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.