A case report on spontaneous hemoperitoneum in COVID-19 patient

Omental venous malformation: a rare cause of spontaneous haemoperitoneum

Spontaneous haemoperitoneum is a rare condition with a variety of aetiologies. Regardless of the cause, it is invariably a life-threatening condition that requires urgent diagnosis and management. The most common causes of spontaneous haemoperitoneum include gynaecological, hepatic, splenic and vascular causes. However, here, we present a rare case of spontaneous haemoperitoneum secondary to idiopathic omental venous malformation.Our patient presented with acute onset of right iliac fossa pain, and a CT scan revealed a massive haemoperitoneum. A laparoscopic converted to open laparotomy was performed to diagnose and treat the patient. We discuss the management approach for such patients with spontaneous haemoperitoneum.

Splenic Artery Infarct Requiring Surgery: A Rare Complication of COVID-19 Infection

Introduction. Coronavirus disease (COVID-19) from SARS-CoV-2 infection is linked to a hypercoagulable state, leading to arterial and venous thrombotic events, of which pulmonary embolism is the most frequent. However, arterial thromboembolisms may also occur as visceral infracts in unusual sites, such as the renal, splenic, and intestinal arteries. Case Report. A 46-year-old unvaccinated male with a COVID-19 infection was admitted to the COVID-19 isolation ward with symptoms of respiratory infection. He complained of epigastric pain and fever for several days; radiological imaging of the abdomen revealed complete splenic arterial occlusion due to a large infarct. He was treated with low molecular weight heparin (enoxaparin) in therapeutic doses, resulting in minimal improvement. However, the pain worsened, and eventually, a laparotomy and splenectomy were performed. He was hospitalized for another 36 days before he was discharged in good condition. A second surgery was performed to remove a noninfected encapsulated hematoma from the subdiaphragmatic space. The patient remained healthy afterward, with no relapses. Discussion. Although rare, the number of cases of visceral infarcts in COVID-19 patients has increased. Splenic artery infarct is an exceptional case of acute abdominal pain that can be treated successfully with anticoagulant medication. Splenectomy may be required to manage refractory pain after failure of conservative management.

De novo pancytopaenia in an older adult with severe COVID-19 infection

During the COVID-19 pandemic, it was recognised that SARS-CoV-2 can cause multisystem illness. Non-respiratory complications observed early in the pandemic were haematological in nature. A rare but serious haematological complication of COVID-19 infection is pancytopaenia. We describe a case of an older adult without pre-existing haematological disease or risk factors for cell dyscrasia with severe pancytopaenia induced by COVID-19, who developed critical illness requiring respiratory support in intensive care and died. Our case report highlights that de novo pancytopaenia may only present with mild dermatological manifestations and may indicate severe COVID-19 infection. Management is primarily supportive and early involvement of haematology should be sought.

Incidental and Asymptomatic Splenic Infarction and Infrarenal Thrombus in a COVID-19 Patient

The cytokine storm associated with coronavirus disease 2019 (COVID-19) triggers a hypercoagulable state leading to venous and arterial thromboembolism. Lab findings associated with this phenomenon are elevated D-dimer, fibrinogen, C-reactive protein (CRP), ferritin, and procalcitonin. We present the case of a 66-year-old male with dyslipidemia who was diagnosed with COVID-19 with worsening shortness of breath, myalgia, and loss of taste. Physical examination was remarkable for crackles with diminished lung sounds and use of his accessory muscles. Labs showed normal white blood cell count, D-dimer of 1.42 mg/L, ferritin of 961 ng/mL, lactate dehydrogenase (LDH) of 621 U/L, and CRP of 2.1 mg/dL. Chest X-ray showed atypical pneumonitis with patchy abnormalities. He required oxygen supplementation with fraction of inspired oxygen of 100% proning as tolerated. He received remdesivir, ceftriaxone, azithromycin, dexamethasone, prophylactic enoxaparin, and a unit of plasma therapy. His D-dimer had increased from 1.65 to 3.51 mg/L with worsening dyspnea. At this time, computed tomography angiogram (CTA) of the chest showed extensive ground-glass opacities and a 2.4 × 1.9 × 1.3 cm distal thoracic aortic intraluminal thrombus. He was started on a heparin drip. A follow-up CTA of the aorta showed thrombus or hypoattenuation within the splenic artery and wedge-shaped areas extending from the hilum with possible infarction and a 6 mm thrombus in the infrarenal abdominal aorta. He was transitioned to enoxaparin 1 mg/kg twice daily. He remained asymptomatic from his splenic infarction. This case adds more insight to splenic infarction associated with COVID-19 in addition to the 32 reported cases documented thus far. Management of thromboembolism includes a therapeutic dose of anticoagulation. To prevent thromboembolism, prophylactic anticoagulation is recommended for those hospitalized with COVID-19.

Splenic infarct in a COVID-19 patient under anticoagulant therapy with normal D-dimer levels

BACKGROUND

Many studies have shown that COVID-19 can progress with coagulopathy and multisystemic thrombotic events. We report a patient who presented with abdominal pain after COVID-19 and was found to have splenic infarction (SI) concomitant with acute myocardial infarctus (MI) under anticoagulant treatment.

CASE PRESENTATION

A 45-year-old man was admitted to the emergency department with left-sided abdominal pain radiating through to his back persisting for one day. He had COVID-19 PCR positivity nine days ago. After seven days of hospitalization due to COVID-19 pneumonia, he had been discharged with low-molecular-weight heparin (LMWH). Abdominal computerized tomography (CT) showed SI. His ECG and laboratory parameters were normal except for 17.2 × 10∧3/μL leukocytosis. The anticoagulant drug dose that he was taking was increased to 2 × 0.6 mL during hospitalization. He described new-onset chest pain during follow-up. Acute anterior MI was detected on ECG. Successful percutaneous coronary angiography was performed by cardiologists. No problems were observed in the follow-up. The patient was discharged on the fifth day of conservative treatment due to splenic infarction.

CONCLUSION

Thrombosis prophylaxis with prophylactic doses of LMWH in hospitalized COVID-19 patients may not be sufficient to prevent the development of coagulopathy in patients. Abdominal-visceral thromboembolism should be suspected in a COVID-19-positive patient presenting with abdominal pain despite receiving anticoagulant therapy and normal d-dimer levels.

GASTROINTESTINAL COMPLICATIONS OF CORONAVIRUS DISEASE (COVID-19)

Background:

It is currently understood that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) directly enters target cells by binding to the angiotensin-converting enzyme 2 (ACE2) receptor. Accordingly, tissues with high expression levels of ACE2 are more susceptible to infection, including pulmonary alveolar epithelial cells, small intestine enterocytes, cholangiocytes, and vascular endothelial cells. Considering the atypical manifestations of COVID-19 and the challenges of early diagnosis, this review addresses the possible gastrointestinal complications of the disease.

Method:

The phrase “Gastrointestinal complication of COVID” was searched in the PubMed, Medline, and SciELO databases. Due to the heterogeneity of the studies included in the present review, a narrative synthesis of the available qualitative data was performed.

Result:

The literature search retrieved 28 articles, primarily case reports and case series, for the qualitative analysis of gastrointestinal complications of COVID-19, in addition to two retrospective cohort and one case-control. The studies focused on hemorrhagic, thrombotic, ischemic, and perforation complications, in addition to acute pancreatitis and pneumatosis intestinalis.

Conclusion:

There is a straight relationship between high expression levels of ACE2 in the gastrointestinal tract and its greater susceptibility to direct infection by SARS-CoV-2. So, it is important to consider the gastrointestinal infection manifestations for early diagnosis and treatment trying to avoid more serious complications and death.

SARS-CoV-2 and splenic infarction: a rarely described thromboembolic presentation

We report the case of a COVID-19 patient presenting with fever, headache and dyspnea, evolving with severe acute abdominal pain. A contrast-enhanced computed tomography (CT) scan diagnosed splenic infarction. We emphasize the importance of seeking the identification of complications of SARS-CoV-2 infection, notably thromboembolic events, with the potential to reduce the morbidity and mortality of the disease. Studies on radiological aspects involving the spleen and splenic infarctions associated with COVID-19 are rare.

Pathogenesis and Mechanism of Gastrointestinal Infection With COVID-19

As a new infectious disease, COVID-19 is spread through the respiratory tract in most cases. Its source and pathological mechanism are not clear. The most common clinical feature is pulmonary infection. Also, a lot patients have gastrointestinal symptoms. Angiotensin-converting enzyme 2 (ACE2) is a functional cellular receptor for SARS-CoV-2, which is like SARS-CoV, a coronavirus associated with severe acute respiratory syndrome (SARS) outbreak in 2003. The tissues and cells expressing ACE2 are potential targets for SARS-CoV-2 infection, and the high expression of ACE2 in intestinal epithelial cells marks that SARS-CoV-2 may directly infect intestinal epithelial cells. Recent studies also suggest that SARS-CoV-2 existed and replicated in intestinal environment for a long time. The interaction between SARS-CoV-2 and RAS system leads to the decrease of local anti-inflammatory ability. The virus cycle leads to excessive imbalance of immune response and cytokine release. The downregulation of ACE2 after viral infection leads to gastrointestinal dysfunction. The above are the causes of gastrointestinal symptoms. Here, we reviewed the possible causes and mechanisms of gastrointestinal symptoms caused by COVID-19. Additionally, we discussed the influence of gastrointestinal symptoms on the prognosis of patients.

Post COVID-19 splenic infarction with limb ischemia: A case report

Introduction

and importance: COVID-19 has been associated with thrombotic events in a variety of organs and systems, with pulmonary embolism being the most prevalent. Splenic infarction, renal infarction, and intestinal ischemia have all been documented recently as abdominal visceral infarctions.

Case presentation

A 59 years old female patient with a history of COVID-19 disease was admitted to our hospital due to her left upper quadrant abdominal and left flank pain. She had a history of left heel color change in few days. We perform an ultrasound and it was shown vein thrombosis. So, heparin infusion was started for her. We also performed a thoraco-abdominopelvic computed tomography (CT) with intravenous and oral contrast. Total evidence suggests a splenic system infarction. A regular clinical examination for malignancy was performed on the patient and there was no evidence of cancer. Other probable reasons were ruled out. The patient was diagnosed with splenic infarction, Due to coagulopathy caused by SARS-Cov-2 infection. Treatment with heparin was continued for 5 days and she was discharged home on day 9 with oral agents. The patient was asymptomatic when she returned. The spleen had decreased in size on the follow-up CT, and there were no clinical complications.

Discussion and conclusions

Spleen artery thrombosis is a rare complication of COVID-19. In this report, we described a 59 years old female with a history of COVID-19. She was discharged home and in follow-up, there was no evidence of thrombosis anymore.

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Due to COVID-19 pandemic, it is important to report any new cases.

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Splenic infarction is reported as a COVID-19 complication.

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Limb ischemia simultaneously with spleen infarction is very rare.

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It is important to notice coagulopathy and its treatment in COVID-19 patients.

A Systematic Review of Abdominal Imaging Findings in COVID-19 Patients

OBJECTIVE

The objective of this systematic review was to evaluate key imaging manifestations of COVID-19 on abdominal imaging by utilizing a comprehensive review of the published literature.

METHOD

A systematic literature search from PubMed, Google Scholar, and Scopus was performed for studies mentioning abdominal imaging findings in COVID-19 patients. Studies published from inception to 15 March 2021 were included.

RESULTS

A total of 116 studies comprising 1,198 patients were included. Abdominal pain was the most common indication for abdominal imaging in 50.2% of the patients. No abnormality was seen in 48.1% of abdominopelvic computed tomography scans. Segmental bowel wall thickening (14.7%) was the most common imaging abnormality, followed by bowel ischemia (7.1%), solid organ infarction (6.7%), vessel thrombosis (6.7%), and fluid-filled colon (6.2%). Other relevant findings were dilated air-filled bowel, pancreatitis, pneumatosis/portal venous gas, bowel perforation, and appendicitis. Other than abdominal findings, COVID-19-related basal lung changes were incidentally detected in many studies. Moreover, the presence of bowel imaging findings was positively correlated with the clinical severity of COVID-19 infection.

CONCLUSION

This review describes the abdominal imaging findings in COVID-19 patients. This is pertinent for the early diagnosis of COVID-19 in patients presenting solely with abdominal symptoms as well as in identifying abdominal complications in a known case of COVID-19.

Massive late postoperative bleeding after abdominal surgery in a haematologic patient with postoperative CoV-2 infection

The role of viral infection in extrapulmonary postoperative complications in CoV-2 patients is still debated. Perioperative bleeding is rare compared with thrombotic events, but can be related to a haemorrhagic CoV-2-associated disseminated intravascular coagulopathy-like syndrome.

Massive intraperitoneal hemorrhage in patients with COVID-19: a case series

Coronavirus disease (COVID-19) initiates several life-threatening complications including coagulopathies with a unique characteristic that made this problem challenging. Here we presented 4 cases of RT-PCR positive patients that have experienced deadly intraperitoneal hemorrhage with fourth WHO Bleeding Grade after overcoming their respiratory phase. COVID-19 could induce several coagulopathies with different features that besides iatrogenic interventions increases its mortality and morbidity due to lack of clinical evidence based on well-designed randomized clinical trials on anticoagulation therapies (AT) and administration of varieties of newly approved and non-approved medicines. This report showed the urgent need for investigation on the pathophysiology of COVID-19-associated coagulopathy esp. in hemorrhagic events which are needed to make the best therapeutic decision.

Splenic infarction with aortic thrombosis in COVID-19

Coronavirus disease 2019 (COVID-19) has been associated with an increased risk of venous and arterial thrombotic disease. Although pulmonary embolism has been the most common thrombotic complication, there have been recent reports of COVID-19-associated large-vessel ischemic stroke, acute upper- and lower-limb ischemia, as well as infarctions of the abdominal viscera, including renal, splenic, and small bowel infarctions. Here, we describe a case of splenic infarction (SI) associated with aortic thrombosis, which evolved despite the prophylactic use of low-molecular-weight heparin (LMWH), in a 60-year-old female patient with COVID-19. The patient was treated clinically with a therapeutic dose of LMWH, followed by warfarin, and eventually presented a favorable outcome. We also present a review of the literature regarding SI in patients with COVID-19.

Atraumatic Splenic Rupture in a SARS-CoV-2 Patient: Case Report and Review of Literature

Splenic rupture in the absence of trauma or previously diagnosed disease is rare. Due to the delay of diagnosis and treatment, this is a potentially life-threatening condition. We report a case of atraumatic splenic rupture in a SARS-CoV-2 patient. This report is of particular interest as it first identifies SARS-CoV-2 infection as a possible cause of spontaneous rupture of the spleen. A 46-year-old Caucasian woman presented at the emergency department pale and sweaty, complaining of syncopal episodes, tachycardia, hypotension, diarrhea, intense abdominal pain, diffuse arthromyalgia, and fever from the day before. RT-PCR was positive for SARS-CoV-2 infection. CT scan demonstrated extensive hemoperitoneum due to rupture of the splenic capsule. The patient required an emergency open splenectomy because of an unresponsive hemorrhagic shock. At the end of the surgery, the patient was relocated to a COVID-19 dedicated facility. COVID-19 is a new disease of which all manifestations are not yet known. Inpatients affected by SARS-CoV-2 infection with abdominal pain and spontaneous splenic rupture should be considered to avoid a delayed diagnosis.

COVID-19 With an Initial Presentation of Intraperitoneal Hemorrhage Secondary to Spontaneous Splenic Rupture

The WHO declared coronavirus disease 2019 (COVID-19) a global pandemic in early 2020. As the pandemic has continued to evolve over a period of several months, many cases of unusual presentations are now emerging, which pose a greater challenge for physicians in terms of quickly identifying COVID-19 patients based on initial signs and symptoms. In this report, we present one such unusual presentation in a patient with sudden intraperitoneal hemorrhage and spontaneous splenic rupture with COVID-19 as the likely etiology and contributing factor. The patient was a 75-year-old Caucasian woman who presented to the emergency department (ED) with complaints of severe left-sided abdominal pain for several days without any preceding trauma. A CT of the abdomen/pelvis revealed a large amount of fluid in the abdomen, which raised suspicion of bleeding. An exploratory laparotomy revealed splenic rupture with hemoperitoneum, and the patient subsequently underwent an emergent splenectomy. The patient's COVID-19 antigen test returned positive during the surgery and was subsequently confirmed with a polymerase chain reaction (PCR) test. COVID-19 has been found to result primarily in respiratory symptoms through its ability to invade endothelial cells via angiotensin-converting enzyme 2 affinity. It is speculated that this mechanism may cause a predisposition to micro-thromboses, which can eventually lead to manifestations such as large lymphoid organ thrombosis. Based on this case presentation and the evolving literature on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), spontaneous splenic rupture is an emergent differential diagnosis that should be considered in COVID-19 patients presenting with gastrointestinal complaints such as abdominal pain and nausea.

Splenic infarction as a complication of covid-19 in a patient without respiratory symptoms: A case report and literature review

Introduction

Multiple studies suggest that SARS-CoV-2 infection is associated with a pro-thrombotic state and thrombotic events have been recorded in several organs and systems. We report a patient with no respiratory symptoms, presented with abdominal pain and an extensive splenic infarction after COVID-19.

Case report

A 67 year-old man was admitted to the emergency department with a moderate, dull, left-sided abdominal pain. The patient denied respiratory symptoms but referred contact with family members positive for COVID-19. He tested positive for COVID-19 and had increased D-dimer levels. Imaging studies revealed splenic infarcts and ground-glass opacities in bilateral pulmonary bases. He was treated with full-dose anticoagulation and was discharged home on oral Rivaroxaban.

Discussion

Although rare in the literature, cases of acute abdomen in COVID-19 patients associated with vascular infarctions have increased. Coagulopathy may be present even without clinical respiratory manifestations of the disease. Patients meeting disseminated intravascular coagulation criteria or with markedly elevated D-dimer may benefit from anticoagulant therapy.

Conclusion

Clinicians should suspect of abdominal visceral infarctions in COVID-19 patients presented with acute abdominal pain, despite the absence of respiratory symptoms.

Splenic infarction and spontaneous rectus sheath hematomas in COVID-19 patient

Multiple studies and reports have suggested that coronavirus disease-19 (COVID-19) promotes arterial and venous thrombotic events in multiple organ systems, although the mechanism leading to a hypercoagulable state is still unknown. Few cases of splenic infarction associated with COVID-19 have been reported, of which half were found incidentally upon autopsy. This may be due to a clinically silent presentation or the symptoms being wrongfully attributed to pain caused by the effects of COVID-19. Due to the rarity of the condition and its lack of consistent symptomatology, splenic thromboembolism can be difficult to diagnose. Awareness of the condition and high clinical suspicion will help the clinician identify and manage the problem. Hemorrhage in patients with COVID-19 is uncommon in the hypercoagulable state that threatens thrombus formation in patients with COVID-19 infection. Despite prophylactic treatment with anticoagulation therapies, patients are more prone to developing clots. It is also well-known that therapeutic anticoagulation can place patients at a higher risk of bleeding. Thus, this unique population is at risk of developing both thrombotic and hemorrhagic events. We report a rare case of splenic infarction in a patient with confirmed COVID-19 infection despite prophylactic treatment with low-molecular-weight heparin which was found incidentally during workup for 2 other rare conditions: spontaneous rectus sheath hematoma and microhemorrhage or thrombus of the mesenteric vessels.