Subject(s)
Aortic Diseases , COVID-19 , Pulmonary Embolism , Severe Acute Respiratory Syndrome , Thrombosis , Humans , COVID-19/complications , Severe Acute Respiratory Syndrome/complications , Pulmonary Embolism/complications , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/drug therapy , Thrombosis/complications , Thrombosis/diagnostic imaging , Thrombosis/drug therapy , Aortic Diseases/complications , Aortic Diseases/diagnostic imaging , Acute DiseaseABSTRACT
We present the case of a 72-year-old male with upper gastrointestinal bleeding. He had been discharged from hospital two weeks before after severe COVID-19 infection, treated with lopinavir-ritonavir (L-R), hydroxychloroquine, tocilizumab, and methylprednisolone. On presentation, he was in hypovolemic shock. Esophagogastroduodenoscopy showed an ulcer in the third duodenal portion, which was sclerosed and hemodynamic stability was recovered. A scan was performed as it was in an atypical location for ulcers, showing an aortic aneurysm in close relationship to the duodenum, suggesting a primary aortoenteric fistula (PAEF).
Subject(s)
Aortic Diseases , COVID-19 , Duodenal Diseases , Intestinal Fistula , Vascular Fistula , Aged , Aortic Diseases/complications , Aortic Diseases/diagnostic imaging , Duodenal Diseases/complications , Duodenal Diseases/diagnostic imaging , Gastrointestinal Hemorrhage/etiology , Humans , Intestinal Fistula/complications , Intestinal Fistula/diagnostic imaging , Male , SARS-CoV-2 , Vascular Fistula/complications , Vascular Fistula/diagnostic imagingABSTRACT
Arterial thromboembolic complications reported in patients with COVID-19 infection suggested that SARS-CoV-2 can trigger atherosclerotic plaque vulnerability. While endothelial cells in healthy subjects protect against thrombus formation, after injury they show prothrombotic activity. In addition, it has been hypothesized that "cytokine storm" might stimulate the production of neo-platelets triggering an abnormal "immunothrombosis" responsible for the hypercoagulable state induced in COVID-19 patients. The aim of this study is to report a case of severe COVID-19 infection characterized by the occurrence of microthrombosis in the vasa vasorum of the aorta. A 67-year-old male patient, in good health status and without comorbidities, who underwent a severe COVID-19 infection with fatal outcome, showed scattered aortic atherosclerotic plaques, characterized by multiple occlusive micro-thromboses in the vasa vasorum, spread out lymphocytic infiltrates and foci of endotheliitis and endothelial detachment. This case report confirms the previously described thrombotic involvement of vasa vasorum in COVID-19. The occurrence of the synchronous damage involving both the lumen surface (endothelial dysfunction, endotheliitis and endothelial detachment) and the adventitia (inflammation and occlusive thrombosis of vasa vasorum) could be the key points related to the fatal outcome of the SARS-CoV-2 patients. In our opinion, vasa vasorum thrombosis may thus initiate an atherogenic process that could be characterized by a much more rapid development.