Between a clot and a hard place: Unusual COVID-19 thromboses in patients with liver disease

ABSTRACT

Introduction: It is established that COVID-19 predisposes patients to arterial and venous thrombotic disease,1 though the exact mechanism is unknown. Cases of PE and DVT are well described, while arterial and multi-vessel thromboses are rare.2 We report COVID-19 associated hepatic artery thrombosis (HAT) and portal and superior mesenteric vein (PV;SMV) thrombosis, both resulting in compromised liver function. Case Description/Methods: A 47-year-old man with a history of remote orthotopic liver transplantation (OLT) for HBV cirrhosis presented to the ED with two days of RUQ pain and vomiting. Physical exam revealed tenderness to palpation in the RUQ. Labs were normal, including liver synthetic function. COVID-19 nasopharyngeal swab was positive. CT of the abdomen and pelvis with IV contrast revealed complete acute thrombosis of the aortohepatic conduit near its origin, new from imaging six months prior. He received remdesivir and methylprednisolone and was discharged on a DOAC. A 57-year-old man with a history of Lynch syndrome and decompensated alcoholic cirrhosis presented to the ED with 3 days of LUQ pain, melena, coffee ground emesis and subjective fever. Physical exam and vital signs were normal. Labs showed Hgb 5.4 and WBC 15.2. COVID-19 nasopharyngeal swab was positive. CT of the abdomen and pelvis with IV contrast revealed extensive PV and SMV thrombosis. The patient was treated with pRBC, PPI, octreotide, and empiric antibiotics. He was given IV heparin and bridged to warfarin. Discussion: Thrombosis is a serious complication of COVID-19 infection. While there are known macrovascular thrombotic events associated with COVID-19, there are no reports of HAT, and one reported case of PV and SMV thrombosis. It is important to evaluate for thromboses in patients with cirrhosis or prior OLT and COVID-19 due to elevated thrombotic risk. Thromboses in these patients can compromise blood supply and further worsen liver function.