Extensive Aortic Thrombosis in a Patient With COVID-19

To the Editor:

An 83-year-old female nursing home resident with hypertension and type 2 diabetes mellitus was brought to the emergency department by emergency medical services. In the nursing home, blue and pale lower extremities were noted by a physician.

The patient lost consciousness in the ambulance. Asystole as initial rhythm was documented. Return of spontaneous circulation was achieved after 20 minutes of cardiopulmonary resuscitation. The examination revealed a distended abdomen. Laboratory tests showed an elevated WBC count of 20,700/μL (normal range 3,900 to 10,900/μL), Lactate dehydrogenase of 464 U/L (normal range <247 U/L), D-dimer level of 15,280 μg/L (normal range <500 μg/L), and fibrinogen level of 5.60 g/L (normal range 1.8 to 3.5 g/L). Lactate level was 12.9 mmol/L (normal range <2.0 mmol/L). Antithrombin activity was mildly reduced (75%; normal range 80% to 150%). Creatinine and blood urea nitrogen levels were grossly elevated, at 5.62 mg/dL (normal range 0.66 to 1.09 mg/dL) and 299 mg/dL (normal range 21 to 43 mg/dL), respectively.

Contrast-enhanced computed tomography (CT) showed severe aortic thrombosis extending from the lower thoracic aorta just above the diaphragm to the abdominal aorta and the iliac arteries (Figure ). Thrombotic material was particularly noted in the center of the aortic lumen, leaving variable amounts of contrast flowing within a thin lamella between the thrombus core and the aortic wall. This pattern was observed at the caudal end of the scan volume, leaving the overall impression of subtotal abdominal aortic and pelvic artery occlusion.

Figure.

Curved coronal multiplanar reformation of the CT angiogram showing extensive thromboembolic material, particularly in the center of the abdominal aortic lumen, extending into the iliac arteries with subtotal occlusion (arrows). The image also depicts numerous and diffusely distributed microinfarctions within the left side of the renal cortex (asterisks).

The superior mesenteric artery and right renal artery were completely occluded. Intestinal pneumatosis and dilatated paralytic small bowel loops with reduced mural enhancement were in keeping with acute mesenteric ischemia. Chest computed tomography pulmonary angiogramm revealed subsegmental pulmonary embolism in the posterobasal right lower lobe segment and in the posterior upper lobe on the left side, as well as patchy coalescing consolidations and ground-glass opacities, respectively, in the right upper and middle lobe, compatible with atypical pneumonia.

An oropharyngeal swab result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction testing was positive.

In the ICU, the patient required increasing doses of vasopressors. Based on the patient’s goals of care, comfort measures were instituted.

Emerging evidence shows that severe coronavirus disease 2019 has a prothrombotic effect, predisposing to high risk of venous thromboembolism.¹ Our report highlights the importance of considering arterial thrombosis in patients with severe disease.