Superior Mesenteric Artery Thrombosis Following Severe COVID-19 Pneumonia

Abstract

Thrombotic events are well-recognized complications of coronavirus disease 2019 . The incidence of such complications is highly related to the severity of COVID-19 pneumonia. Recent evidence suggests that the coagulopathy of COVID-19 may persist for some period even after the full recovery from pneumonia. We report the case of a 35-year-old man who presented with a 10-day history of fever and cough. His plain radiograph showed bilateral peripherally located opacities suggestive of COVID-19. The diagnosis was confirmed by the reverse transcriptase-polymerase chain reaction (RT-PCR) for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He was placed on a non-invasive ventilator but it failed to maintain normal oxygen saturation. Hence, the decision for intubation was made. He was extubated after 10 days in the ICU. The patient had a complete recovery. One week after discharge, the patient presented with severe abdominal pain that was out of proportion to the physical examination findings. He had an abdominal CT scan, which demonstrated a large thrombus occluding the superior mesenteric artery. There was no bowel dilatation or focal mural thickening to suggest bowel ischemia. The patient was resuscitated with intravenous fluid hydration. Opioid analgesics were administered to control the pain. After stabilizing the patient, he underwent laparotomy with thrombectomy. The patient tolerated the operation with no complications and had an uneventful recovery. The patient was discharged in good condition with no active issues after four days of hospitalization. The superior mesenteric thrombosis is an unusual complication of COVID-19 pneumonia. This case provides further evidence on the possibility of thrombotic events following the recovery from COVID-19. There is a pressing need for future studies to investigate the role of prophylactic antithrombotic and anticoagulants in patients who recovered from severe COVID-19.

Scoping Review of Clinical Presentations and Outcomes in Patients with Concomitant COVID-19 Infection and Acute Mesenteric Ischaemia

“…These studies underwent full-text evaluation, and a further three studies were retrieved upon screening these studies’ references. Forty-one studies reporting on 44 patients were included in the final selection [ 14 , 16 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. Of these, 32 were case reports, and the remaining 9 were case series.…”

“…Five patients presented with solely respiratory symptoms, and all developed abdominal pain later during their admission [ 43 , 53 , 54 , 65 , 66 ]. Thirteen patients who tested positive for COVID-19 made contact with healthcare services before presenting to the emergency department with gastrointestinal symptoms [ 16 , 30 , 31 , 32 , 35 , 37 , 38 , 40 , 41 , 45 , 48 , 54 , 63 ]. All patients had cross-sectional imaging to confirm the diagnosis of acute mesenteric ischaemia.…”

Acute mesenteric ischemia and COVID-19: an integrative review of the literature

“…Only four reports did not mention the diagnostic method 28 , 52 , 57 , 62 and there was detection of viral RNA in the intestinal mucosa of a patient through the In Situ Hybridization technique, performed due to the high clinical suspicion associated with a previously negative PCR and absence of inflammatory patterns characteristic of COVID-19 on their chest CT 23 . Fever, cough, and dyspnea were the most reported symptoms 7 , 10 , 20 , 24 , 27 , 28 , 30 - 33 , 37 - 39 , 41 , 47 , 48 , 51 , 53 , 54 , 57 - 61 .…”

“…In the studies that cited the gastrointestinal clinical manifestations, the most frequent was abdominal pain with or without other complaints ( Table 1 ), being characterized as intense 7 , 8 , 20 , 24 , 25 , 30 , 31 , 38 , 39 , 41 , 43 , 44 , 51 , 62 , of sudden onset 8 , 31 , 35 , 36 , 38 - 40 , 47 , 58 , 59 , in cramps and without clear triggering factor 34 , 49 , 51 , of diffuse location 8 , 9 , 20 , 28 , 38 , 40 , 41 , 45 , 60 , and epigastric and/or mesogastric 25 - 27 , 49 , 51 .…”

“…He continued with oral anticoagulation for 6 months. Discharge Cheung et al 45 USA 1 55 Abdominal pain and tenderness, nausea and vomiting, diarrhea, decreased BS SMA Thrombosis Therapeutic anticoagulation, SMA thrombectomy, and laparotomy with resection of necrotic bowel NR Nada et al 46 USA 1 49 Abdominal pain, signs of peritonitis SMA thrombosis, signs of intestinal ischemia and pneumatosis, pneumoperitoneum, renal infarction Conservative treatment with LMWH due to advanced intestinal necrosis Death Alali et al 47 Saudi Arabia 1 35 Abdominal pain and tenderness, vomiting SMA Thrombosis Therapeutic anticoagulation, later laparotomy Discharge Khaleghi et al 48 Iran 1 54 Abdominal pain, tenderness and distention, nausea and vomiting SMA thrombosis, bowel loop dilation Laparotomy with resection of necrotic bowel, relaparotomy to assess abnormalities NR Posada-Arango et al 49 Peru 3 62 Abdominal pain, vomiting …”