PATIENT 5
A 85-year old man reporting persistent fever, history of contact with a laboratory-confirmed COVID-19 case and sudden onset of left lower limb pain presented to the emergency department. SARS-CoV-2 infection was confirmed by a positive nasopharyngeal swab and by typical findings in the chest ct scan. doppler ultrasound examination demontrated a long occlusion of the superficial femoral artery, treated with surgical thrombectomy and subsequent angioplasties of some underlying arterial stenosis.
The purpose of the current paper is to report a possible association between the novel SARS-CoV-2 infection and a higher rate of major arterial thrombo-embolic events. The clinical characteristics of the included subjects are in keeping with current published literature, as we noted an unfavourable prognosis mostly in older male patients with higher level of pro-inflammatory factors and d-dimer (sometimes >10ULN), as recent studies outlined[5,8,10–12]. In particular older age and coagulation disfunctions were related to ARDS development and subsequent death afterwards[8]. The higher incidence of arterial events we observed could be related to the loss of equilibrium between prothrombotic and antithrombotic factors during severe pulmonary infections. Arterial thrombosis has a different pathogenesis compared to venous thromboembolism and is related to endothelial disfunction and endovascular damage. The majority of patients with COVID-19 are reported to have cardiovascular comorbidities such as hypertension and diabetes[8] which are known to be associated with endothelial disfunction[13,14], and when present these comorbidities are associated with a worse prognosis[8]. Pulmonary infections are knows to increase the risk of thrombo-embolic diseases with peak observed during active disease or shortly afterwards[15]. Major thrombo-embolic events have been reported following viral infections in past pandemic outbreaks[16,17]), with high as 25% prevalence in patients with severe manifestations of H1N1 influenza[18]. However further studies are needed addressing the link between thrombo-embolism and COVID-19 because current published data are sparse[19].
In our opinion, arterial thrombotic events may be more common in COVID-19 patients than is generally appreciated. The clinical impact is not negligible since a major thrombo-embolic event could be unexpected and result in rapid worsening of patient conditions, ultimately leading to death. Clinicians should be more aware of this uncommonly reported complications and have lower thresholds compared to routine clinical practice for the identification of high risk patients even in the outpatient setting, for starting appropriate thrombotic prophylaxis[20] and prescribing further diagnostic evaluation or blood test[21] in COVID-19 patients.