Splanchnic venous thrombosis in a nephrotic patient following COVID-19 infection: a case report

Abstract

Background As the COVID-19 pandemic spread worldwide, case reports and small series identified its association with an increasing number of medical conditions including a propensity for thrombotic complications. And since the nephrotic syndrome is also a thrombophilic state, its co-occurrence with the SARS-CoV-2 infection is likely to be associated with an even higher risk of thrombosis, particularly in the presence of known or unknown additional risk factors. Lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) are the most common manifestations of COVID-19-associated hypercoagulable state with other venous or arterial sites being much less frequently involved. Although splanchnic vein thrombosis (SVT) has been reported to be 25 times less common than usual site venous thromboembolism (VTE) and rarely occurs in nephrotic patients, it can have catastrophic consequences. A small number of SVT cases have been reported in COVID-19 infected patients in spite of their number exceeding 180 million worldwide. Case presentation An unvaccinated young adult male with steroid-dependent nephrotic syndrome (SDNS) who was in a complete nephrotic remission relapsed following contracting SARS-CoV-2 infection and developed abdominal pain and diarrhea. Abdominal US revealed portal vein thrombosis. The patient was anticoagulated, yet the SVT rapidly propagated to involve the spleno-mesenteric, intrahepatic and the right hepatic veins. In spite of mechanical thrombectomy, thrombolytics and anticoagulation, he developed mesenteric ischemia which progressed to gangrene leading to bowel resection and a complicated hospital course. Conclusion Our case highlights the potential for a catastrophic outcome when COVID-19 infection occurs in those with a concomitant hypercoagulable state and reminds us of the need for a careful assessment of abdominal symptoms in SARS-CoV-2 infected patients.

Elevated Soluble Podoplanin Associates with Hypercoagulability in Patients with Nephrotic Syndrome

“… 30 And since the nephrotic syndrome is also a hypercoagulable state, its co-occurrence with the COVID-19 infection is likely to be associated with an even higher risk of thrombosis. 31 It would be interesting to study PDPN in this setting in future studies.…”

Ultrasound features of abdominal thrombosis in COVID 19 patients

“…Both small and large vessel thrombosis has been reported in patients with COVID-19 [16,17]. Published reports have mentioned VSM, PV, aortic, hepatic artery, splanchnic vein, portomensenteric and ovarian vein thrombosis as a result of the hypercoagulable state due COVID-19 [2,16,[18][19][20][21][22][23][24][25][26]. The digestive manifestations of a SARS-CoV-2 infection are varied and nonspecific.…”

Acute Pediatric Pancreatitis Presenting with Splenic Vein Thrombosis

“…Patients with the following characteristics are suspected of having SVT: patients with a history of pancreatitis or gastrointestinal bleeding; patients with splenomegaly without portal vein hypertension; cirrhosis; or hematologic disease; and finally, patients with gastric varices alone [ 14 ]. SVT presents in most cases with gastric varices [ 15 ]. If there are gastric varices but no esophageal varices, or if gastric varices are more prominent than esophageal varices, then SVT should be suspected [ 15 ].…”

“…SVT presents in most cases with gastric varices [ 15 ]. If there are gastric varices but no esophageal varices, or if gastric varices are more prominent than esophageal varices, then SVT should be suspected [ 15 ]. Patients with SVT can be asymptomatic or can present with a variety of symptoms.…”

“…Patients with SVT can be asymptomatic or can present with a variety of symptoms. These symptoms include abdominal pain, variceal bleeding, splenomegaly, and thrombocytopenia [ 15 ]. In 60% of patients, pancreatitis is the initiating cause of thrombosis.…”