Out of the blue: A case report of fatal COVID-19-related aortic thrombosis

ABSTRACT

INTRODUCTION: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection can lead to a constellation of viral and immune symptoms called Coronavirus Disease 2019 (COVID-19). Emerging literature increasingly supports the premise that SARS-CoV-2 promotes a prothrombotic milieu. However, to date there have been few reports of an acute aortic occlusion (AAO), itself a rare phenomenon. We report a case of fatal AAO in a patient with COVID-19. METHODS: A 59-year-old Caucasian male with a past medical history of peripheral vascular disease presented to the Emergency Department (ED) for evaluation of shortness of breath, fevers, and dry cough. His symptoms started 5-7 days prior to the ED visit;received antibiotics in the outpatient setting without any effect. He was found to be febrile, tachypneic, and hypoxemic. He was placed on supplemental oxygen via a nonrebreather mask. Chest X-ray (CXR) showed multifocal opacifications. Intravenous antibiotics for possible pneumonia was initiated. Hydroxychloroquine was initiated to cover possible COVID-19 pneumonia. During the hospitalization, the patient became progressively hypoxemic for which he was placed on bilevel positive airway pressure (BiPAP). D-dimer, ferritin, lactate dehydrogenase, C-reactive protein were all elevated. SARS-CoV-2 Reverse Transcription Polymerase Chain Reaction (RT-PCR) was positive. On day 3, the patient was upgraded to the intensive care unit (ICU). Soon after he was intubated, he developed a mottled appearance of skin which extended from his bilateral feet up to the level of the subumbilical plane. Bedside ultrasound revealed an absence of flow from the mid-aorta to both common iliac arteries. The patient was evaluated emergently by vascular surgery. After a discussion with the family, it was decided to proceed with comfort-directed care and the patient expired later that day RESULTS: Viral infections have been identified as a source of prothrombotic states due to the direct injury of vascular tissue and inflammatory cascades. SARS-CoV-2 appears to follow a similar pattern with numerous institutions identifying elevated levels of thrombotic complications. We believe that healthcare providers should be aware of both venous and arterial thrombotic complications associated with COVID-19, including fatal outcomes.