A COVID-19 patient with recurrent acute limb ischaemia despi
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This report describes a case of threatening limb ischaemia in a patient infected with COVID-19 who was on therapeutic dose anticoagulation at the time of diagnosis. He went on to develop recurrent limb ischaemia despite treatment with two consecutive and different types of anticoagulation as well as a successful thrombolysis. He ultimately required open thrombectomy for the recurrent disease and made a full recovery.

A 60-year-old man with a medical history of hypertension, hyperlipidaemia, intermittent asthma, gastritis, arthritis and no smoking history presented to the emergency department with worsening dyspnoea for the past 4?days. He reported testing positive for SARS-CoV-2, a few months prior. He was noted to be in significant respiratory distress, diaphoretic and tachycardic. His oxygen saturation was 83% and only improved to 95% on proning with high-flow nasal cannula and non-rebreather oxygen mask.

X-ray of the chest showed patchy bilateral airspace consolidations. Electrocardiogram (EKG) showed normal sinus rhythm at 96 beats/min. Nasopharyngeal swab tested positive for SARS-CoV-2. The patient was started on remdesivir, dexamethasone, azithromycin and ceftriaxone. Given the patient’s clinical presentation, COVID-19 positive status and elevated D-dimer, there was a high clinical suspicion for pulmonary embolism.

He was, however, deemed too clinically unstable to undergo CT pulmonary angiogram at the time of presentation, as he was only able to saturate 90% while lying prone on high-flow oxygen. He was transferred to the intensive care unit (ICU) and empirically started on treatment dose enoxaparin 70?mg (1?mg/kg) every 12 hours on admission.

On day 5 of admission, the patient reported a few hours’ history of altered sensation, pain and reduced ability to move his right foot. On physical examination, the right foot was pale in appearance and cool to touch compared with the left foot. There was weakness in the right ankle and toe extension and flexion. On palpation, popliteal pulse was reduced, and dorsalis pedis (DP) and posterior tibial (PT) pulses were absent on the right. DP pulses were absent, while PT pulses were detectable with handheld doppler. He was immediately switched from therapeutic dose enoxaparin to heparin infusion protocol.

He underwent angiogram on day 6 of admission, and was diagnosed with right popliteal artery, tibial and peroneal artery thrombosis (figure 1). He underwent right popliteal artery catheter-directed thrombolysis, with palpable pulses and patent popliteal artery shown on completion angiogram the next day. On day 8 of admission, the patient developed severe respiratory distress requiring endotracheal intubation. On day 9, he developed right foot ischaemia due to recurrent thrombosis of right popliteal, tibial and peroneal arteries (postoperative day 3).

This was despite being on heparin infusion protocol since day 5 of admission. He underwent open thrombectomy of the right popliteal, tibial and peroneal arteries, and the right foot remained well perfused on examinations postoperatively. He was extubated successfully, and his anticoagulation was switched from heparin to apixaban.

Source: https://casereports.bmj.com/content/14/8/e245040?rss=1
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