Life and Limb: a Case of COVID-19-Associated Multisystem Thrombosis and Review of the Literature

Atypical Immunologic Manifestations of COVID-19: a Case Report and Narrative Review

COVID-19 usually presents with classic signs and symptoms, but it can involve multiple systems in atypical cases. SARS-CoV-2 has a complex interaction with the host immune system leading to atypical manifestations. In our case, a 32-year-old male patient presented with fatigue, sores on hands and feet, headache, productive cough with blood-tinged mucus, conjunctival hyperemia, purpuric rash on hands and feet, and splinter hemorrhages of fingernails for 2 weeks. The patient's SARS-CoV-2 antigen and PCR test were positive. Chest X-ray showed mixed density perihilar opacities in both lungs. Computed tomography of the chest showed extensive airspace opacities in both lungs, suggesting COVID-19 multifocal, multilobar pneumonitis. A renal biopsy indicated limited thrombotic microangiopathy and tubulointerstitial nephritis, for which he was started on steroids, and his renal functions gradually improved. He tested positive for C-ANCA during an immune workup. He was discharged with a steroid taper for nephritis. Once the taper reached less than 10 mg/day, he developed acute scleritis and a new pulmonary cavitary lesion of 6 cm. The biopsy via bronchoscopy revealed acute inflammatory cells with hemosiderin-laden macrophages. He was restarted on systemic steroids for scleritis after failing topical steroids, which incidentally also reduced the size of the cavitary lesion, indicating an immune component. Our case demonstrates the involvement of kidneys and vasculitis of the skin, sclera, and lungs by COVID-19. The patient's symptoms were not explained by any diseases other than COVID-19. Atypical cases of COVID-19 disease with multifocal systemic symptoms involving the skin, sclera, lungs, and kidneys should be high on differentials. Early recognition and intervention may decrease hospital stays and morbidity.

Acute Limb Ischemia in Critically ill COVID-19 Patients: a Case Series and Literature Review

Background: The vascular burden increased by COVID-19 infection and including acute limb ischemia (ALI) quickly emerged as a major medical challenge with devastating consequences such as limb loss, multiorgan dysfunction and death. We report a case series of COVID-19 infection associated with ALI to raise awareness and knowledge towards this life-threatening association. Methods: COVIDS-19 patients with acute limb ischemia (ALI) managed in a Moroccan 14 beds COVID-19 ICU between March 2020 and January 2021, were reviewed. Data collected included demographics, clinical presentation, treatments and outcomes. Results: Over the 10-month period, our ICU cared for 407 hospitalized patients with confirmed COVID-19. A total of 6 COVID-19 patients with ALI were identified. The mean age was 61 years (52 - 70) and 5 were men. The most common preexisting condition was diabetes (50%). The mean CRP level was 219 mg/L. Five patients had thrombus in multiple locations. No concomitant deep vein thrombosis was identified. Four patients presented with signs of acute No arterial ischemia with or without respiratory symptoms and were subsequently diagnosed with COVID-19. The remaining two patients developed ischemia during hospitalization. Mean SOFA score was 5 (2 -9). Respiratory support, corticosteroids and heparin therapies were used in all patients. Intubation and vasopressors were required in four patients. Revascularization was performed in five patients and reintervention was necessary in three cases. Four patients died in the ICU while two were successfully discharged. Conclusion: ALI in COVID-19 patients is a challenging life-threatening vascular emergency that requires appropriate multidisciplinary management (intensivists, anesthesiologists, vascular surgeons and interventionists, radiologists, haematologists…) and further studies focused on anticoagulation. Keywords: Acute Limb ischemia, Coagulopathy, COVID-19, SARS-CoV-2, Thrombosis