A 61-Year-Old Man with SARS-CoV-2 Infection and Venous Thrombosis Presenting with Painful Swelling and Gangrene of the Lower Limb Consistent with Phlegmasia Cerulea Dolens

Abstract

Patient: Male, 61-year-old Final Diagnosis: Phlegmasia cerulea dolens Symptoms: Bilateral leg swelling • breathlessness • cough • fever Medication: — Clinical Procedure: — Specialty: Cardiology • Infectious Diseases • Medicine, General and Internal Objective: Rare disease Background: Coronavirus disease 2019 (COVID-19) is a novel infectious disease with an evolving understanding of its clinical manifestations, complications, and therapeutic implications. Thromboembolic disease and coagulopathy are common and have been seen in COVID-19 patients. Phlegmasia cerulea dolens had been reported in previous cases associated with malignancy which is a known cause of a procoagulable state. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may also induce a procoagulable state and be associated with PCD. Case Report: A 61-year-old man presented with a painful, swollen limb and gangrene, findings consistent with a diagnosis of PCD due to venous thrombosis. The patient tested positive for SARS-CoV-2 infection after a nasopharyngeal swab sample using the XPRSARS-COV2-10 reverse transcription polymerase chain reaction kit. He had bilateral leg swelling with a gangrenous left fourth digit in the presence of a palpable peripheral pulse. His venous duplex showed bilateral acute deep venous thrombosis, whereas his arterial Doppler scan was normal and his skin biopsy was negative for vasculitis. One of our screening blood tests was suggestive of an antiphospholipid-like syndrome. These clinical and radiologic findings were consistent with PCD. This patient was promptly anticoagulated; other supportive treatments were also initiated. He had a significant resolution of his pedal swelling with the associated revitalization of his previously gangrenous toe. Conclusions: This case report shows the importance of testing for SARS-CoV-2 infection in patients who present with unusual thrombotic symptoms and signs and highlights the potential severity of these thrombotic complications.

A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy

“…Symptom's from DVT can present on a scale of asymptomatic with minor limb swelling, to more life threating complications such as pulmonary embolism, or local limb complications such as phlegmasia cerulean dolens (PCD) [ 8 , 9 ]. The pathophysiology behind PCD includes an extensive iliofemoral DVT causing severe venous outflow obstruction, leg edema, impaired arterial flow due to compartment syndrome causing tissue ischemia and ultimately venous gangrene [10] .…”

Corona Virus Disease 2019 (COVID-19) as a System-Level Infectious Disease With Distinct Sex Disparities

“…In some clinical patients with SARS-CoV-2 infection, acral gangrene in hypercoagulation state has been described pathophysiologically, indicating that coagulation is the most significant cause of vascular thrombosis and venous gangrene in COVID-19 cases (149). Of note, the serological observations of these COVID-19 patients revealed increased D-dimers associated with antithrombin III deficiency, illustrating wide vascular microthrombi and necrosis in skin biopsy (148,149). Finally, Similar to COVID-19 non-survivors, DIC is one of the major complications reported in fatal MERS-CoV cases.…”

“…Third, hospitalized severe COVID-19 patients are more likely to have risk factors such as advanced age, underlying diseases, long-term bed rest, and receiving invasive treatment, which are risk factors for hypercoagulability or thrombosis. To point out, the dissection of the lungs of critically ill patients with COVID-19 shows occlusion of small pulmonary vessels and microthrombosis ( 148 ). Fourth, some patients may develop septic coagulopathy or even DIC.…”

Venous gangrene associated with COVID-19: Successful limb preservation strategies with optimal wound management

“…Furthermore, pedal gangrene associated with VTE in the context of COVID-19 infection has been reported in some case reports. 8 , 9 , 10 , 11 , 12 Currently, methods such as anticoagulation alone, mechanical thrombectomy, catheter-directed thrombolysis, prone positioning with veno-venous extracorporeal membrane oxygenation, and amputation have been trialed with varying levels of success. 8 , 9 , 10 , 11 , 12 In other similar reports, COVID-positive patients with concomitant VTE and arterial thromboembolism (ATE) ultimately required more proximal amputation in the acute setting.…”