Images in Vascular Medicine: Peripheral artery thrombosis in critically ill patients with COVID-19

Nuri Tutar, Burcu Baran Ketencioglu, Şahin Temel, Kürşat Gündoğan, Özgür Karabıyık, Murat Sungur


A 75-year-old man with a history of hypertension and type 2 diabetes mellitus presented to the coronavirus disease 2019 (COVID-19) outpatient clinic with a sore throat and cough for 5 days. History was negative for coronary artery disease and he was not taking antiplatelet or anticoagulation therapy on admission. A physical exam was notable for fever (36.9°C, 103.3°F), blood pressure (BP) 120/70 mmHg, and oxygen saturation (SpO2) 96% on room air without tachypnea. His blood examination showed C-reactive protein (CRP) was 91.7 mg/L (normal range: 0–5 mg/L), white blood cell count (WBC) was 9310/mm3 (4800–10,700/mm3) with 1400/mm3 lymphocytes (1300–2900/mm3), and a platelet count was 261 × 109/L (130–400 × 109/L). His chest computed tomography (CT) revealed bilateral ground glass opacities with peripheral and basilar predominance (Panel A-1); nasopharyngeal polymerase chain reaction (PCR) testing for COVID-19 was positive. The patient was hospitalized and started on hydroxychloroquine, levofloxacin, and oseltamivir. His D-dimer was 1630 ng/mL (0–500 ng/mL) and enoxaparin sodium 40 mg once a day was started. On the 5th day of hospitalization, his oxygen requirements increased and the patient was transferred to the intensive care unit (ICU). Favipiravir and piperacillin-tazobactam were started with proning protocols. The patient progressed to SpO2 70% on 100% FiO2 with a non-rebreather mask (NRB) and was eventually intubated. Five days later, darkening and ischemic changes in the right toes developed, consistent with gangrene (Panel A-2). Doppler ultrasound revealed thrombosis in the right great saphenous vein and deep crural veins below the knee; in addition, there was no flow in the right distal dorsalis pedis artery. We did not perform CT angiography because of renal insufficiency…

Vascular Medicine 2020, Vol. 25(5) 479–481
DOI: 10.1177/1358863X20938431
© The Author(s) 2020