ACUTE DIGITAL GANGRENE TRIGGERED BY COVID-19 COAGULOPATHY

ABSTRACT

SESSION TITLE Post-COVID-19 Infection Complications SESSION TYPE Case Report Posters PRESENTED ON 10/17/2022 1215 pm - 0115 pm INTRODUCTION: As the coronavirus pandemic continues to burden the global health care system, strong associations have emerged with hypercoagulability. Recent reports of Covid-19 support both venous and arterial thromboembolism, thus coagulopathy emerging as one of the most severe sequelae of the disease, which has also been associated with poorer outcomes. CASE PRESENTATION A 71-year-old female with a past medical history of hypertension, type 2 diabetes, and obesity presented with progressively worsening shortness of breath and cough. She was found to be hypoxic to 80% on arrival and tested positive for COVID-19. She was subsequently intubated and admitted to the ICU. Her D-dimer was noted to be 9.04mcg/mLFEU (0-0.55mcg/mLFEU), ferritin 256ng/mL(10-291ng/mL), LDH 707 U/L(130-270U/L), CRP 138mg/L (< 10mg/L). She was treated with a ten-day course of dexamethasone and a five-day course of Remdesivir. On Day 7, purple discoloration was noted in the second to fifth digits of the left hand, concerning acute ischemia. Left upper extremity ultrasound revealed intraluminal heterogeneous echogenicity likely occlusive ulnar arterial thrombus with no flow to mid or distal segment and normal flow in the radial artery into a complete palmar arch. This was seen to be classical for micro-embolic phenomenon attributable to the hypercoagulable state associated with Covid-19 infection. Treatment with Heparin drip was initiated along with the local application of nitro paste. The patient was subsequently discharged home but re-presented a month later for gastrointestinal bleeding. At this admission, her left second digit was noted to express purulent drainage. Imaging confirmed osteomyelitis in the second through fifth digits and was referred to a tertiary center for definitive treatment. DISCUSSION: Covid-19 has been shown to provoke catastrophic inflammatory responses by triggering a dysfunctional cascade of thrombosis in the pulmonary vasculature leading to both micro and macroangiopathic manifestations. The quick progression of ischemia to digital gangrene, despite collateral circulation and early intervention, indicates severe microangiopathy. CONCLUSIONS: Thus physicians must always have a high index of suspicion for thromboembolic complications in patients with Covid-19. The development of severe complications despite prompt anticoagulation highlights the need for alternative or newer therapies like targeted immunotherapy that would effectively manage these complications of SARS-CoV-2. Reference #1 Digital Gangrene as a Sign of Catastrophic Coronavirus Disease 2019-related Microangiopathy Jessica S. Wang, MD,* Helena B. Pasieka, MD, MS,† Vesna Petronic-Rosic, MD, MSc, MBA,† Banafsheh Sharif-Askary, MD,* and Karen Kim Evans, MDcorresponding author Reference #2 Galván Casas C, Català A, Carretero Hernández G, Rodríguez-Jiménez P, Fernández-Nieto D, Rodríguez-Villa Lario A, Navarro Fernández I, Ruiz-Villaverde R, Falkenhain-López D, Llamas Velasco M, García-Gavín J, Baniandrés O, González-Cruz C, Morillas-Lahuerta V, Cubiró X, Figueras Nart I, Selda-Enriquez G, Romaní J, Fustà-Novell X, Melian-Olivera A, Roncero Riesco M, Burgos-Blasco P, Sola Ortigosa J, Feito Rodriguez M, García-Doval. Classifications of the cutaneous manifestations of Covid-19 a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. 2020 Jul;183(1)71-77. doi 10.1111/bjd.19163. Epub 2020 Jun 10. Reference #3 Mouhamed Yazan Abou-Ismail 1, Akiva Diamond 2, Sargam Kapoor 3, Yasmin Arafah 2, Lalitha Nayak 4.The hypercoagulable state in COVID-19 Incidence, pathophysiology, and management Thromb Res. 2020 Oct;194101-115. doi 10.1016/j.thromres.2020.06.029. Epub 2020 Jun 20. DISCLOSURES No relevant relationships by Navyamani Kagita No relevant relationships by ABHIGNA KULKARNI No relevant relationships by Rajesh Thirumaran