key: cord-1006061-glaaaqbt
authors: Santos Leite Pessoa, Mariana; Franco Costa Lima, Carla; Farias Pimentel, Ana Carla; Godeiro Costa, José Carlos; Bezerra Holanda, Jorge Luis
title: Multisystemic Infarctions in COVID-19: Focus on the Spleen
date: 2020-06-03
journal: Eur J Case Rep Intern Med
DOI: 10.12890/2020_001747
sha: 8ce04b0ebd931fe2fee48033d40c5cc8e40c2b15
doc_id: 1006061
cord_uid: glaaaqbt

The literature suggests that COVID-19 provokes arterial and venous thrombotic events, although the mechanism is still unknown. In this study, we describe patients with confirmed coronavirus infection associated with multisystemic infarction, focusing on splenic infarction. More data are required to elucidate how COVID-19 and thrombotic disease interact and so that preventive and early diagnosis strategies can be developed. LEARNING POINTS: Thrombotic disease as a complication of COVID-19 must be suspected by clinicians, and recognized and monitored by radiologists. Thrombosis is often the initial manifestation of SARS-CoV-2, hence the importance of early diagnosis to avoid complications and reduce morbidity and mortality.

The coronavirus disease 2019 (COVID-19) pandemic is a challenge for healthcare systems worldwide, with large numbers of patients requiring intensive care [1] . The disease appears to have a strong thrombotic tendency due to thrombo-inflammation, probably driven by distinct but as yet uncertain processes [2] . These mechanisms may predispose patients to arterial and venous thrombosis [2, 3] , although the risk estimates for these complications have not yet been properly defined [4] . Autopsy examinations have demonstrated microcirculation damage in patients with COVID-19 [5] , and recent studies suggest that haemostatic abnormalities, including disseminated intravascular coagulation (DIC), occur in these patients [6] . A study conducted in a hospital in China revealed that 71.4% of those who died with COVID-19 and 0.6% of survivors met criteria for DIC during later stages of the disease [6] . The most consistent haemostatic abnormalities include mild thrombocytopenia [7] and increased D-dimer levels [8] , which are associated with severe disease. These haemostatic changes indicate some forms of coagulopathy that may predispose to thrombotic events, although the cause is uncertain [3] . Whether the haemostatic changes are a specific effect of SARS-CoV-2 or whether they are a consequence of cytokine storm that precipitates the onset of systemic inflammatory response syndrome (SIRS), as observed in other viral diseases, is not completely understood [9, 10] . More data are required on how COVID-19 and thrombotic disease interact [3] . To date, cases of splenic infarction associated with SARS-CoV-2 infection are rare in the literature. However, arteriolar thrombosis and splenic infarction were observed in one patient in a study that evaluated splenic pathological changes identified on autopsy in 10 cases of COVID-19 [11] .

European Journal of Case Reports in Internal Medicine © EFIM 2020

Patients with confirmed SARS-CoV-2 infection associated with splenic infarction and/or other multisystemic infarctions were selected from a hospital database in Ceará-Brazil, based on computed tomography (CT), CT angiography (CTA) and ultrasound findings

A 67-year-old, previously hypertensive, male patient was admitted with a 1-day history of weakness in the left upper limbf drooping of the mouth. The patient reported having cough, headache and mild dyspnoea for about 10 days. Naso-and oropharyngeal swabs using the RT-PCR method and rapid test were both positive for SARS-CoV-2 coronavirus infection. CT images showed an area of acute ischemic stroke in the brain (Fig. 1) ; ground-glass opacities, pulmonary consolidations and findings suggestive of pulmonary thromboembolism (Fig. 2) ; as well as areas suggestive of splenic infarction (Fig. 3) . 

A 53-year-old female patient with rheumatoid arthritis reported dry cough, fever and anosmia, together with dyspnoea. A naso/ oropharyngeal swab using the RT-PCR method was positive for SARS-CoV2 coronavirus. The CT images showed areas suggestive of splenic infarction, which was also seen on ultrasound (Fig. 4) ; CTA confirmed filling failures in the subsegmental branches of the splenic artery (Fig. 5) . Chest CT scan showed ground-glass opacities and mosaic paving, suggestive of viral infection (Fig. 6) . 

The described cases highlight splenic infarction as a thrombotic complication of COVID-19. It is extremely important to identify complications associated with this disease. Although thrombotic events are one of the main complications of SARS-CoV-2 infection, reports and imaging findings of splenic infarction are scarce in the literature. The incidence of splenic infarctions is probably underestimated as abdominal imaging is not routinely performed, and they are often incidental findings from chest CT scans that extend to the abdomen.

In the current pandemic, clinicians should be aware of thrombotic disease as a complication of COVID-19 and radiologists should monitor patients for thrombosis to facilitate early diagnosis. Further studies should be carried out to elucidate the pathophysiological mechanisms of COVID-19-related coagulopathy, and so that early preventive and therapeutic strategies can be developed to reduce morbidity and mortality.

COVID-19 and haemostasis: a position paper from Italian Society on Thrombosis and Haemostasis (SISET)

Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia

COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up

Incidence of thrombotic complications in critically ill ICU patients with COVID-19

SARS-CoV-2 and viral sepsis: observations and hypotheses

Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia

Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: a meta-analysis

D-dimer is associated with severity of coronavirus disease 2019 (COVID-19): a pooled analysis

COVID-19: consider cytokine storm syndromes and immunosuppression

Diagnosis, prevention and treatment of thromboembolic complications in COVID-19: report of The National Institute of Public Health for the Netherlands

Pathological changes of the spleen in ten patients with new coronavirus infection by minimally invasive autopsies