key: cord-0733071-m0aopdpn authors: de Oliveira Costa, Víctor; de Almeida, Guilherme Bicalho Civinelli; Nicolini, Eveline Montessi; de Abreu Rodrigues, Guilherme; da Costa, Bruna Malaquias Arguelles; Carvalho, Guilherme Heluey; dos Reis, Álvaro Luiz Segregio; Colen, Davi Pinto title: Acute arterial occlusion of the lower limb as the main clinical manifestation in a patient with Covid-19 – Case Report date: 2020-11-11 journal: Int J Surg Case Rep DOI: 10.1016/j.ijscr.2020.11.046 sha: 0d4308d923f21f8ea179f816e09830cb13357ee6 doc_id: 733071 cord_uid: m0aopdpn INTRODUTION: COVID-19 infection may predispose to venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilization and disseminated intravascular coagulation; however, there are few reports of lower limb ischemia as the main manifestation of the disease. PRESENTATION OF CASE: Male patient, 69 years old, asthmatic, ex-smoker and bearer of systemic arterial hypertension, has been admitted to the emergency department with sudden onset of pain in the right lower limb (RLL), associated with cyanosis and reduced temperature of the limb. He has been tested for COVID-19 in the OR with positive result for IGG and IGM. Computed tomography angiography (AngioCT) was performed, showing signs of arterial embolization to both limbs, right internal iliac artery, and superior mesenteric artery. Faced with the threat of limb loss and the absence of signs and symptoms of visceral ischemia, the patient underwent full anticoagulation and RLL thromboembolectomy and tricompartmental fasciotomy. He was discharged after 7 days of hospitalization and demonstrated no other signs and symptoms of COVID-19, following outpatient follow-up. DISCUSSION: COVID-19 is associated with high risk of thrombotic complications being related to the clinical severity of the patient, with few studies that show symptoms of sudden pain in the lower limb without other complaints. CONCLUSION: Individuals infected with COVID-19 are at risk for arterial thromboembolic events, and knowledge of such cases is essential in order to create specific protocols for prophylaxis of thrombotic events in these patients, in addition to increasing the suspicion of infection in individuals with acute arterial occlusion, mostly during pandemic times. Coagulopathies and thrombotic complications have been increasingly observed in patients with severe disease 1, 2, 3, 4 . Several necropsy studies have revealed platelet- circulating coagulation factor VII to trigger a proteolytic cascade culminating in generation of thrombin and fibrin (extrinsic coagulation). TF expression is negligible in healthy non-inflamed endothelial cells, but it can be increased in transcription level by various pro-inflammatory stimuli that activate the NF-kappaB transcription factor 5 . In view of the relation between thromboembolic events and patients infected with COVID-19, the need of protocols for the prevention of thrombotic events in these patients is evident, as well as the suspicion of COVID-19 infection in patients who present the thrombotic or thromboembolic event as the first symptom. The report has been arranged in line with SCARE guidelines 6 . AngioCT or duplex ultrasound was used to diagnose deep vein thrombosis (DVT), which was detected in 27% and arterial thrombotic events in 3.7%. Pulmonary embolism was the most common thrombotic complication (81%) 12 In another case report, a 57-year-old patient who presented edema, pain, heat and redness in the left lower limb (LLL) was described, having been treated with heparin. The LLL venous doppler revealed dilation and thrombosis in the external iliac vein up to the bifurcation level of the common iliac veins, in addition to thrombosis of the great and small saphenous vein, implying a DVT predisposition resulting from COVID-19 15 . In another case, a nonsmoker 48-year-old male patient, with a history of coronary artery disease, was hospitalized with COVID-19, having received prophylaxis for thrombosis with heparin, returned to the hospital two weeks later with pain in his right lower limb, being diagnosed with DVT in femoral, popliteal and gastrocnemic veins, which suggested the prothrombotic condition present in COVID-19 infections 16 . In a report similar to our case, a 68-year-old patient with a history of smoking, SAH, coronary artery disease and deep vein thrombosis was admitted for acute bilateral ischemia of the lower limbs, in which obstructive thrombosis of the abdominal aorta and bilateral thrombosis of the common iliac arteries. Axillobifemoral bypass was performed, followed by therapeutic anticoagulation with good initial results, but the patient died after seven days due to severe bleeding 17 . In another case report, a 60-yearold patient went to the hospital with sudden numbness and loss of strength in both legs. Before that, he reported a dry cough, fever and general malaise for 2 weeks before the hospital presentation, but no pre-existing symptoms of peripheral vascular disease. AngioCT revealed an acute thrombotic occlusion of the infrarenal aorta that extended to the common iliac arteries. The patient underwent thromboembolectomy with retrieval of a large burden of acute thrombus. He had a good outcome after surgery and was discharged 18 . In recent evidence, the involvement of arterial beds is usually associated with hospitalization for longer periods or patients in the ICU, being related to the clinical severity of the patient, with few studies that show symptoms of sudden pain in the lower limb without other complaints, as seen in our report 19, 20 . This case aims to raise the awareness of the medical community regarding thrombotic events as a clinical symptom of COVID-19, even if the patient does not have typical symptoms of COVID-19, demanding immediate treatment in order to reduce complications resulting from these events. In addition, it is notable that even patients receiving prophylaxis for thrombosis can develop this condition, which demonstrates the need for specific protocols for venous and arterial prophylaxis in patients with COVID-19. No conflict of interest. No fund to my research to be disclosed. This is case report study and ethical approval not required. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Name of the registry: Not applicable 2. Unique identifying number or registration ID: Not applicable Hyperlink to your specific registration (must be publicly accessible and will be checked): Not applicable Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in COVID-19 pneumonia with hemoptysis: acute segmental pulmonary emboli associated with novel coronavirus infection Acute pulmonary embolism and COVID-19 pneumonia: a random association? Thrombotic complications of COVID-19 may reflect an upregulation of endothelial tissue factor expression that is contingent on activation of endosomal NADPH oxidase For the SCARE Group. The SCARE 2018 Statement: Updating Consensus Surgical CAse REport (SCARE) Guidelines Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia High risk of thrombosis in patients in severe SARS-CoV-2 infection: a multicenter prospective cohort study Pulmonary embolism in COVID-19 patients: awareness of an increased prevalence Prevention of thrombotic risk in hospitalized patients with COVID-19 and hemostasis monitoring Thrombosis risk associated with COVID-19 infection. A scoping review Incidence of thrombotic complications in critically ill ICU patients with COVID-19 A case of coronavirus disease 2019 with concomitant acute cerebral infarction and deep vein thrombosis Venous thrombosis and arteriosclerosis obliterans of lower extremities in a very severe patient with 2019 novel coronavirus disease: a case report COVID-19 Presented With Deep Vein Thrombosis: An Unusual Presenting Deep venous thrombosis in a non-critically ill patient with novel COVID-19 infection 4 Cases of Aortic Thrombosis in Patients With COVID-19 Acute aorto-iliac and mesenteric arterial thromboses as presenting features of COVID-19 COVID-19 associated with extensive pulmonary arterial, intracardiac and peripheral arterial thrombosis Arterial thrombotic complications in COVID-19 patients Image showing biphasic flow echo-Doppler in right lower limb arteries