key: cord-0742053-ynhh9hgp
authors: Uthayakumar, Amaravathi; Nathan, Balamurugan; Pillai, Vivekanandan; Ayyan, S.Manu
title: Superior Mesenteric Arterial and Venous thrombosis in COVID-19
date: 2021-01-05
journal: J Emerg Med
DOI: 10.1016/j.jemermed.2020.12.016
sha: 20d72565ae15fb928b927c1e430209e15f4eca5e
doc_id: 742053
cord_uid: ynhh9hgp

Background COVID-19 commonly presents with fever, constitutional symptoms, and respiratory symptoms. However atypical presentations are also well known. Though isolated mesenteric arterial occlusion associated with COVID-19 is reported in literature, combined superior mesenteric arterial and venous thrombosis is very rare. We report a case of combined superior mesenteric arterial and venous occlusion associated with COVID-19 infection. Case report We report a case of a 45-year-old male health care worker who presented to the emergency department with severe abdominal pain. Clinical examination was unremarkable but imaging revealed acute mesenteric ischemia due to superior mesenteric artery (SMA) and superior mesenteric vein (SMV) occlusion. The chest imaging was suggestive of COVID-19 infection which was later confirmed with an RT-PCR of his nasopharyngeal swab. To date, only one case of combined SMA and SMV thrombosis due to COVID 19 had been reported Why should an emergency physician be aware of this During the COVID-19 pandemic it is important to keep mesenteric ischemia in the differential diagnosis of unexplained abdominal pain. Routinely adding HRCT of the chest to abdominal imaging should be considered in patients with acute abdomen as it can help to identify COVID-19 immediately.

caused a devastating pandemic affecting more than 29 million people resulting in the death of 23 more than nine hundred thousand people all over the world as of 17, September 2020. 1 9 24 months into the epidemic, our knowledge of the virus and the disease is quite limited. 25 COVID-19 commonly presents with fever, constitutional symptoms and respiratory 26 symptoms. However atypical presentations are well known particularly arterial or venous 27 occlusion including stroke, myocardial infarction, acute limb ischemia, mesenteric ischemia, 28 deep venous thrombosis and pulmonary embolism. 2 We report an unusual combination of 29 superior mesenteric arterial and venous occlusion in COVID-19. 30

A 45-year male who is working as a healthcare worker in our hospital presented to the 32 emergency department (ED) with acute abdominal pain of two hours duration. The pain was 33 excruciating in nature and did not respond to narcotic analgesia. The pain was felt in the 34 epigastric and umbilical region and did not radiate anywhere else. He vomited once and the 35 vomitus was unremarkable. There was no fever, loose stools, hematemesis, melena or 36 bleeding per rectum. He did not have any comorbidities and was not on any regular 37 medications. On examination he was diaphoretic but his vitals were stable with a pulse rate 38 of 58, blood pressure of 140/90, respiratory rate of 18, and a room air saturation of 98%. 39

Abdomen was soft, non-tender, and non-distended with normal bowel sounds. Cardiovascular 40 and respiratory systems were unremarkable. ECG revealed sinus bradycardia but was 41 otherwise normal. Initially, he was treated with intravenous pantoprazole, ondansetron and 42 morphine. The pain did not resolve and hence he was also given fentanyl for his pain relief. 43 X-ray and ultrasound of the abdomen were normal. Given his persistent pain which was out 44 of proportion to the examination findings mesenteric ischemia was suspected and the patient abdominal imaging which covered the lower part of the lungs revealed features suggestive of 48 COVID-19 infection. This made us proceed with an HRCT thorax which showed bilateral 49 peripheral ground glass opacities with a CO-RADS grading of 5 and CT severity index of 5 50 ( Figure 3 ). In our case, the patient did not report any COVID related symptoms at 51 presentation. But on careful questioning we also obtained the information that he had mild 52 fever and sore throat prior to the presentation for 5 days for which he didn't seek any medical J o u r n a l P r e -p r o o f 

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