The thromboembolic nature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been established since the onset of the global coronavirus 2019 (COVID-19) pandemic. Mesenteric artery thrombosis and acute mesenteric ischemia, by themselves, are rare and often present with fatal gastrointestinal (GI) diseases that require prompt identification and physician intervention to improve clinical outcomes. SARS-CoV-2 infection can present with acute gastrointestinal disease and requires further investigation regarding anticoagulant therapy in patients infected with COVID-19. We report a 64-year-old woman with SARS-CoV-2 who suffered from superior mesenteric artery thrombosis and acute intestinal ischemia.
Infection with the coronavirus disease 2019 (SARS-CoV-2) coronavirus 2 (SARS-CoV-2) has been increasingly associated with coagulopathy and thrombotic complications. Although pulmonary presentations of the disease predominated, extrapulmonary complications have also been reported in individuals with confirmed COVID-19. [1,2]. Acute mesenteric ischemia (AMI) is a less common thrombotic complication, and is described in a few case reports. but with high rates of morbidity and mortality [1,2,4]. This report describes a patient with COVID-19 presenting with superior mesenteric artery thrombosis (SMA) and acute intestinal ischemia.
A 64-year-old woman with a previous medical history of hypertension and diabetes presented to the emergency department after two days of experiencing constipation, abdominal pain and bloating. While waiting at triage, the patient collapsed and became unresponsive. He was found to have hypotension with a Glasgow Coma Scale (GCS) of 5, and she was quickly taken to a shock bay, intubated, and began to compress the vessels. Laboratory work was significant for lactic acid of 9.6 mmol/L, a predominantly neutrophilic leukocytosis of 19.37 x 10^3 cells/L, elevated D-dimer >20 μg/ml, and SARS-CoV-2 detected on BioFire® Respiratory panel (BioFire Diagnostics, Salt Lake City, Utah, USA). The electrocardiogram showed sinus tachycardia and there was a slight elevation of troponin, consistent with type II myocardial infarction (MI). Abdominal and pelvic computed tomography with contrast was significant for pneumonia disseminated into loops of the small intestine in the left lower quadrant and pelvis (Figs. 1And the 2) as well as decreased caliber of the diffuse ventral axis and superior mesenteric artery with the presence of air pockets in the mesenteric vessels in the left lower quadrant (Figs. 3And the 4).
These findings were highly suggestive of non-obstructive intestinal ischemia and the patient was taken for an urgent exploratory laparotomy. At that time, the patient was discovered to have ischemia in the SMA distribution area, which was removed, along with ischemia of the large intestine resulting in the resection of the entire colon; The patient was left with an estimated 150 cm of viable small intestine upon closure. The ABTHERA™ vacuum-assisted wound closure device (Acelity LP Inc., San Antonio, TX, US) was placed and the patient was returned to the Intensive Care Unit for follow-up follow-up and care. Over the next two days after surgery on high-dose vasoconstrictors, the patient continued to deteriorate with progressive failure of several organs. The patient was taken for an urgent second exploratory laparotomy, which was significant for a 1 cm area of necrosis on the anterior aspect of the rectal stump. As a result, the rectal stump was excised, effectively removing the ischemia area. However, the patient continued to deteriorate clinically. Nine days after his admission to the hospital, the patient’s family decides to take only comfortable care measures, after which the patient quickly expires.
It has been suggested that SARS-CoV-2-induced thrombosis is due to microcirculatory changes. One hypothesis suggests that viral replication causes inflammatory cells to infiltrate the endothelium leading to endothelial apoptosis and subsequent microvascular thrombosis events. . In addition, SARS-CoV-2 has been shown to act on the ACE-2 receptors in the lungs, which are also found in the vascular endothelium and in enterocytes of the small intestine, supporting the microvascular coagulation effects of SARS-CoV-2 on small vessels. . Intestine . Presentation of pulmonary embolism accounts for the majority of coagulopathy associated with COVID-19; However, there have been reported cases including venous thromboembolism, arterial thrombosis, myocardial infarction, stroke, and microvascular thrombosis. .
Infection with SARS-CoV-2 is caused by inhalation of aerosol droplets and is primarily characterized by respiratory symptoms. Gastrointestinal manifestations of COVID-19 such as nausea, vomiting, diarrhea, and abdominal pain have been documented; However, the true prevalence of gastrointestinal symptoms among patients infected with the COVID-19 virus is unknown, ranging from less than 10% to 70% in various reports. [3,7]. While AMI is rare and is generally less than 1%, AMI in the case of COVID-19 warrants a high degree of suspicion to avoid harmful, and possibly fatal complications. . Patients recently medically treated in hospital for COVID-19 prophylactic extended-release with randomized and controlled rivaroxaban (MICHELLE) therapy indicate improved clinical outcomes with prolonged use of rivaroxaban anticoagulant in high-risk patients after hospital discharge, supporting prevention Anticoagulant for patients at increased risk of thromboembolism .
As SARS-CoV-2 continues to create a significant burden on healthcare, many unexpected disease manifestations continue to be described. Thromboembolic presentations of the virus, such as AMI, present significant clinical challenges to clinicians due to their catastrophic and unpredictable nature. Early recognition of AMI and identification of those most at risk is important for prompt clinical diagnosis and treatment, which may lead to better clinical outcomes. Future investigation regarding anticoagulant prophylaxis in patients infected with COVID-19 is warranted considering the individual patient risks and elevated morbidity and mortality associated with AMI.