Discussion
In this report, we described a 46 year old woman with past medical
history of stage 1 hypertension which was under control, hyperlipidemia
and recent COVID-19 whom represented with acute chest pain and cold
sweat. The patient reported no traumatic events and no history of
connective tissue disorders. Her clinical examination showed unequal
radial pulses and a blood pressure difference between arms. During
patient’s hospitalization, her blood pressure was within the normal
range. The laboratory tests showed elevated D-dimer, troponin, ESR and
CRP. The diagnosis and management of aortic dissection in early stages
is of importance since it has numeric manifestations and can mimic other
life threatening events such as myocardial infarction and pulmonary
embolism 7. Silvestri et al., reviewed seventeen cases
of aortic pathology in patients with clinically suspected or PCR
confirmed COVID-19 and also reported hypertension as the most frequent
comorbidity; they suggested a potential link between COVID-19 and aortic
dissection 8.
There are some potential mechanisms for arterial pathology in COVID-19
patients. SARS-CoV-2 has spike proteins on its surface that binds a
receptor which is expressed in the endothelium called angiotensin
converting enzyme 2 (ACE-2). This means that SARS-CoV-2 can injure
vascular endothelium in the body 9. SARS-CoV-2
downregulates ACE-2 which leads to over activation of classical
renin-angiotensin system (RAS) and vasoconstriction10. ACE Inhibitor (ACEI) and angiotensin receptor
blocking (ARB) drugs, which are used commonly for hypertension as in our
patient, upregulate ACE-2 expression that can potentially increase the
vascular entry of and injury by SARS-CoV-2. On the other hand,
upregulation of ACE-2 can have vasodilatory and anti-inflammatory
effects as a result of conversion of angiotensin II to angiotensin 1-711. However, in a study of 1128 hospitalized patients
with COVID-19, those who took ACEI/ARB drugs had a lower all-cause
mortality than those who didn’t take 12.
Another possible cause of arterial dissection in COVID-19 patients can
be cytokine storm and inflammatory responses which leads to endothelial
dysfunction 13. Inflammation may cause rupture of
atherosclerotic plaque which can lead to dissection14. Studies have shown that the number of patients
with aortic dissection were increased during the influenza season15, 16. Akgul et al., presented an aortic dissection
in a COVID-19 patient which during the aortomy, they noticed significant
aorta wall thickening as seen in inflammatory aortic pathologies17. Their finding is consistent with the potential
association of inflammation caused by SARS-CoV-2 with aortic dissection.
As it has been suggested before, SARS-CoV-2 is a virus that causes
multi-organ diseases and can manifests as life-threatening events10. Therefore, it is important to evaluate the
association between COVID-19 and aortic dissection and the
pathophysiology of it. Further studies are needed to establish this
association.