Digital Ischemia in COVID-19 Patients: Case Report

Case Report: Extensive Gangrene: A Rare Presentation of Multisystem Inflammatory Syndrome in Children

A wide spectrum of cutaneous manifestations are reported in multisystem inflammatory syndrome in children (MIS-C). However, gangrenous changes are less frequently reported. A 3-year old boy, with a known case of unoperated tetralogy of Fallot, presented with a short history of fever, rash, and melena. The rash was black and diffuse, with a rapid progression. The patient was stable hemodynamically at admission, with pallor, grade II clubbing, edema, and oral ulcers. Inflammatory markers were raised. He developed gangrenous changes over the ears and acral areas. He had very high levels of antibodies to severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) infection and was diagnosed as having MIS-C. Skin biopsy revealed near total epidermal necrosis with dermal vascular thrombi and negative immunofluorescence. Skin biopsy was positive for IgG antibodies to SARS-CoV-2. He was treated with antibiotics, immunomodulation with steroids, intravenous immunoglobulin, and plasmapheresis. He had features of both micro- and macroangiopathy. Gradually the child improved, with residual deformity.

Radial arterial thrombosis in COVID-19: A case report

Thrombosis due to hypercoagulable state is an important cause of morbidity and mortality in coronavirus disease 2019 (COVID-19). Increased D-dimer levels are an important marker of the presence and risk of thrombosis. In this report, we present that a 59-yearold male patient developed thrombosis in the distal radial arteries despite normal D-dimer level. The patient was treated with enoxaparin, iloprost infusion, and cilostazol. This case should lead us to be very careful that people diagnosed with COVID-19 with normal D-dimer levels may also have thrombosis.

Upper-Extremity Phlegmasia Cerulea Dolens With Compartment Syndrome in Coronavirus Disease 2019 Sepsis

A 54-year-old woman with leukemia presented with coronavirus disease 2019 and a right upper-extremity indwelling peripherally inserted central catheter line for chemotherapy administration. On hospital admission day 9, she developed acute right upper-extremity edema and pain. Ultrasound demonstrated complete superficial and deep venous thrombosis up to the proximal subclavian vein. Her examination result was consistent with acute phlegmasia cerulea dolens and compartment syndrome, but respiratory instability prevented transfer and vascular surgery intervention. Instead, we performed bedside fasciotomies and administered therapeutic heparin, and the limb was salvaged. This case underscores the potential for successful limb salvage in patients with phlegmasia in the setting of coronavirus disease 2019 via compartment release and therapeutic anticoagulation.

Hereditary Thrombophilia in the Era of COVID-19

Thrombophilia, also called hypercoagulability or prothrombotic condition, usually reflects a certain imbalance that occurs either in the coagulation cascade or in the anticoagulation/fibrinolytic system. A similar imbalance may be induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thrombotic complications are associated with multiorgan failure and increased mortality. In this context, activation of coagulation and thrombocytopenia appeared as prognostic markers in COVID-19. Our work provides a structured and updated analysis of inherited thrombophilia and its involvement in COVID-19, emphasizing the importance of diagnosing and initiating thromboprophylaxis. Since the state of hypercoagulation is directly correlated with COVID-19, we consider that studies on the genetic profiles of proteins involved in thrombophilia in patients who have had COVID-19 and thrombotic events are of great importance, both in treating and in preventing deaths due to COVID-19.

Digital ischaemia and necrosis from oxaliplatin

Oxaliplatin is a chemotherapeutic agent used in a variety of malignancies such as colorectal cancer and pancreatic cancer. It is a platinum derivative that results in direct cell cytotoxicity with resultant cell death. The most common side effects often noted are neurotoxicity, nausea, vomiting, diarrhoea, hepatotoxicity and myelosuppression. Oxaliplatin induced digital ischaemia and necrosis is a rare side effect that was observed in our patient. In general, digital ischaemia is a rare vascular disorder that is often associated with autoimmune disease. A patient with digital ischaemia due to oxaliplatin will be described in this case report.

Upper extremity necrotizing fasciitis in a Covid-19 patient

The novel COVID-19 virus has resulted in an immense burden in healthcare throughout the world. In addition to respiratory complications, COVID-19 has been associated with hypercoagulability and ischemic changes. We report a case of a patient with COVID-19 who presented with a rapidly progressing necrotizing fasciitis treated in our institution.

Editor's Choice - Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature

OBJECTIVE

To perform a scoping review of how patients with COVID-19 are affected by acute limb ischaemia (ALI) and evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients.

METHODS

Research questions were defined, and a systematic literature search was performed following the PRISMA guidelines. Abstracts and unpublished literature were not included. The definition of ALI in this review is in accordance with the ESVS guidelines.

RESULTS

Most identified papers were case reports or case series, although population based data and data from randomised controlled trials were also identified. In total, 114 unique and relevant papers were retrieved. Data were conflicting concerning whether the incidence of ALI increased, or remained unchanged, during the pandemic. Case reports and series reported ALI in patients who were younger and healthier than usual, with a greater proportion affecting the upper limb. Whether or not this is coincidental remains uncertain. The proportion of men/women affected seems unchanged. Most reported cases were in hospitalised patients with severe COVID-19. Patients with ALI as their first manifestation of COVID-19 were reported. Patients with ALI have a worse outcome if they have a simultaneous COVID-19 infection. High levels of D-dimer may predict the occurrence of arterial thromboembolic events in patients with COVID-19. Heparin resistance was observed. Anticoagulation should be given to hospitalised COVID-19 patients in prophylactic dosage. Most of the treatment recommendations from the ESVS Guidelines remained relevant, but the following were modified regarding patients with COVID-19 and ALI: 1) CTA imaging before revascularisation should include the entire aorta and iliac arteries; 2) there should be a high index of suspicion, early testing for COVID-19 infection and protective measures are advised; and 3) there should be preferential use of local or locoregional anaesthesia during revascularisation.

CONCLUSION

Although the epidemiology of ALI has changed during the pandemic, the recommendations of the ESVS ALI Guidelines remain valid. The above mentioned minor modifications should be considered in patients with COVID-19 and ALI.

Acute limb ischemia among patients with COVID-19 infection

OBJECTIVE/BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with thrombotic complications such as deep vein thrombosis or stroke. Recently, numerous cases of acute limb ischemia (ALI) have been reported although pooled data are lacking.

METHODS

We systematically searched PubMed, Embase, Scopus, and the Cochrane Library for studies published online up to January 2021 that reported cases with SARS-CoV-2 infection and ALI. Eligible studies should have reported early outcomes including mortality. Primary endpoints included also pooled amputation, clinical improvement, and reoperation rates.

RESULTS

In total, 34 studies (19 case reports and 15 case series/cohort studies) including a total of 540 patients (199 patients were eligible for analysis) were evaluated. All studies were published in 2020. Mean age of patients was 61.6 years (range, 39-84 years; data from 32 studies) and 78.4% of patients were of male gender (data from 32 studies). There was a low incidence of comorbidities: arterial hypertension, 49% (29 studies); diabetes mellitus, 29.6% (29 studies); dyslipidemia, 20.5% (27 studies); chronic obstructive pulmonary disease, 8.5% (26 studies); coronary disease, 8.3% (26 studies); and chronic renal disease, 7.6% (28 studies). Medical treatment was selected as first-line treatment for 41.8% of cases. Pooled mortality rate among 34 studies reached 31.4% (95% confidence interval [CI], 25.4%%-37.7%). Pooled amputation rate among 34 studies reached 23.2% (95% CI, 17.3%-29.7%). Pooled clinical improvement rate among 28 studies reached 66.6% (95% CI, 55.4%%-76.9%). Pooled reoperation rate among 29 studies reached 10.5% (95% CI, 5.7%%-16.7%). Medical treatment was associated with a higher death risk compared with any intervention (odds ratio, 4.04; 95% CI, 1.075-15.197; P = .045) although amputation risk was not different between the two strategies (odds ratio, 0.977; 95% CI, 0.070-13.600; P = .986) (data from 31 studies).

CONCLUSIONS

SARS-CoV-2 infection is associated with a high risk for thrombotic complications, including ALI. COVID-associated ALI presents in patients with a low incidence of comorbidities, and it is associated with a high mortality and amputation risk. Conservative treatment seems to have a higher mortality risk compared with any intervention, although amputation risk is similar.

Ulnar Nerve Palsy as COVID-19 Sequelae in Three Patients

The pathophysiology and treatment of COVID-19 have been at the forefront of medical research this past year. While great strides have been made in our knowledge of the disease, there is still much that is unknown. More than one-third of patients with COVID-19 present with symptoms involving the nervous system. The reason for this is unclear, although several theories have been postulated. In this case study, we present 3 patients with severe ulnar nerve dysfunction following treatment for COVID-19 in the intensive care unit. We discuss reasons why this may have occurred, the etiology of which is likely multifactorial. We are reporting these cases to inform and alert physicians to the possibility of ulnar nerve involvement in the presentation of patients with COVID-19.

Is digital necrosis in COVID-19 caused by neutrophil extracellular traps: Potential therapeutic strategies

Some of the COVID-19 patients present with ischemic lesions of their finger and toes. Standard anticoagulant therapy is usually unsuccessful for the treatment of this unique presentation of COVID-19. In this review current evidence is presented, which supports the hypothesis that these necrotic lesions are primarily related to the formation of neutrophil extracellular traps is blood vessels. Also, currently available and potential pharmacological methods of the management of this unique thrombotic complication are discussed. Drugs that possibly could be used in COVID-19 patients suffering from acute ischemia of distal parts of the extremities particularly comprise DNase I and DNase1L3, which could directly dissolve these extracellular webs that are mostly composed of DNA. However, at the moment, none of these enzymes are registered for an intravascular administration in humans. Lactoferrin and dipyridamole are other pharmaceutical agents that could potentially be used for the treatment of neutrophil extracellular traps-evoked digital ischemia. These agents exhibit prophylactic activity against excessive formation of these extracellular structures. Such an experimental treatment should probably be accompanied by standard antithrombotic management with heparin. Open-label and then randomized trials are needed to confirm feasibility, safety and efficacy of the above-suggested management of critically ill COVID-19 patients.

COVID-19 and acute limb ischemia: a systematic review

INTRODUCTION

The main goal of this systematic review is to analyze the outcomes of acute limb ischemia (ALI) in patients suffering from the novel Coronavirus COVID-19 (Sars-Cov-2).

EVIDENCE OF ACQUISITION

A systematic review on MEDLINE and Embase was conducted up to May 15, 2021. All papers were sorted by abstract and full text by two independent authors. Systematic reviews, commentaries, and studies that did not distinguish status of COVID-19 infection were excluded from review. Patient demographics were recorded along with modality of treatment (endovascular and/or surgical). We analyzed 30-day outcomes, including mortality. Primary outcome was to evaluate clinical characteristic of ALI in patients affected by SARS-CoV-2 in term of location of ischemia, treatment options and 30-day outcomes.

EVINDENCE SYNTHESIS

We selected 36 articles with a total of 194 patients. The majority of patients were male (80%) with a median age of 60 years old. The treatment most used was thromboembolectomy (31% of all surgical interventions). A total of 32 patients (19%) were not submitted to revascularization due to critical status. The rate of technical success was low (68%) and mortality rate was high (35%).

CONCLUSIONS

This review confirms that Sars-Cov-2 is associated with a high risk of ALI. Further studies are needed to investigate the association and elucidate potential mechanisms, which may include a hypercoagulable state and hyperactivation of the immune response. Furthermore, management of ALI is not standardized and depends on patient's condition and extension of the thrombosed segment. ALI in COVID-19 patients is associated with high risk of failure of revascularization and perioperative mortality.

COVID-19 and peripheral arterial complications in people with diabetes and hypertension: A systematic review

AIMS

Identify the prevalence, risk factors and outcomes of lower extremity ischemic complications.

METHODS

A systematic review was conducted by searching PubMed and SCOPUS databases for SARS-CoV-2, COVID-19 and peripheral arterial complications.

RESULTS

Overall 476 articles were retrieved and 31 articles describing 133 patients were included. The mean age was 65.4 years. Pain and gangrene were the most common presentation. Hypertension (51.3%), diabetes (31.9%) and hypercholesterolemia (17.6%) were associated co-morbidities. Overall, 30.1% of patients died and amputation was required in 11.8% patients.

CONCLUSIONS

COVID-19 patients with diabetes or hypertension are susceptible for lower limb complications and require therapeutic anti-coagulation.

"COVID toes": A meta-analysis of case and observational studies on clinical, histopathological, and laboratory findings

BACKGROUND

Coronavirus disease (COVID-19) is related to several extrapulmonary disorders; however, little is known about the clinical, laboratory, and histopathological characteristics of pernio-like skin lesions associated with COVID-19 infection.

OBJECTIVE

To evaluate and summarize the clinical, laboratory, and histopathological characteristics of pernio-like lesions reported in the literature.

METHODS

We conducted a search of the PubMed, SciELO, and ScienceDirect databases for articles published between January 1, 2020 and November 30, 2020, following the PRISMA recommendations (PROSPERO registration ID: CRD42020225055). The target population was individuals with suspected or laboratory-confirmed COVID-19 with pernio-like lesions. Observational studies, research letters, and case/series reports were all eligible for inclusion. Observational studies were evaluated using a random-effects model to calculate the weighted mean prevalence, overall mean, and 95% confidence interval. We evaluated case studies using the chi-square test for dichotomous variables and the Mann-Whitney test for continuous variables.

RESULTS

A total of 187 patients from case reports and 715 patients from 18 observational studies were included. The mean age of patients was 16.6 years (range 14.5-18.8). Feet were affected in 91.4% (87.0-94.4%) of patients in observational studies. The proportion of patients with a positive RT-PCR test was less than 15%. Lesion topography and morphology were associated with age.

CONCLUSION

Lesions mostly occurred in pediatric patients, and the morphological characteristics tended to differ between pediatric and non-pediatric populations. There is a possible multifactorial component in lesion pathophysiology. The non-positivity of laboratory tests does not exclude an association with COVID-19. Pernio-like lesions may be a late manifestation of COVID-19.

Post-acute physical therapy for a patient with critical illness associated with COVID-19: A case report

BACKGROUND

: The COVID-19 pandemic is expected to bring a surge of survivors in need of post-acute rehabilitation. Preliminary research and clinical guidelines suggest patients recovering from critical illness associated with COVID-19 will present compromised function similar to acute respiratory distress syndrome (ARDS) and ICU-acquired weakness (ICUAW). However, information regarding physical therapy and progressions of physiological and functional outcomes is currently limited. This case report describes the course of recovery of a patient without significant preexisting medical conditions.

CASE DESCRIPTION

: The patient RW (male, age 56) tested positive for COVID-19, and was admitted to ICU for 29 days. After weaning off mechanical ventilation after 2 months of hospitalization, he was transferred to our post-acute rehabilitation facility to recover from the residual effects. Physical therapy evaluation showed that while the patient was cognitively alert, he exhibited impaired general strength and activity intolerance due to severe exertional dyspnea. The patient received physical therapy aimed at improving his functional capacity. During his 16-day stay, the patient was able to significantly improve his capacities (i.e. 600% increase in 30-second chair stand test, 69.5% improvement in walking distance in 6-minute walk test, and 132.4% longer time to exhaustion during level ground ambulation). Dyspnea remained the main factor that limited his activities.

DISCUSSION

: This case demonstrated that post-acute physical therapy appeared to be effective and safe in improving function after critical illness due to COVID-19 for this patient. Physical therapists are encouraged to closely monitor respiratory parameters such as heart rate, oxygen saturation, and levels of dyspnea during treatment for patient response and decisions regarding activity progression.

COVID-19 Sepsis: Pathogenesis and Endothelial Molecular Mechanisms Based on "Two-Path Unifying Theory" of Hemostasis and Endotheliopathy-Associated Vascular Microthrombotic Disease, and Proposed Therapeutic Approach with Antimicrothrombotic Therapy

COVID-19 sepsis is characterized by acute respiratory distress syndrome (ARDS) as a consequence of pulmonary tropism of the virus and endothelial heterogeneity of the host. ARDS is a phenotype among patients with multiorgan dysfunction syndrome (MODS) due to disseminated vascular microthrombotic disease (VMTD). In response to the viral septicemia, the host activates the complement system which produces terminal complement complex C5b-9 to neutralize pathogen. C5b-9 causes pore formation on the membrane of host endothelial cells (ECs) if CD59 is underexpressed. Also, viral S protein attraction to endothelial ACE2 receptor damages ECs. Both affect ECs and provoke endotheliopathy. Disseminated endotheliopathy activates two molecular pathways: inflammatory and microthrombotic. The former releases inflammatory cytokines from ECs, which lead to inflammation. The latter initiates endothelial exocytosis of unusually large von Willebrand factor (ULVWF) multimers and FVIII from Weibel-Palade bodies. If ADAMTS13 is insufficient, ULVWF multimers activate intravascular hemostasis of ULVWF path. In activated ULVWF path, ULVWF multimers anchored to damaged endothelial cells recruit circulating platelets and trigger microthrombogenesis. This process produces "microthrombi strings" composed of platelet-ULVWF complexes, leading to endotheliopathy-associated VMTD (EA-VMTD). In COVID-19, microthrombosis initially affects the lungs per tropism causing ARDS, but EA-VMTD may orchestrate more complex clinical phenotypes, including thrombotic thrombocytopenic purpura (TTP)-like syndrome, hepatic coagulopathy, MODS and combined micro-macrothrombotic syndrome. In this pandemic, ARDS and pulmonary thromboembolism (PTE) have often coexisted. The analysis based on two hemostatic theories supports ARDS caused by activated ULVWF path is EA-VMTD and PTE caused by activated ULVWF and TF paths is macrothrombosis. The thrombotic disorder of COVID-19 sepsis is consistent with the notion that ARDS is virus-induced disseminated EA-VMTD and PTE is in-hospital vascular injury-related macrothrombosis which is not directly  related to viral pathogenesis. The pathogenesis-based therapeutic approach is discussed for the treatment of EA-VMTD with antimicrothrombotic regimen and the potential need of anticoagulation therapy for coinciding macrothrombosis in comprehensive COVID-19 care.

Digital Ischemia as an Initial Presentation in a COVID-19-Positive Patient Without Any Significant Respiratory Symptoms

Coronavirus disease 2019 (COVID-19) is an evolving situation worldwide, which is associated with a broad range of symptoms from pneumonia/acute respiratory distress syndrome (ARDS) to multiorgan failure. So far, we have also encountered several patients with coagulopathy, including pulmonary embolism and deep vein thrombosis. A few cases of limb ischemia related to COVID-19 have been reported as well, but most of them involve critically ill patients. In this report, we discuss a case of COVID-19 in a patient who presented with right thumb ischemia without any significant respiratory symptoms.

The Impact of COVID-19 on Vascular Surgery Practice: A Systematic Review

BACKGROUND

COVID-19 is characterized by a pulmonary interstitial compromise which can require intensive care unit (ICU) and mechanical ventilation. Covid patients develop a wide range of pathologies. This study aims to identify the impact of COVID-19 in diseases commonly treated by vascular surgeons.

METHODS

Four conditions were selected: venous thromboembolism (VTE), pulmonary embolism (PE), peripheral arterial disease (PAD), and microangiopathy. A systematic review of the literature using PRISMA guidelines was.

RESULTS

Out of 1195 papers reviewed for conditions in COVID-19 patients relevant to routine vascular surgery practice, 43 papers were included and analyzed. Venous thrombosis was found to be the most common COVID-19 associated pathology with a cumulative incidence of 25% at 7 days and 48% at 14 days. Additionally, D-dimer levels proved to be a good predictor, even in the early stages of the disease with a sensitivity of 85%, specificity of 88.5% and a negative predictive value of 94.7%. Patients in the ICU demonstrated a significantly higher risk of developing VTE, even when receiving pharmacologic thromboprophylaxis. Although evidence of arterial thrombosis was less common (1% to 16.3%), its consequences were typically more serious, including limb loss and death even in young individuals (OR = 25, 95% CI). Finally, microangiopathy has a wide spectrum of clinical presentations from retinal microangiopathy to other more severe manifestations such as myocardial injury, pulmonary compromise and potential multiple organ dysfunction syndrome.

CONCLUSIONS

Although the pathophysiological pathway by which COVID-19 produces thrombosis is not completely clear, the incidence of both arterial and venous thrombosis is increased. D-dimer screening should be done in all COVID-19 patients, as a predictor of thrombotic complications.

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

Machine learning predictive model for severe COVID-19

To develop a modified predictive model for severe COVID-19 in people infected with Sars-Cov-2. We developed the predictive model for severe patients of COVID-19 based on the clinical date from the Tumor Center of Union Hospital affiliated with Tongji Medical College, China. A total of 151 cases from Jan. 26 to Mar. 20, 2020, were included. Then we followed 5 steps to predict and evaluate the model: data preprocessing, data splitting, feature selection, model building, prevention of overfitting, and Evaluation, and combined with artificial neural network algorithms. We processed the results in the 5 steps. In feature selection, ALB showed a strong negative correlation (r = 0.771, P < 0.001) whereas GLB (r = 0.661, P < 0.001) and BUN (r = 0.714, P < 0.001) showed a strong positive correlation with severity of COVID-19. TensorFlow was subsequently applied to develop a neural network model. The model achieved good prediction performance, with an area under the curve value of 0.953(0.889-0.982). Our results showed its outstanding performance in prediction. GLB and BUN may be two risk factors for severe COVID-19. Our findings could be of great benefit in the future treatment of patients with COVID-19 and will help to improve the quality of care in the long term. This model has great significance to rationalize early clinical interventions and improve the cure rate.

SARS-CoV-2 and limb ischemia: A systematic review

BACKGROUND

Recent spread of severe acute respiratory coronavirus syndrome-2 (SARS-CoV-2) has led to the coronavirus disease (COVID-19) pandemic, resulting in new challenges across all medical specialties. Limb and digit ischemia have been associated with COVID-19 infection. This systematic review includes primary studies of COVID-19 limb ischemia to identify risk factors, comorbidities, case characteristics, and treatment strategies to better understand the nature of this disease and its effects on the extremities.

METHODS

A literature search for studies detailing COVID-19 infected patients with limb or digit ischemia was performed, identifying 157 articles, 12 of which met inclusion criteria, accounting for 47 patients. Inclusion criteria were (1) primary studies, (2) positive disease diagnosis (3) limb ischemia, (4) reported treatment. Demographic data, case characteristics, treatments, outcomes and mortality were collected and pooled.

RESULTS

The average patient age was 67.6 years, predominantly male (79.6%). Of the 44 cases discussing treatment, 13 (30%) patients underwent medical treatment alone, while 23 (52.3%) patients underwent medical plus surgical treatment. Four patients (9.1%) were treated with observation. In 10 of the 12 studies, lab findings, thrombosis, or conclusions supporting a hypercoagulable state as a cause of limb/digit ischemia were cited. Five patients (10.6%) were on vasopressors and 8 patients (17.0%) were on a ventilator. Of those treated with observation alone, there was 100% resolution of symptoms. Of those treated medically without surgical intervention (17 patients), 6 patients (35.3%) were reported to have revascularization, 6 patients (35.3%) died, and the remaining outcomes were not reported. Medical and surgical treatment resulted in one limb amputation (4.4%) and altogether 74% of patients achieved revascularization of the affected limb/digit. Mortality rate was 45%.

CONCLUSIONS

COVID-19 infection may be associated with increased risk of limb or digital ischemia, although the quality of evidence supporting this theory is limited. Evidence of inflammatory-mediated thrombosis and endothelial injury are possible explanations which would support the use of immunotherapy in addition to anticoagulation for treatment or prevention of thromboembolic events. Current outcomes and treatment strategies are variable.

LEVEL OF EVIDENCE

IV.

Acute Limb Ischemia in a Peruvian Cohort Infected by COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) infection can cause alterations in the coagulation mechanism conditioning thrombotic phenomena such as acute limb ischemia (ALI) as the only manifestation of the infection. The aim of the study was to describe clinical and surgical characteristics of a group of patients infected with severe acute respiratory syndrome coronavirus 2 who presented ALI in the context of the COVID-19 pandemic at Lima, Peru.

METHODS

A multicenter, observational, and retrospective study was performed in six general hospitals, from March to July 2020. The variables considered were the pathological history and associated habits, laboratory tests, the severity of COVID-19 infection and ALI, the anatomic location of the lesion, treatment, evolution, and discharge conditions.

RESULTS

Thirty patients with ALI infected with COVID-19 were evaluated. Their mean age was 60 ± 15 years, the condition being more frequent in men (76.6%). The main comorbidities were arterial hypertension (33.3%), obesity (33.3%), and diabetes mellitus 2 (26.6%). There were 23.3% asymptomatic patients, and their only manifestation was ALI. Rutherford IIA and IIB stage included 93.2% of patients. The most frequent location of the thrombosis was the lower limbs (73.3% vs. 26.6%). Thrombectomy was performed in 76.6% of the patients, and amputation (primary and secondary) was performed in 30% of the patients. The mortality rate was 23.3%, all of it because of acute respiratory distress syndrome.

CONCLUSIONS

ALI is a vascular pathology associated with embolic and thrombotic processes. COVID-19 infection can cause severe alterations in coagulation mechanisms, leading some patients to present severe acute arterial complications such as thrombosis, as the only associated manifestation. We report a younger cohort than those described in other studies and with a high frequency of amputations despite adequate surgical treatment.

Thrombotic Complications of COVID-19 Infection: A Review

The novel coronavirus (severe acute respiratory syndrome CoV-2 [SARS-CoV-2]), also known as COVID-19, is a single-stranded enveloped RNA virus that created a Public Health Emergency of International Concern in January 2020, with a global case burden of over 15 million in just 7 months. Infected patients develop a wide range of clinical manifestations-typically presenting with fever, cough, myalgia, and fatigue. Severely ill patients may fall victim to acute respiratory distress syndrome, acute heart injuries, neurological manifestations, or complications due to secondary infections. These critically ill patients are also found to have disrupted coagulation function, predisposing them to consumptive coagulopathies, and both venous and thromboembolic complications. Common laboratory findings include thrombocytopenia, elevated D-dimer, fibrin degradation products, and fibrinogen, all of which have been associated with greater disease severity. Many cases of pulmonary embolism have been noted, along with deep vein thrombosis, ischemic stroke, myocardial infarction, and systemic arterial embolism. The pathogenesis of coronavirus has not been completely elucidated, but the virus is known to cause excessive inflammation, endothelial injury, hypoxia, and disseminated intravascular coagulation, all of which contribute to thrombosis formation. These patients are also faced with prolonged immobilization while staying in the hospital or intensive care unit. It is important to have a high degree of suspicion for thrombotic complications as patients may rapidly deteriorate in severe cases. Evidence suggests that prophylaxis with anticoagulation may lead to a lower risk of mortality, although it does not eliminate the possibility. The risks and benefits of anticoagulation treatment should be considered in each case. Patients should be regularly evaluated for bleeding risks and thrombotic complications.

High prevalence of cryofibrinogenemia in patients with chilblains during the COVID-19 outbreak

BACKGROUND

Many cutaneous manifestations have been described in possible association with the COVID-19 pandemic, including acral lesions resembling chilblains. The underlying pathomechanisms of COVID-19 chilblains are not fully understood. The aim of this study was to describe the clinical, pathological, and laboratory findings of a series of patients who developed chilblains during the COVID-19 outbreak and to investigate the possible factors that could be involved in the pathogenesis of these lesions.

METHODS

We conducted a prospective cohort study that included 54 patients who presented with chilblains during the highest peak in the incidence of COVID-19 in Cantabria (northern Spain). Skin biopsies were performed on 10 of these patients who presented with recent lesions. Laboratory investigations, including immunological analysis, serological studies, and the assessment of cryoproteins, were also performed.

RESULTS

Most patients presented erythematous plaques located on the toes and/or purpuric macules located on the feet. Histopathological findings were compatible with those of idiopathic chilblains. Immunohistochemical evaluation showed C3d and C4d deposits in the vessel walls in seven cases. The autoimmunity panel was negative in most of our series. Cryoprotein testing showed positive cryofibrinogen in two-thirds (66.7%) of the patients assessed. On follow-up, most patients presented almost complete resolution, although six patients required prednisone and antiaggregant drug treatment.

CONCLUSIONS

This study shows, for the first time to our knowledge, a high prevalence of cryofibrinogenemia in patients with chilblains during the COVID-19 pandemic. Cryofibrinogenemia could be implicated in the pathogenesis of chilblains related to COVID-19.

Extracorporeal membrane oxygenation for COVID-19 induced hypoxia: Single-center study

INTRODUCTION

The pandemic of the coronavirus disease 2019 (COVID-19) and associated pneumonia represent a clinical and scientific challenge. The role of Extracorporeal Membrane Oxygenation (ECMO) in such a crisis remains unclear.

METHODS

We examined COVID-19 patients who were supported for acute respiratory failure by both conventional mechanical ventilation (MV) and ECMO at a tertiary care institution in Washington DC. The study period extended from March 23 to April 29. We identified 59 patients who required invasive mechanical ventilation. Of those, 13 patients required ECMO.

RESULTS

Nine out of 13 ECMO (69.2%) patients were decannulated from ECMO. All-cause ICU mortality was comparable between both ECMO and MV groups (6 patients [46.15%] vs. 22 patients [47.82 %], p = 0.92). ECMO non-survivors vs survivors had elevated D-dimer (9.740 mcg/ml [4.84-20.00] vs. 3.800 mcg/ml [2.19-9.11], p = 0.05), LDH (1158 ± 344.5 units/L vs. 575.9 ± 124.0 units/L, p = 0.001), and troponin (0.4315 ± 0.465 ng/ml vs. 0.034 ± 0.043 ng/ml, p = 0.04). Time on MV as expected was significantly longer in ECMO groups (563.3 hours [422.1-613.9] vs. 247.9 hours [101.8-479] in MV group, p = 0.0009) as well as ICU length of stay 576.2 hours [457.5-652.8] in ECMO group vs. 322.2 hours [120.6-569.3] in MV group, p = 0.012).

CONCLUSION

ECMO is a supportive intervention for COVID-19 associated pneumonia that could be considered if the optimum mechanical ventilation is deemed ineffective. Biomarkers such as D-dimer, LDH, and troponin could help with discerning the clinical prognosis in patients with COVID-19 pneumonia.

Acute Ischemic Stroke in COVID-19: A Case-Based Systematic Review

Corona virus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) is recognized as a global pandemic by WHO 2020 with 5,934 936 infections, 367,166 deaths and affecting over 200 countries as of 30th May 2020. Acute Ischemic Stroke (AIS) in brain is also emerging as an important neurovascular/neurological complication of COVID-19, associated with extreme immune responses leading to dysregulated coagulation system and generalized thrombo-embolic status and increased risk of AIS especially among usually less vulnerable younger adults in this cohort. Thus, in early June 2020, we aimed to review the clinical data on all published cases of COVID-19 and concomitant AIS, with a view to understanding the pertinent clinical, laboratory and imaging features. The neutrophil-lymphocyte ratio (NLR) at time of hospital admission for COVID infection correlates positively with the duration of time before onset of clinical features of AIS. Higher NLR, C-Reactive protein, serum ferritin, D-dimer and fibrinogen levels are associated with poor prognosis of AIS in COVID-19 with 75% of patients dying or being severely disabled at present. Currently it is too early to comment on the long-term outcomes for survivors.

The Cutaneous Manifestations Associated with COVID-19: A review

IMPORTANCE

As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic spreads, increasing cases of dermatologic manifestations of the disease continue to be reported.

OBSERVATIONS

In this general review of the case reports, case series, and other systematic reviews on this subject, several patterns of cutaneous lesions have been compiled. These include viral exanthems, papulovesicular, pernio-like, vasculopathy-related, and other miscellaneous rashes.

CONCLUSIONS AND RELEVANCE

While clinical observations and subjective cases of rashes associated with SARS-CoV-2 are important to furthering our research and study of this viral disease, we as clinicians must be cautious in attributing causation with correlation. Continued research and study are needed before we can attribute a source for these dermatologic manifestations.

Bilateral Acute Lower Limb Ischemia Secondary to COVID-19

COVID-19 has to date affected over 5 million people worldwide and caused in excess of 300000 deaths. One of the principal finding is that of a thrombotic tendency within the lungs leading to high mortality. There have been increasing number of reports of peripheral arterial thrombosis as well. Most cases of arterial thrombosis is noted in patient in intensive care setting. Here-in we report a case of acute bilateral lower limb arterial thrombosis in a patient recovering at home with mild COVID-19 symptoms, highlighting that patients with milder symptoms may also suffer from prothrombotic state resulting in acute arterial occlusions. Arterial thrombosis should be suspected in these patients despite the absence of predisposing factors.

Emergency Hand and Reconstructive Microsurgery in the COVID-19-Positive Patient

The case spectrum in hand surgery is one of extremes-purely elective day surgery cases under local anesthesia to mangling limb injuries that require immediate, and frequently, lengthy, surgery. Despite the cancellation of most elective orthopedic and plastic surgical procedures, hand surgeons around the world continue to see a steady stream of limb-threatening cases such as severe trauma and infections that require emergent surgical care. With the increase in community-spread, an increasing number of COVID-19-infected patients may be asymptomatic or have mild, nonspecific or atypical symptoms. Some of them may already have an ongoing, severe infection. The time-sensitive nature of some of these cases means that hand surgeons may need to operate urgently on patients who may be suspected of COVID-19 infections, often before confirmatory test results are available. General guidelines for perioperative care of the COVID-19-positive patient have been published. However, our practices differ from those of general orthopedic and plastic surgery, primarily because of the focus on trauma. This article discusses the perioperative and technical considerations that are essential to manage the COVID-19 patient requiring emergency care, without compromising clinical outcomes and while ensuring the safety of the attending staff.