COVID-19 With Limb Ischemic Necrosis

To the Editor:

A 53-year-old man from Wenzhou, Zhejiang, China was admitted to the First Affiliated Hospital of Wenzhou Medical University on February 1, 2020, with a 9-day history of fever with dizziness, cough, and sputum. On presentation, his temperature was 38.6°C. Laboratory tests showed a C-reactive protein concentration of 70.5 mg/L (normal range, 0.00-10.00 mg/L). Complete blood count showed elevated white blood cell count (14.9 × 10⁹/L [normal range, 3.5-9.5 × 10⁹/L]), neutrophils (14.2 × 10⁹/L [1.8-6.3 × 10⁹/L]), and monocytes (0.42 × 10⁹/L [0.1-0.6 × 10⁹/L]). D-dimer was 0.68 mg/L (0.00-0.5 mg/L) and platelet count was 163 × 10⁹/L, whereas the lymphocyte count (0.25) decreased (normal range, 1.0-3.2 × 10⁹/L). The computed tomography scan presented multiple ground-glass opacities with consolidation and bilateral lung involvement. The patient was diagnosed with coronavirus disease 2019 (COVID-19) on the basis of reverse transcription-polymerase chain reaction (RT-PCR) analysis of sputum samples. The patient developed complications including septic shock, multiple organ dysfunction syndrome, acute respiratory distress syndrome, thrombocytopenia, acute kidney injury, and catheter-related infections. The patient was treated with antibacterial, antiviral, and corticosteroid treatments, mechanical ventilation, and extracorporeal membrane oxygenation.

During hospitalization, peripheral ischemia appeared on the right fingers and toes and gradually resulted in gangrene (Fig 1, Fig 2 ). Beginning on February 29th, the patient's right fingertip began to show a slight cyanosis, and on March 7th, the patient's right fingertip cyanosis continued to progress and the boundaries were clear (Fig 1). After March 10th, the patient started to develop black gangrene-like manifestations on his fingertips (Fig 2).

Fig 1.

Right fingers showed cyanosis.

Fig 2.

Black gangrene-like manifestations on the fingertips.

Limb ischemic necrosis is a rare but dreadful complication. Tissue necrosis in the fingers was irreversible. Although the precise mechanism of limb ischemic necrosis is unclear, this may be related to high-dose use of norepinephrine.¹ Acute ischemic hepatitis (“shock liver”) has been identified as a potential risk factor for limb ischemic necrosis or symmetrical peripheral gangrene.² The previous study shows that abnormal coagulation results, especially markedly elevated D-dimer and fibrin degradation product, are common in deaths with COVID-19.³ Therefore, the occurrence of limb ischemic necrosis in COVID-19 patients should be monitored closely.