Spontaneous aortic thrombosis in neonates: a case report and review of literature

Feline Aortic Thromboembolism: Recent advances and future prospects

PRACTICAL RELEVANCE

Feline aortic thromboembolism (FATE) is commonly encountered in clinical medicine, especially in emergency situations. This often devastating syndrome usually develops secondarily to severe heart disease, and has short- and long-term consequences.

CLINICAL FEATURES

The clinical presentation of FATE is consistent with peripheral ischemic neuropathy, usually in both pelvic limbs. Diagnosis is relatively straightforward, but can be assisted with Doppler ultrasound, point-of-care ultrasound or infrared thermal imaging.

RECENT ADVANCES AND FUTURE PROSPECTS

Interpretation of survival rates in cats with FATE has been hampered by historically high admission euthanasia, but recent studies suggest a survival rate with supportive care of 30-40%. Moreover, with advances in post-FATE thromboprophylaxis, median survival times of over 1 year are being achieved. Future directions include use of thrombolytic agents and treatment of common FATE sequelae such as acute kidney injury and reperfusion injury.

OUTLINE

This article, aimed at small animal veterinarians, including emergency practitioners, reviews key aspects of the clinical presentation, diagnosis and treatment options for FATE, with a view to guiding client and veterinarian decision-making. Three case studies are included to illustrate the practical application of information presented in the review.

EVIDENCE BASE

There are limited prospective studies on FATE, although the recent literature reflects a resurgence in clinical research interest in the past few years. Advances in FATE treatment will benefit many cats and it is important that research efforts continue to identify appropriate treatment modalities.

Aortic thrombosis in a neonate with COVID-19-related fetal inflammatory response syndrome requiring amputation of the leg: a case report

Neonatal infection with SARS-CoV-2 is considered to have no major complications. A neonate with lower limb gangrene owing to spontaneous aortic thrombosis in the setting of a fetal inflammatory response syndrome (FIRS) post-intrauterine COVID-19 infection is presented. A healthy full-term newborn discharged from hospital on Day 3 developed irritability and progressive blackish discoloration of the toes of the right lower limb on Day 6 of life. Doppler imaging revealed acute thrombosis of the abdominal aorta with a critically ischaemic right lower limb. On Day 11 of life, SARS-CoV-2 RT-PCR was negative but total antibodies (IgG and IgM) were positive in both mother and neonate. The neonate showed raised inflammatory markers including CRP, ESR, interleukin-6, procalcitonin, ferritin and LDH along with elevated N-terminal pro-brain natriuretic peptide and D-dimer. In the absence of clinical signs of sepsis, FIRS was diagnosed. The neonate was treated with corticosteroids, heparin infusion and recombinant tissue plasminogen activator, and required surgical embolectomy followed by right limb amputation. By Day 31 of life, inflammatory markers showed serial return to normal and the neonate was discharged on oral steroids and aspirin. Intrauterine SARS-CoV-2 infection may trigger a systemic inflammatory response in some fetuses which is similar to post-COVID-19 multisystem inflammatory syndrome in children (MIS-C). Development of lower limb gangrene is a unique COVID-19-related neonatal complication and is attributed to thrombo-inflammation.ABBREVIATIONSCRP: C-reactive protein; FIRS: fetal inflammatory response syndrome; MIS-C: multisystem inflammatory syndrome in children; NT-proBNP: N-terminal pro-brain natriuretic peptide; RT-PCR: real-time polymerase chain reaction.

Case of right ventricular and aortic thrombi in a patient with severe COVID-19

Emerging evidence suggests that novel COVID-19 is associated with increased prothrombotic state and risk of thromboembolic complications, particularly in severe disease. COVID-19 is known to predispose to both venous and arterial thrombotic disease. We describe a case of a 61-year-old woman with history of type II diabetes, hypertension and hyperlipidaemia who presented with dry cough and acute abdominal pain. She was found to have a significantly elevated D-dimer, prompting imaging that showed thrombi in her right ventricle and aorta. She had rapid clinical deterioration and eventually required tissue plasminogen activator with subsequent durable clinical improvement. This case highlights a rare co-occurrence of venous and arterial thrombi in a patient with severe COVID-19. Further studies are needed to clarify the molecular mechanism of COVID-19 coagulopathy, the utility of D-dimer to predict and stratify risk of thrombosis in COVID-19, and the use of fibrinolytic therapy in patients with COVID-19.