Hyperacute multi-organ thromboembolic storm in COVID-19: a case report

Abstract

Acute viral pneumonia, hypoxemic respiratory failure and severe inflammatory response are hallmarks of severe coronavirus disease 2019 (COVID-19). The COVID-19-associated inflammatory state may further lead to symptomatic thromboembolic complications despite prophylaxis. We report a 66-year-old female patient with post-mortem diagnosis of COVID-19 who presented progressive livedo racemosa, acute renal failure and myocardial injury, as well as an absence of respiratory symptoms. Transthoracic echocardiography showed severe spontaneous echo contrast in the right cardiac chambers and right-sided cardiac overload presumed to result from pulmonary microvascular thrombosis or embolism. d-dimer levels were increased. The patient developed an acute ischemic stroke and died 2 days following presentation despite therapeutic anticoagulation. Her predominantly thromboembolic presentation supports the concept of coronavirus infection of endothelial cells and hypercoagulability, or COVID-19 endotheliitis. The case we report highlights that COVID-19-associated hyperacute multiorgan thromboembolic storm may precede or present disproportionately to respiratory involvement. Keywords COVID-19 • Thromboembolism • Spontaneous echo contrast Highlights • Thromboembolic complications of COVID-19 may precede respiratory symptoms. • Direct endothelial cell infection and hypercoagulability may cause COVID-19-associated thromboembolisms. • Multi-organ thromboembolisms may occur despite therapeutic anticoagulation. • Future studies should prospectively assess thromboembolic prophylaxis and treatments in COVID-19.

Predictors of COVID‐19 severity: A literature review

“…Furthermore, restored platelet counts during hospitalization have been shown to predict survival 65 . Studies suggest that patients with severe COVID‐19 develop hypercoagulability rather than consumptive coagulopathy, resulting in excessive fibrin polymerization and elevated risk of thrombosis 66‐69 . Similarly, high levels of Factor VIII, a procoagulant acute phase reactant and low Protein C activity, an endogenous anticoagulant, have been described in some critically ill patients, suggesting that these biomarkers may be useful to predict COVID‐19 severity 70 .…”

Cutaneous Manifestations in Adult Patients with COVID-19 and Dermatologic Conditions Related to the COVID-19 Pandemic in Health Care Workers

“…Livedo reticularis or racemosa is defined by a mottled, lace-or net-like vascular pattern of erythematous to violaceous discoloration associated with ischemia of the cutaneous capillaries. Compared with other cutaneous findings in COVID-19, livedo reticularis seems less common (2.3%) but associated with more severe disease and possibly greater mortality [3,4,77]. Livedo eruptions are described in multiple case reports potentially due to inflammation caused by SARS-CoV-2 binding to vascular endothelium (Table 2) [31,33,77,78].…”

“…Compared with other cutaneous findings in COVID-19, livedo reticularis seems less common (2.3%) but associated with more severe disease and possibly greater mortality [3,4,77]. Livedo eruptions are described in multiple case reports potentially due to inflammation caused by SARS-CoV-2 binding to vascular endothelium (Table 2) [31,33,77,78]. Patients may be at risk for massive systemic thromboembolic events and multi-organ involvement [34,77].…”

“…Livedo eruptions are described in multiple case reports potentially due to inflammation caused by SARS-CoV-2 binding to vascular endothelium (Table 2) [31,33,77,78]. Patients may be at risk for massive systemic thromboembolic events and multi-organ involvement [34,77].…”

Sex differences underlying preexisting cardiovascular disease and cardiovascular injury in COVID-19

“…Histology on post-mortem lungs and skin from COVID-19 patients revealed thrombogenic vasculopathy [ 93 , 94 ]. Moreover, thromboembolisms have been observed in several organs in COVID-19 patients [ [95] , [96] , [97] ]. Overall, 20–30% of COVID-19 patients in the ICU have been reported to suffer from thrombosis and major thromboembolic sequelae [ 7 ].…”