A case presentation of a 29-year-old male suffering from COIVD-19 pneumonia who developed acute leg pain.
An otherwise healthy, 29-year-old Bangladeshi male was brought to the emergency department with complaints of breathlessness and hypoxemia for the past 6 days. The patient was admitted to the hospital with a suspicion of COVID 19 infection. The patient had no significant past medical, surgical, or psychiatric history.
The patient had no complaints and was doing fine until 6 days before the presentation when he developed fever and cough.
On examination in the emergency department, the patient appeared ill and lethargic, but conscious. His vitals revealed a body temperature of 38.8 °C, heart rate of 110 beats per minute, a blood pressure of 120/80 mmHg, and a respiratory rate of 30 breaths per minute. Pulse oximetry showed an oxygen saturation of 94% while the patient was receiving supplemental oxygen through a nasal cannula at a rate of 4 liters per minute.
Initial serological investigation showed the following results:
- Hemoglobin 14.1 g/dL (13-17 g/dL)
- Total leukocyte count 5.64 × 10^3 /μL (4-11 × 10^3/μL)
- Absolute neutrophil count 4.51 × 10^3/μL (2-7 × 10^3/μL)
- Absolute lymphocyte count 0.718 × 10^3/μL (1.5-4 × 10^3/μL)
- Platelets 145 × 10^3/μL (150-450 × 10^3/μL)
- Blood urea nitrogen 13.74 mg/dL (8.9-20.6 mg/dL)
- Serum creatinine 0.75 mg/dL (0.7-1.3 mg/dL )
- Prothrombin time 12.40 sec (11.5-15 sec)
- Partial thromboplastin time 40.80 sec (26-40 sec)
- International normalized ratio 0.92 (0.9-1.1)
- D-dimer 0.47 ug/mL (0-0.5 ug/mL)
- Creatine kinase 83 U/L (30-200 U/L)
- Lactate dehydrogenase 383 U/L (125-243 U/L)
- Ferritin level 1073.20 ng/mL (21.81-274 ng/mL)
- C-reactive protein 9.260 mg/dL (< 1).
A nasopharyngeal sample was collected via swab. Nucleic acid testing of the sample was positive for SARS-CoV-2 but it was negative for influenza A and B viruses and respiratory syncytial virus.
Imaging Studies:
Bilateral patchy airspace opacities were identified on the chest radiography.
The electrocardiogram showed sinus tachycardia of 115 beats/minute.
Management:
The patient was started on empirical therapy with ceftriaxone, azithromycin, and hydroxychloroquine. He was also given acetaminophen to control the body temperature.
During the hospital stay on the fourth day, the patient complained of abrupt onset of severe pain in the left arm with a bluish hue to the skin. On examination of the limb, obvious cyanosis was noticed and the radial and brachial pulses were absent.
A diagnosis of acute upper limb ischemia was made.
The patient was started on heparin was taken to the operating room for emergency embolectomy by a vascular surgeon. Embolectomy is the procedure by which an embolus or blood clot, which is obstructing the blood flow is removed from the vessels. The embolus blocks the blood passage, consequently leading to ischemia and infarction. In emergent cases, embolectomy can be life- and limb-saving
On the first post-op day, the radioulnar pulses on the left side were palpable with clips removed. He was started on oral Warfarin, an anticoagulant.
An echocardiogram was performed which showed normal LV systolic function with an ejection fraction of 55%, normal LV internal dimensional, no RSWMA, normal mitral and aortic valve morphology, and functionality but mild tricuspid regurgitation was appreciated. No masses, effusion, or thrombi were noticed.
Ten days after the embolectomy, the patient was discharged with a prescription of regular oral anticoagulants.
References:
Alosaimi R, Albajri A, Albalwi RM (2020) Acute Upper Limb Ischemia in a Patient with COVID-19 Pneumonia. Clin Med Rev Case Rep 7:317. doi.org/10.23937/2378-3656/1410317
