Multiorgan infarct due to extensive thrombosis in numerous arteries in COVID-19 patient even after adequate thromboprophylaxis

ABSTRACT

Introduction: •COVID-19 is a thrombotic state (hypercoagulable) •Incidence of thromboembolic complications •DVT 25%. •Combined DVT, PE, and arterial thrombosis 31%. •Anticoagulation therapy is recommended to prevent thrombotic complications. •Rare case of extensive thrombosis of abdominal arteries - multiorgan infarct being reported first time even after giving anticoagulation prophylaxis. Materials and methods: Case •A 60-year-old male, k/c/o hypertension on medication, diagnosed to have COVID-19 pneumonia, with SpO2 of 85% on 15 L/minute O2 through a face mask. •Fully conscious, with normal vitals admitted in ICU. Results: Treatment given •Azithromycin 500 mg od •Dexamethasone 6 mg IV od •Remdesivir 100 mg IV od •LMWH 0.4 mL SC bd COURSE IN ICU DAY 5 Developed severe, constant abdominal pain. •P/A Soft, tender in umbilical, hypogastric area •CECT Abdomen Superior mesentric artery (SMA) thrombus, edematous wall bowel loops, caecum, colon. •Thrombolysis with streptokinase done, Heparin therapeutic bolus dose followed by infusion given, aPTT targeted for 3 times normal. DAY 6,7 Abdominal pain improved, passed stools. Oral liquid started DAY and Pain increased, whole abdomen tender, gaurding. Emergency laparotomy done and bowels excised. CECT Abdomen Massive infarct in spleen, Multiple Massive infarct in both kidneys, ischaemic bowel loops. Celieac artery, bilateral renal artery, splenic artery occluded Emergency Laparotomy and ischaemic bowel loops excised. POD1 He developed refractory hypoxemia, shock and cardiac arrest and died on POD 1. Course in ICU Day 5 Developed severe, constant abdominal pain. •P/A Soft, tender in umbilical, hypogastric area. •CECT Abdomen Discussions Pathophysiology of COVID-19 Induced Hypercoagulopathy •Multifactorial. •Acute inflammatory response cytokine stromea activation of platelet, endothelial cells, tissue factor, changes in levels of thrombomodulin, proteins C and S. •Binding of SARS-CoV-2 to angiotensin-converting enzyme a endothelial activation. •Bedridden. •Presence of large vascular catheters. Conclusion: •COVID-19 patients can develop thromboembolism even after adequate thromboprophylaxis. •Thromboprophylaxis to be started either with LMWH, heparin. •Point of care ultrasound (POCUS) screening should be done for early diagnosis of any thrombotic complication. •PT/INR, aPTT, D-dimer to be monitored every 48 hours.