Frequent debridement and negative pressure wound therapy were performed to heal the right upper extremity skin defect. Afterwards, the patient experienced hemorrhage in her left upper extremity and was treated conservatively with simple compression. This report suggests that patients undergoing anticoagulation therapy for antiphospholipid syndrome should be closely monitored for subcutaneous hemorrhage, and that prompt diagnosis and treatment may prevent adverse re-sults. If massive skin necrosis occurs, multiple surgical debridement procedures and application of negative pressure wound therapy may be an option. © 2022 Korean Wound Management Society.

Isolated Compartment Syndrome of the Hand After Intravenous Doxycycline Infiltration Injury.

Isolated compartment syndrome of the hand, although uncommon, can lead to considerable functional deficits if not treated promptly. The most common etiologies are related to trauma, burns, or electric injuries; however, some cases have been reported after intravenous infiltration events, particularly rapid intravenous contrast injection. In this case report, we describe the development of compartment syndrome in the hand of a critically ill patient with COVID-19 pneumonia and sepsis 16 days after doxycycline infiltration injury. She presented with worsening pain, swelling, bullous eruption, and intrinsic minus hand posturing. Emergent surgical release of intrinsic hand compartments and evacuation of a hematoma resolved her symptoms and preserved hand function. Early recognition and surgical intervention of compartment syndrome of the hand after infiltration injury in medically complex patients will reduce morbidity in this patient population.

Increase in pediatric thrombotic amputations during the SARSCoV- 2 pandemic: manifestation of macrophage activation syndrome

Background. This study was inspired by the sudden unexplained increase in pediatric amputations during the SARSCoV- 2 pandemic. Method(s): With appropriate IRB approval, pathology files were searched for all amputations from Jan 2017 to May 2022. All available slides on thrombotic amputations of 2020 and 2021 were reviewed. Additional immunohistochemical stains for CD3, CD20 and CD163 were performed. Medical records were reviewed. Result(s): Total yearly amputations from 2017 to 2020 ranged from 17 to 19;they increased to 26 in 2021. They remained stable in etiologies such as oncologic, diabetic, traumatic, congenital anomalies, and infectious, but rose for thrombotic/ischemic etiology. Between Jan 2020 and Oct 2021, 10 children (M:F 1:1), ranging from 36 days to 19 years in age underwent lower extremity amputations secondary to large vessel thrombosis (compared to 2 in 2017 and 0 for 2018-2019). All except 3 were previously healthy. Five were African American, 3 Caucasian, and 2 Hispanic. At admission, 4 were SARS-CoV-2 positive (RT-PCR), 2 showed elevated SARS-CoV-2 IgM antibody suggestive of recent exposure/infection, and 4 were negative or non-tested. One was vaccinated 6 months prior (2 doses) with reported recent COVID-19 exposure. Four had co-existing viral positivity including Influenza B, parainfluenza virus type 3, Parvovirus B19, and HSV-1. Six had secondary bacterial sepsis during the course of illness. At presentation, 8/10 had cardiac, renal and/or respiratory failure;6/10 showed all three. Seven were started on ECMO at or immediately after presentation. Elevation in BNP was seen in 7, CRP in 9, and ferritin in 7. All were diagnosed with compartment syndrome and underwent multiple fasciotomies before amputations. Tissue was available as thrombectomy, amputation specimens, and autopsy. Admission to amputation interval ranged from 2 days to 3.5 months. Three patients died of multiorgan failure. Histopathology review showed microthrombi (10/10), medium/large vessel thrombi (10/10), intravascular macrophages (9/10), extravascular macrophages (9/10), vasculitis (6/10), and myositis (5/10). Histologic lympho- and hemophagocytosis was seen in 7/10 cases. Immunostains showed scant T and B cells with abundance of CD163 positive foamy macrophages. No such cases have been seen since Oct 2021 to May 2022. Conclusion(s): Sudden unexplained rise in pediatric amputations was noted during the SARS-CoV-2 pandemic. Histopathology showed large, medium and small vessel thrombosis. Clinical elevation of inflammatory markers in conjunction with histologic abundance of macrophages and occurrence of lympho- and hemophagocytosis suggests macrophage activation syndrome as a likely thrombotic etiology.

Thromboprophylaxis in gynaecology: a review of current evidence

Key content: Thromboembolism is a major cause of preventable morbidity and mortality. Hospital acquired thrombosis (HAT) accounts for 50-60% of all thromboembolic events. As well as effects on patient safety, there are considerable cost implications to both prophylaxis and treatment. While guidance exists on thromboprophylaxis for patients in obstetrics and those undergoing general surgery, there is a paucity of guidance relating to gynaecological practice. Increasing prevalence of risk factors and multimorbidity is paralleled by higher risk of thromboembolic events. Gynaecological surgery presents some unique risk factors for thrombosis. Learning objectives: To understand the basic pathophysiology of thrombosis in relation to risk factors particularly relevant to gynaecology and pelvic surgery. To know the current evidence in key areas relevant to gynaecological practice: early pregnancy;day case surgery;minimally invasive gynaecological surgery;open and complex benign gynaecology and gynaecological oncology. To be aware of proposed guidance on risk assessment and prophylaxis in thrombosis as relevant to the gynaecologist based on current evidence. Ethical issues: Problems with thromboprophylaxis in high-risk patients include noncompliance and refusing animal products/injections. Clinicians may be reluctant to institute thromboprophylaxis, most times because of the possible risks of bleeding. Copyright © 2022 Royal College of Obstetricians and Gynaecologists.

Acute upper limb ischemia as initial presentation of COVID-19 infection in a 49-year-old male: A case report

Background: Coronavirus disease-19 (COVID-19) is an emerging threat because of its significant damage to the lungs and its risk of thrombosis in microvascular, venous, and arterial beds. Moreover, thrombosis in patients with the COVID-19 infection may also be more extensive, leading to limb loss and death. One of the thrombotic complications reported in COVID-19 is acute limb ischemia (ALI), which is characterized with an abrupt decrease in the arterial perfusion of a limb, threatening its viability and integrity. In this report, we describe an unusual case of an unvaccinated patient who presented with acute unilateral upper extremity ischemia as the initial manifestation of COVID-19. Case presentation: A 49-year-old man, unvaccinated for COVID-19, presented to the emergency room due to worsening left hand and forearm pain of one week duration. The brachial, radial, and ulnar pulses were absent. Emergency arterial duplex scan of the left arm showed acute thrombi totally occluding the lumen of axillary artery and extending to the proximal to distal brachial, proximal to distal radial and ulnar arteries. Anticoagulant infusion in the form of heparin was immediately started was titrated accordingly depending on aPTT. Surgical embolectomy was offered but could not be immediately done within 6 hours of presentation due to positive result for SARSCoV2. Patient denied history of respiratory symptoms and was also noted to have normal lung findings. During surgical embolectomy, a significant amount of large, elongated acute thrombi were retrieved. Anticoagulation was resumed post-operatively and no signs and symptoms of compartment syndrome were noted. Patient slowly recovered his sensory and motor functions within a month from onset of ALI. Conclusion(s): Thrombotic events such as acute limb ischemia may be the initial manifestation of COVID-19 infection. In this patient, what we found particularly peculiar was that he had no respiratory symptoms despite being unvaccinated during the time that the Delta variant was the prevailing strain of coronavirus. This case underscores the fact that clinicians should have high index of suspicion of COVID-19 infection as a cause of thrombotic events, especially in patients with no or very few risk factors.

A RARE CASE OF ASYMPTOMATIC COVID-19 INFECTION MASQUERADING AS PHLEGMASIA CERULEA DOLENS

SESSION TITLE: Look again: Infections and Mimics SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Phlegmasia Cerulea Dolens (PCD) is a rare and critical condition caused by venous thrombosis requiring emergent treatment to prevent limb ischemia. COVID 19 has been widely reported to cause venous thromboembolism and compromise of tissue perfusion. We report a case of PCD in a patient with asymptomatic COVID-19 infection. CASE PRESENTATION: A 60 year-old female with no known medical history, unvaccinated for COVID-19 presented with sudden onset left lower extremity pain and swelling associated with numbness. Physical examination was remarkable for left lower extremity swelling with bluish discoloration, poikilothermia, and paraesthesia. Computed tomography angiogram (CTA) chest, abdomen and pelvis revealed left lower extremity deep vein thrombosis with compromised blood flow with focal thrombosis of the IVC extending inferiorly to the great saphenous and popliteal vein, along with small bilateral segmental and subsegmental pulmonary emboli. Diffuse Ground glass opacities suspicious for COVID-19 pneumonia. COVID-19 PCR was positive. Anticoagulation with heparin drip was initiated, and the patient underwent successful left iliocaval to popliteal vein thrombectomy and venoplasty by interventional radiology with successful restoration of circulation to the affected extremity. She was eventually transitioned to apixaban. She experienced marked improvement in her symptoms post procedure. DISCUSSION: Patients with COVID 19 develop venous thromboembolisms at an alarming rate despite thromboprophylaxis. The mechanism is likely explained by the virchow's triad (venous stasis, hypercoagulable state, vessel wall injury) in the setting of increased pro-inflammatory markers. We report the first case at our institution of PCD in the setting of COVID-19.We noted that our patient had a similar presentation as those reported in literature, which include acute leg swelling associated with pain and cyanosis. Complications include venous outflow obstruction, which can result in compartment syndrome with arterial ischemia, eventually progressing to gangrene of the affected limb. PCD is a very rare but life-threatening complication caused by extensive clot burden associated with acute limb ischemia and increased mortality rates. This condition requires emergent initiation of intravenous anticoagulation and thrombectomy with or without tissue plasminogen activator (tPA). If this condition is not treated in a timely fashion, it can result in acute limb ischemia and gangrene requiring amputation. CONCLUSIONS: Physicians should recognize PCD in patients who have been exposed to COVID-19 as it is a life-threatening condition which requires emergent initiation of anticoagulation and treatment. Diagnosis is usually made with clinical examination and ultrasonography or CT imaging. Management options include open thrombectomy with leg fasciotomy or catheter directed thrombolysis or percutaneous transluminal angioplasty. Reference #1: Chun TT, Jimenez JC, Pantoja JL, Moriarty JM, Freeman S. Phlegmasia cerulea dolens associated with acute coronavirus disease 2019 pneumonia despite supratherapeutic warfarin anticoagulation. J Vasc Surg Cases Innov Tech. 2020;6(4):653-656. doi:10.1016/j.jvscit.2020.10.002 Reference #2: Gutierrez JR, Volteas P, Skripochnik E, Tassiopoulos AK, Bannazadeh M. A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy. Ann Vasc Surg. 2022 Feb;79:122-126. doi: 10.1016/j.avsg.2021.07.034. Epub 2021 Oct 10. PMID: 34644637;PMCID: PMC8502248 Reference #3: : Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med. 2020;38(9):1978.e1-1978.e3. doi:10.1016/j.ajem.2020.05.022 DISCLOSURES: No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Steven Miller N relevant relationships by jasparit minhas No relevant relationships by houman mirtorabi No relevant relationships by Kunal Nangrani No relevant relationships by Gaurav Parhar No relevant relationships by Kiran Zaman

WHEN ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) IS JUST THE BEGINNING: DISSEMINATED INTRAVASCULAR COAGULATION (DIC) FROM COVID-19 INFECTION PRESENTING AS ACUTE MYOCARDIAL INFARCTION

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: COVID-19 is associated with a hypercoagulable state and has been linked with Disseminated Intravascular Coagulation (DIC) [1]. DIC causes systemic thrombosis in micro- and macro- vasculature and in rare instances can involve coronary arteries [2]. In this case report, we present a patient who presented as an ST-segment elevation myocardial infarction (STEMI) and DIC in the setting of severe COVID-19 disease. CASE PRESENTATION: A 46-year-old lady with a history of hypertension presented with acute onset of typical chest pain. She tested positive for COVID-19 infection. Emergency room EKG showed anterior STEMI, and the patient underwent cardiac catheterization via a femoral approach which revealed a 99% stenosis in the proximal LAD, with filling defects consistent with a thrombus. Thrombectomy was performed and three drug-eluting stents were placed in the left anterior descending artery. Following stent placement, the patient went into ventricular fibrillation cardiac arrest followed by PEA. ROSC was attained after 3 rounds of CPR. Labs showed an acute drop in hemoglobin from 14 gm/dL to 5 gm/dL with CT evidence of extensive retroperitoneal bleed, extraperitoneal bleed, and large abdominal aorta thrombus proximal to the bifurcation. Labs were significant for prolonged INR (2.1), PT (23.4 seconds), PTT (106.7 seconds), elevated D-dimer (>4.0), decreased platelets (101K/μl), and increased fibrin split products (80uG/mL) consistent with DIC. The acute aortoiliac occlusive thrombus resulted in acute limb ischemia, rhabdomyolysis causing renal failure, and compartment syndrome requiring bedside fasciotomy. She was treated with triple therapy and demonstrated gradual clinical improvement. DISCUSSION: DIC was a possible precipitant of STEMI in this patient with evidence of thrombotic occlusion of LAD. DIC is a life-threatening coagulopathy characterized by mixed hypo- and hypercoagulation. This often leads to a systemic distribution of clots, evidenced by thrombi present in the coronary and aortoiliac arteries. Historically, bacterial sepsis was more strongly linked with DIC than viral causes;however, there has been an increasing amount of evidence linking COVID-19 with DIC, likely due to the severity of the illness. In this patient with recent stent placement, large aortic thrombus, and extensive retroperitoneal bleed, management was complicated by need for dual antiplatelet therapy for drug-eluting stents as well as anticoagulation for acute limb ischemia. Another diagnosis to keep in the differential includes heparin-induced thrombocytopenia, characterized by similar findings to DIC, but is associated with antibodies against platelet factor 4, which was not found in our patient. CONCLUSIONS: In this case, a young female patient without traditional cardiac risk factors was found to have an anterior STEMI, likely precipitated by DIC as a complication of COVID-19 infection. Reference #1: Asakura, Hidesaku, and Haruhiko Ogawa. "COVID-19-associated coagulopathy and disseminated intravascular coagulation.” International journal of hematology vol. 113,1 (2021): 45-57. doi:10.1007/s12185-020-03029-y Reference #2: M. Sugiura, K. Hiraoka, and S. Ohkawa, "A clinicopathological study on cardiac lesions in 64 cases of disseminated intravascular coagulation,” Japanese Heart Journal, vol. 18, no. 1, pp. 57–69, 1977. DISCLOSURES: No relevant relationships by radhika deshpande No relevant relationships by Shruti Hegde No relevant relationships by Robert Kropp No relevant relationships by Prashanth Singanallur

Decompressive Laparotomy for Veno-Venous Extracorporeal Membrane Oxygenation Failure due to Intra-Abdominal Hypertension in Critically Ill COVID-19 Patient.

The use of extracorporeal membrane oxygenation (ECMO) has increased over the course of the SARS-CoV-2 pandemic. Intra-abdominal hypertension resulting in abdominal compartment syndrome (ACS) during ECMO support is a rare but life-threatening complication, with previous case series describing mortality rates of 44%-100%. Bleeding complications, linked to both patient-related and device-related factors, also characterize prolonged ECMO support and have been reported in up to 60% of ECMO patients. We hereby describe a critically ill COVID-19 patient who underwent emergent bed-side decompressive laparotomy for acute ECMO failure related to the development of ACS. The discussion is focused on surgical considerations including the delicate balance between anticoagulation and thrombosis, as anticoagulation-free ECMO support may be required due to hemorrhagic complications.

Undifferentiated Shock: A Case of Idiopathic Capillary Leak Syndrome

Systemic capillary leak syndrome (SCLS or Clarkson's disease) is a rare condition characterized by episodes of vascular hyperpermeability. The extravasation of plasma to the interstitial space results in hemoconcentration, hypoalbuminemia, hypovolemia and compartment syndrome of the extremities. The disease can be idiopathic or secondary to causes including viral infections or chemotherapeutic toxicity. We present a fatal case of idiopathic SCLS which rapidly deteriorated to multiple organ failure despite initial improvement with methylene blue. A 57-year-old male presented for worsening back pain over one month. He described a flulike illness 2 weeks prior. Testing for respiratory viruses including SARS-CoV-2 was negative. He received intravenous crystalloid fluids acutely developed respiratory distress and hypotension requiring emergent intubation and initiation of norepinephrine infusion. CT angiography of the chest demonstrated pulmonary edema. Early during his hospitalization urine output ceased and body weight increased by 10 kg, developing tense anasarca. Hematocrit concentrated from 42.7 to 54.4%. Serum albumin dropped from 4.6 to 2.5 g/dL. C1 esterase inhibitor level and IgM were normal. Ferritin was elevated at 2515 ng/ml. He received cefepime and vancomycin, though infectious workup returned unremarkable. Continuous renal replacement therapy and stress dose steroids were initiated. Vasopressor requirement worsened until he was on three vasopressors at one point. Given the constellation of hemoconcentration, hypoalbuminemia, and shock a diagnosis was made of idiopathic SCLS. Treatment was started with methylene blue, montelukast, and the β-adrenergic agonist terbutaline. Blood pressure improved and patient came off pressors and lactate improved from 13 to 4. However, he later developed rising creatine kinase continued to climb to >40,000 U/L. He developed rhabdomyolysis with concern for compartment syndrome of the extremities due to third spacing of fluids. Orthopedic surgery was consulted;but did not believe a fasciotomy was indicated due to rapid decline. Lactic acidosis rose to 18 mmol/L. His family decided to transition to comfort measures. He passed with family at bedside on Day 4 of hospitalization. There are fewer than 500 cases of SCLS reported since initial discovery in 1960. Given the overlap in presentation with common causes of plasma leakage such as sepsis, it is likely that many cases are unrecognized. Patients are often mismanaged;development of severe hypovolemia despite fluids and compartment syndrome is overlooked. This case builds on our evolving recognition of this disease, and the potential for the use of methylene blue to help acute exacerbations of the disease.

COVID-19 ARDS with Concurrent Methicillin-Sensitive Staphylococcus aureus Bacterial Infection Requiring Extracorporeal Membrane Oxygenation

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that causes the disease entity COVID- 19. Initially, reports showed children had generally mild disease, with few requiring hospitalization. However, as of December 2021 in Arkansas, USA, children and young adults aged 24 years and younger accounted for approximately 166,000 cases with over 1,800 hospitalizations and 27 deaths (3 deaths under age 17). Comparatively, there have been over 6 million cases nationally in children and young adults, with over 1,000 deaths. Bacterial, viral, and fungal co-infections are known complications of viral respiratory illnesses that can lead to increased mortality. There have been multiple reports in adults on the incidence and type of co-infections seen with COVID-19, but few in pediatric patients. Adult data shows that co-infections are present in approximately 13-45% of patients with COVID-19, most commonly with bacterial pathogens of Mycoplasma pneumoniae and Haemophilus influenzae. Methods: We describe four patients with acute SARS-CoV-2 infection, requiring intubation, mechanical ventilation, and extracorporeal membrane oxygenation (ECMO), all of whom had methicillin-sensitive Staphylococcus aureus(MSSA) infections discovered within 24 hours of escalating respiratory support. This case series was determined as exempt by the Institutional Review Board at our institution. Results: Our cohort includes 4 patients with a median age of 18 years (range 16-19 years), all of whom required ECMO for acute respiratory distress syndrome (ARDS) secondary to SARS-CoV-2 pneumonia. The median time from intubation to ECMO cannulation was 139 hours (range 3-319 hours). All patients received targeted COVID-19 therapy with dexamethasone, remdesivir, and either tociluzimab or baricitinib during their hospitalization. These patient also all had culture positive MSSA infections from blood and mini-BAL cultures. Three of the four patients had a positive culture within 24 hours of requiring ECMO and one patient had a positive culture within 24 hours of requiring intubation. All of the patients were initially placed on venovenous (V-V) ECMO and three (75%) later required transition to venoarterial venous (VA-V) ECMO for worsening hemodynamics. All were initially cannulated with dual site femoral-internal jugular configuration. Femoral arterial cannulas were used for the transition to VA-V. Complications encountered during ECMO for these patients included GI bleeding (n=1), atrial flutter requiring cardioversion (n=1), lower extremity compartment syndrome (n=1), and dislodgement of a venous ECMO cannula (n=1). One patient received a tracheostomy while on ECMO. The median ECMO duration was 19.35 days (range 11-48.5 days). All patients were successfully decannulated from ECMO and all were discharged from the hospital alive, except one who is still requiring inpatient rehabilitation services. Discussion: We describe 4 pediatric patients with acute SARS-CoV-2 respiratory infections who were found to have MSSA co-infection within 24 hours of escalating respiratory support, all of whom eventually required ECMO support. In a recently published study, Pickens, et al reported that 25% of recently intubated adult COVID-19 patients have a bacterial co-infection. Limited data is available in pediatric patients. Staphylococcus aureus infections are among the most common bacterial infections worldwide. They are responsible for over 100,000 infections in the United States each year and lead to increased morbidity and mortality. All of our patients received immunemodulating therapies with either tociluzimab or baricitinib, which carry the risk of secondary infections due to immunosuppressive effects. Clinicians should maintain a high index of suspicion and be aware of the possibility of secondary bacterial infections in COVID- 19 patients, especially in those treated with immune-modulators. MSSA co-infection can lead to increased morbidity and mortality in patients with SARS-CoV-2, as seen in our cohort. More investigation s needed to further describe co-infections in patients with COVID- 19 and to identify risk factors for the development of co-infections.

Bilateral Lower Extremity Compartment Syndrome Secondary to COVID-19 Myositis in a Young Vaccinated Woman.

Coronavirus disease 2019 (COVID-19) typically manifests with respiratory symptoms and can ultimately progress to severe multiorgan failure. Viral myositis, systemic capillary leak syndrome, and arteriovenous thrombosis are atypical manifestations of COVID-19. We present a case of a 33-year-old woman, fully vaccinated against COVID-19, who developed myositis and shock. She ultimately required bilateral lower extremity fasciotomies secondary to compartment syndrome, presumably from COVID-19 myositis. Although compartment syndrome from COVID-19 myositis has been reported for ocular, hand, and thigh compartment syndromes, this is the first case report showing bilateral lower extremity compartment syndrome secondary to COVID-19 myositis in a fully vaccinated individual. As we learn more about COVID-19 and its extrapulmonary effects, it is imperative to consider all working diagnoses when working up patients. Providers must be aware of extrapulmonary effects of COVID-19, particularly in individuals who might deviate from traditional symptoms.

Impact of Time and Mechanical Ventilation on Convalescent Plasma in Severe/Critically Ill COVID-19 Patients

Background: Convalescent plasma (CP) transfusion is one of the suggested treatments for Coronavirus disease 2019 (COVID-19) especially in critically ill patients. Objectives: This study aimed to investigate the efficacy and safety of CP transfusion were investigated in severe/critically ill COVID-19 patients. Methods: This study was performed on 50 consecutive COVID-19 patients with severe/critically ill disease. Severe disease was defined as having at least one of the following symptoms: shortness of breath, respiratory frequency ≥ 20/min, blood oxygen saturation ≥ 93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio < 300, lung infiltrates > 50% within the last 24-48 h. Critically ill disease was identified by intensive care unit admission, respiratory failure, septic shock, or multiple organ dysfunction or failure. Primary outcomes included the safety of CP transfusion, 14-day and 30-day survival rate, and change in lung computed tomography (CT) scan score. Several other clinical and laboratory features were evaluated as the secondary outcomes. Results: Based on the results, 21 out of 50 consecutive patients were on mechanical ventilation at the time of CP transfusion. In total, 32 patients (64%) survived 30 days after CP transfusion. The survival rates were 74% and 44% in patients who received CP < 7 and ≥ 7 days after admission, respectively. While 92% of patients without mechanical ventilation survived, the survival rate of patients on mechanical ventilation was 29%. Moreover, the CT scan score and some other clinical features were improved in the group that received CP transfusion, and no adverse effects were observed. Conclusion: The CP transfusion is a safe and effective treatment in severe/critically ill COVID-19 patients. The best outcome can be achieved in patients who are not on mechanical ventilation, especially early in the disease course.

Successful surgical-multimodal treatment for vaccine-induced complete splanchnic vein thrombosis after ChAdOx1 nCoV-19 vaccination

Objective Thrombotic-thrombocytopenic events are rare, but life-threatening, complications after ChAdOx1 nCoV-19 vaccination and sometimes present as symptomatic splanchnic vein thrombosis with critical illness. Life-saving aggressive and multimodal treatment is essential in these cases. Design We report on a critically ill 40-year-old male patient with complete splanchnic (portal/mesenteric/splenic) vein thrombosis, becoming symptomatic 7 days after ChAdOx1 nCoV-19 vaccination and diagnosed on day 12. Laparotomy for abdominal compartment syndrome and repeated transjugular/ transhepatic interventional and open surgical thrombectomy procedures were performed. Additional therapy consisted of thrombolysis with recombinant tissue-type plasminogen activator over 5 days, anticoagulation (argatroban), platelet inhibition (Acetylsalicylic acid /clopidogrel), immunoglobulins and steroids. Results This aggressive treatment included 5 laparotomies and 4 angiographic interventions, open abdomen for 8 days, transfusion of 27 units of packed red cells, 9 abdominal and 4 cerebral CT scans, thrombolysis therapy for 5 days, mechanical ventilation for 15 days, and an ICU stay of 25 days. Full patient recovery and near complete recanalization of splanchnic veins was achieved. Conclusion Without treatment, ChAdOx1 nCoV-19 vaccination-induced total splanchnic vein thrombosis has serious consequences with a high risk for death. The case described here shows that an aggressive multimodal surgical-medical treatment strategy in a specialized center can save these patients and achieve a good outcome.

Compartment syndrome: An unsuspected consequence of hypercoagulable state in a patient with severe covid-19 illness

Introduction Coronavirus 19 (COVID-19) is a viral illness that is caused by SARS-CoV-2. It has a surface spike protein that binds to human angiotensin-converting enzyme 2 receptors expressed in the kidneys, lung, and vascular endothelium. Here we present a case of a 73-year-old critically ill male with COVID pneumonia and acute respiratory distress syndrome (ARDS), who developed compartment syndrome and rhabdomyolysis as a consequence of extensive right lower extremity arterial thrombosis related to a COVID induced hypercoagulable state. Case A 73-year-old COVID positive male with past medical history of coronary artery disease status-post triple coronary artery bypass 10 years ago and type 2 diabetes mellitus presented to the emergency department with progressively worsening dyspnea for one week. His initial oxygen saturation on room air measured 85%, so he was placed on 3 liters per minute supplementation via nasal cannula. CXR showed bilateral diffuse alveolar infiltrates and he was admitted for observation. He developed worsening respiratory failure five days into hospitalization, placed on maximum supplementation via high flow nasal cannula (HFNC), and transferred to the medical ICU. Ultimately, he was intubated and mechanically ventilated for the remainder of his hospitalization due to severe ARDS. After three days in the ICU, his right lower extremity was cold, without palpable nor detectable pulses via bedside Doppler from the femoral to pedal landmarks. Formal ultrasound Doppler that morning confirmed arterial clot extending from the right external iliac to posterior tibial arteries. The patient received embolectomy, stenting, and therapeutic heparin. Within 24 hours, though his creatinine kinase was normal, he developed significantly elevated myoglobin, lactate and worsening acidosis. The patient had a fasciotomy to the right lower extremity at bedside. The next day, he was anuric, with severe acidosis, hyperkalemia, and hypotension, requiring continuous renal replacement therapy (CRRT) and vasopressor support. Discussion Compartment syndrome is characterized by increased pressure within fascial compartments, leading to circulatory compromise, cellular necrosis, and rhabdomyolysis. In this case, the COVID-19 viral effect on coagulation led to extensive arterial thrombosis, complicated by compartment syndrome and renal failure necessitating CRRT. While the exact pathophysiology of the hypercoagulable state in COVID-19 illness is debated, we have observed its manifestations ranging from deep venous thrombosis (DVT), pulmonary embolism (PE), to stroke. Conclusion COVID-19 is known to be a virulent, multifactorial, intelligent virus with myriad end-organ and vascular consequences. When attending to the most critically ill patients with COVID-19, it is wise to consider all forms of vascular thromboembolism.

COVID-19, Necrotizing Pancreatitis, and Abdominal Compartment Syndrome: A Perfect Cytokine Storm?

Coronavirus disease 2019 (COVID-19) induces a dysregulated immune response, leading to a drastic elevation of proinflammatory cytokines. This cytokine storm has the potential to aggravate any prior ongoing inflammation. Moreover, acute pancreatitis can cause local necrosis, thereby causing extensive abdominal inflammation. This condition increases the risk of abdominal compartment syndrome (ACS) and its deleterious consequences. We report the case of a 37-year-old male with a past medical history of chronic pancreatitis and alcohol use disorder who presented to the emergency department complaining of abdominal pain. Physical examination revealed a tender abdomen. Initial workup showed elevated amylase and lipase, a positive COVID-19 polymerase chain reaction (PCR) test, and elevated inflammatory markers. The patient denied any respiratory symptoms. Initial abdominal CT scan revealed mild pancreatic inflammation. The patient was admitted to the respiratory ICU and managed with fluid resuscitation and pain control. However, the patient had increasing oxygen requirements, leukocytosis, and worsening kidney function. A trans-bladder measurement of intra-abdominal pressure revealed severe ACS. Broad-spectrum antibiotics were started; however, after 72 hours of treatment, the patient had a cardiopulmonary arrest. He returned to spontaneous circulation after advanced cardiovascular life support (ACLS) protocol and intubation. A repeat CT scan of the abdomen showed necrotizing pancreatitis with a large-volume hemoperitoneum. Urgent pancreatic necrosectomy was performed with drainage of the hemoperitoneum. The patient was transferred to a long-term acute care facility for extended antibiotic therapy where he eventually recovered. This case illustrates the catastrophic consequences of necrotizing pancreatitis complicated by sepsis and ACS in a COVID-19-positive patient.

Upper-Extremity Phlegmasia Cerulea Dolens With Compartment Syndrome in Coronavirus Disease 2019 Sepsis.

A 54-year-old woman with leukemia presented with coronavirus disease 2019 and a right upper-extremity indwelling peripherally inserted central catheter line for chemotherapy administration. On hospital admission day 9, she developed acute right upper-extremity edema and pain. Ultrasound demonstrated complete superficial and deep venous thrombosis up to the proximal subclavian vein. Her examination result was consistent with acute phlegmasia cerulea dolens and compartment syndrome, but respiratory instability prevented transfer and vascular surgery intervention. Instead, we performed bedside fasciotomies and administered therapeutic heparin, and the limb was salvaged. This case underscores the potential for successful limb salvage in patients with phlegmasia in the setting of coronavirus disease 2019 via compartment release and therapeutic anticoagulation.

Spontaneous Retroperitoneal Bleed Coincided With Massive Acute Deep Vein Thrombosis as Initial Presentation of COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that has caused a global pandemic and unfortunately has caused a health crisis. When severe, coronavirus disease 2019 (COVID-19) can manifest with bilateral pneumonia and hypoxemic respiratory failure but also can affect different organ systems. SARS-CoV-2 infection is known to cause a hypercoagulable state resulting in acute thrombotic events, including venous thromboembolism, acute myocardial infarction, acute stroke, acute limb ischemia, and clotting of ECMO (extracorporeal membrane oxygenation) and CRRT (continuous renal replacement therapy) catheters. Even though it commonly causes thrombotic complications, bleeding complications of COVID-19 due to coagulopathy and use of anticoagulation are less commonly reported. We herein present a case of a patient with COVID-19 complicated by spontaneous retroperitoneal bleeding and massive deep vein thrombosis (DVT), which was later complicated by compartment syndrome. To the best of our knowledge, coexistence of spontaneous bleeding with massive DVT has not been reported in the current literature. This case emphasizes that COVID-19 induced hypercoagulable state can cause massive thrombosis, and patients might need anticoagulation therapy. However, clinicians should also consider the risk of hemorrhagic complications of the disease and be cautious when administering anticoagulant therapy in selected cases.