PHLEGMASIA CERULEA DOLENS: AN ATYPICAL COVID-19 PRESENTATION

Autor: Brad Schwartz, Riad Akkari
Jazyk: angličtina
Rok vydání: 2020
Předmět:
Zdroj: Chest
ISSN: 0012-3692
DOI: 10.1016/j.chest.2020.08.1805
Popis: SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The worldwide pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has caused numerous deaths worldwide, most directly due to resultant ARDS and respiratory failure Physicians have seen an increased incidence of venous thromboembolic events (VTE) in COVID-19 patients postulated due to a pro-inflammatory state caused by the virus, with a resultant increase in the frequency of micro thrombotic events [1] We present the case of a patient with severe Phlegmasia cerulea dolens (PCD) in the setting of asymptomatic COVID-19 pneumonia CASE PRESENTATION: A 61 yo African American male with no significant past medical history presented with left leg swelling Arterial and venous doppler ultrasound revealed an extensive thrombus throughout the left femoral and popliteal veins, with occlusion of arterial flow at the distal posterior tibial and peroneal arteries consistent with compartment syndrome and diagnosis of PCD CT scan of the chest resulted in a finding of a large left main pulmonary artery pulmonary embolism with bilateral patchy ground-glass opacities suggestive of COVID-19 pneumonia, which was confirmed positive by rapid nasopharyngeal PCR per our admission protocol despite the absence of fever, cough, shortness of breath or exposure He was started emergently on anticoagulation therapy, intubated prophylactically, and taken to the operating room for emergent fasciotomy His ICU course was complicated by worsening ventilator support, acute respiratory distress syndrome, worsening kidney injury, septic shock, and persistent bleeding from his wound requiring multiple transfusions Due to nonviability and poor healing, the extremity was amputated, with noted systemic improvement in the ensuring days He was extubated, downgraded out of the ICU, but this improvement was short-lived His respiratory status drastically deteriorated, requiring re-intubation for hypoxia with recurrence of septic shock due to E coli bacteremia as well as severe bleeding from the stump site His status-declined with multiorgan failure despite aggressive resuscitation, broad-spectrum antibiotics, blood transfusion, pressor requirement, and continuous renal replacement therapy The decision was made by the family to withdraw life support, and the patient expired DISCUSSION: An increased presence of coagulopathy and VTEs has been seen in COVID-19 patients in both the ICU and medical floors [2] To date, the exact mechanism that leads to thromboembolic disease has yet to be determined but is thought to be due to the familiar combination of Virchow’s triad: endothelial injury, blood stasis, and a hypercoagulable state [2-3] CONCLUSIONS: In our case, the patient continued to deteriorate despite anticoagulation for his VTE While not all patients with COVID-19 develop VTEs, it is important to be aware of the heightened risk for micro- and macro-thrombotic events in patients with SARS-CoV-2 Reference #1: Middeldorp S, Coppens M, van Haaps TF, et al Incidence of venous thromboembolism in hospitalized patients with COVID-19 [published online ahead of print, 2020 May 5] J Thromb Haemost 2020;10 1111/jth 14888 doi:10 1111/jth 14888 Reference #2: Morales MH, Leigh CL, Simon EL COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens [published online ahead of print, 2020 May 15] Am J Emerg Med 2020;10 1016/j ajem 2020 05 022 doi:10 1016/j ajem 2020 05 022 Reference #3: Helms J High risk of thrombosis in patients in severe SARS-CoV-2 infection: a multicenter prospective cohort study Intensive Care Med 2020 doi: 10 1007/s00134-020-06062-x DISCLOSURES: No relevant relationships by Riad Akkari, source=Web Response No relevant relationships by Brad Schwartz, source=Web Response
Databáze: OpenAIRE
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