Case Report: Sublingual Microcirculatory Alterations in a Covid-19 Patient With Subcutaneous Emphysema, Venous Thrombosis, and Pneumomediastinum

Novelties in the evaluation of microcirculation in septic shock

Microvascular alterations were first described in critically ill patients about 20 years ago. These alterations are characterized by a decrease in vascular density and presence of non-perfused capillaries close to well-perfused vessels. In addition, heterogeneity in microvascular perfusion is a key finding in sepsis. In this narrative review, we report our actual understanding of microvascular alterations, their role in the development of organ dysfunction, and the implications for outcome. Herein, we discuss the state of the potential therapeutic interventions and the potential impact of novel therapies. We also discuss how recent technologic development may affect the evaluation of microvascular perfusion.

A Dangerous Duo: Spontaneous Pneumomediastinum and Venous Thromboembolism at Presentation in a Patient with COVID-19 Pneumonia

Background

Coronavirus disease 2019 (Covid-19) is associated with spontaneous pneumomediastinum (SPM) predominantly in those after positive pressure ventilation (PPV) support. Additionally, many cases of venous thromboembolism (VTE) in COVID-19 patients were described. Our case is the first to describe SPM and VTE present on admission in a patient with Covid -19 pneumonia.

Case report

A 53-year-old man presented to the hospital with escalating dyspnea. Two weeks prior to this visit, he had been evaluated in an ambulatory setting and was started on antibiotics and systemic steroids. In the hospital, this patient was found to be in acute hypoxic respiratory failure and was placed on noninvasive PPV. Diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR) test from nasopharyngeal swab specimen. Chest computed tomography (CT) scan revealed multi-lobar pulmonary emboli (PE) and subcutaneous emphysema with pneumomediastinum. The patient was managed conservatively. He never required closed invasive mechanical ventilation. Subsequent serial imaging displayed the resolution of SPM.

Conclusion

The association between VTE and COVID-19 has been established. This report brings attention to SPM as an additional important complication of COVID-19, even in patients without pre-existing predisposing pathology or exposure to PPV.

Microcirculatory changes and thrombotic complications in COVID-19

Despite its many devastating effects, the COVID-19 pandemic has had a positive impact in the ways in which society, scientific institutions, governing bodies, businesses, educational organisations, and communication have functioned unchallenged over the years. Rapid advancement in science enabled identification and characterisation of the virus and in developing vaccines to combat the disease. The mysterious ways in which the virus attacks the vital organs that lead on to multiorgan failure and thrombosis of the arterial and venous system have also been revealed. The ability to study the microcirculatory changes at the bedside and predict prognosis is a way forward. All the evidence suggests that the outcome of COVID-19 infection is related to the severity of the disease seen in the intensive care unit setting. This article discusses microcirculatory changes and immune coagulopathy caused by COVID-19.

Changes in Hematological, Clinical and Laboratory Parameters for Children with COVID-19: Single-Center Experience

Background

COVID-19 wreaked havoc on the healthcare system, with more than 36 million cases reported globally. Although the pediatric population makes up a lesser proportion of total COVID-19 patients than adults, the clinical status, age and comorbidities warrant identifying possible prognostic factors associated with disease severity in this group. The current study aimed to explore the incidence of thrombosis, overall outcome, and different hematological and coagulation markers in children with COVID-19.

Methods

This is a single-center prospective study of 43 patients (age < 14 years) with confirmed COVID-19 diagnosis recruited from April to August 2020. Data for clinical presentation were collected and analyzed. The samples were tested for different hematological and coagulation markers.

Results

Twenty-nine (67.4%) were symptomatic at presentation, with fever being the most common symptom (n = 23, 53.5%), followed by respiratory (n = 5, 11.6%) and gastrointestinal symptoms (n = 3, 7%). Co-morbid conditions were recorded in 26 (60.5%) patients, with malignancy being the commonest (n = 9, 20.9%). In this cohort of patients with age <14 years, hypertension, respiratory symptoms and ABO group-A were significantly associated with pediatric intensive care unit (PICU) admission during the course of treatment. Patients with elevated FVIII and fibrinogen levels at presentation were more likely to have an extended length of hospital stay (LOS) (P-value =0.036 and 0.032 respectively). No thrombotic event was observed in our cohort. D-dimer values were higher (above 0.5 µg/mL) in 24 (55.8%) patients at admission. We found an association between high D-dimer and PICU admission and LOS.

Conclusion

Although we did not observe thrombosis in our cohort, serial measurements of D-dimer and elevated FVIII bear a prognostic value in predicting the need for critical care in children with COVID-19. Further studies with larger sample size can aid in the establishment of prognostic factors for the pediatric COVID-19 population.

Veno-arterial thrombosis and microcirculation imaging in a patient with COVID-19

The Coronavirus pandemic has brought new challenges in intensive care medicine. Understanding of the pathophysiology of the vascular complications of SARS-CoV-2 infection could bring new resuscitation and therapeutic options. In this case report, we present a patient with COVID-19 pneumonia, who was admitted to our ICU and treated with high-flow nasal cannula, dexamethasone, remdesivir and high-dose prophylactic low molecular weight heparin. During ICU admission, substantial venous and arterial thrombosis developed. Meanwhile the microcirculation showed more than double amount of organ perfusion with very high total vessel density. We hypothesize that this might be a compensatory mechanism for the generalized prothrombic state in which the microcirculation increases the oxygen extraction capacity preventing multi-organ failure.