Immune-mediated Acute Limb Ischemia: A Rare Complication of SARS-CoV-19 Infection
Indian Journal of Critical Care Medicine
; 26:S35-S36, 2022.
Article
in English
| EMBASE | ID: covidwho-2006334
ABSTRACT
Occurrence of acute limb ischaemia (ALI) in patients with SARS-CoV-2 is an uncommon complication. COVID-19 has been associated with thrombotic disease secondary to a hypercoagulable state. COVID-19 appears to cause a hypercoagulable state through mechanisms unique to SARS-CoV-2 and centres on the cross-talk between thrombosis and inflammation. The proposed hypothesis includes a severely heightened inflammatory response that leads to thrombotic inflammation, through a mechanism such as cytokine storm, complement activation, and endothelitis. The innate and adaptive immune responses result in immunemediated thrombosis, leading to thrombotic complications, such as myocardial infarction, pulmonary embolism, deep vein thrombosis, and stroke. The activation of coagulation (D-dimer) and thrombocytopenia are important prognostic markers in SARSCoV- 19 infections. At our institution, we found six patients to have ALI and reviewed their characteristics and outcomes. Our findings showed that in severe COVID-19 disease, the association of ALI had high mortality. Materials and methods:
It is a retrospective observational study performed at Bangalore Baptist hospital during the COVID-19 pandemic (August 2020 to August 2021). We report a case series of 6 ALI patients aged between 30 and 55 years. All the patients were tested positive for SARS-CoV-2 disease. All our patients received standard treatment care as per institution protocol for SARS-CoV-2 disease. They were all commenced on therapeutic anticoagulation at admission to ICU. Baseline coagulation profile and inflammatory markers and their trends were followed in all patients. The diagnosis of ALI in all ventilated patients was done clinically by the presence of pallor, pulselessness, acrocyanosis, blisters, and dry care unit with SARS-CoV-2 disease, 6 patients had developed limb ischemia (1.4%). Male and female preponderance was equal. Among 6 patients, 1 was newly detected diabetes mellitus, 2 were diabetic and hypertensive of which one had right upper limb post-polio paralytic sequelae, and the rest had no co-morbidities. The mean duration of ICU stay and mechanical ventilation days was 22 days and 17.8 days, respectively. All the patients had lower limb ischemia of which 3 were unilateral. Discoloration extended up to the ankle joint in almost all cases. As these patients were on the ventilator secondary to severe hypoxemia or vasopressor support, they were managed conservatively. Two patients presented with stroke, pyelonephritis with acute kidney injury, and septic shock requiring high vasopressor support. 5 of 6 patients died during the course of treatment (mortality 83%). All patients showed high inflammatory markers especially D-dimer during the initial development phase of limb ischemia. 1 survived patient required bilateral foot amputation due to dry gangrene.Conclusion:
Limb ischemia with tissue necrosis is a dreadful complication and is associated with high mortality. High incidence of thrombosis despite therapeutic anticoagulation raises a question about pathophysiology unique to COVID-19. Evidence of inflammatory-mediated thrombosis and endothelial injury are possible explanations which would support the use of immunotherapy in addition to anticoagulation for the treatment of thrombotic events. Further insight into the cause and management of thrombosis is needed.
D dimer; hypertensive factor; acrocyanosis; acute kidney failure; acute limb ischemia; adaptive immunity; adult; anticoagulation; artificial ventilation; Baptist; blister; case report; case study; cerebrovascular accident; clinical article; comorbidity; complement activation; complication; conference abstract; coronavirus disease 2019; cytokine storm; deep vein thrombosis; diabetes mellitus; drug therapy; dry gangrene; endotheliitis; endothelium injury; female; foot amputation; heart infarction; human; hypoxemia; immunotherapy; incidence; inflammation; leg ischemia; limb ischemia; lung embolism; male; mortality; nonhuman; observational study; outcome assessment; pallor; pandemic; poliomyelitis; pyelonephritis; retrospective study; SARS coronavirus; septic shock; thrombocytopenia; thrombosis; tissue necrosis; upper limb; ventilated patient; ventilator
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Databases of international organizations
Database:
EMBASE
Language:
English
Journal:
Indian Journal of Critical Care Medicine
Year:
2022
Document Type:
Article
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