Incidental and Asymptomatic Splenic Infarction and Infrarenal Thrombus in a COVID-19 Patient

Abstract

The cytokine storm associated with coronavirus disease 2019 (COVID-19) triggers a hypercoagulable state leading to venous and arterial thromboembolism. Lab findings associated with this phenomenon are elevated D-dimer, fibrinogen, C-reactive protein (CRP), ferritin, and procalcitonin. We present the case of a 66-year-old male with dyslipidemia who was diagnosed with COVID-19 with worsening shortness of breath, myalgia, and loss of taste. Physical examination was remarkable for crackles with diminished lung sounds and use of his accessory muscles. Labs showed normal white blood cell count, D-dimer of 1.42 mg/L, ferritin of 961 ng/mL, lactate dehydrogenase (LDH) of 621 U/L, and CRP of 2.1 mg/dL. Chest X-ray showed atypical pneumonitis with patchy abnormalities. He required oxygen supplementation with fraction of inspired oxygen of 100% proning as tolerated. He received remdesivir, ceftriaxone, azithromycin, dexamethasone, prophylactic enoxaparin, and a unit of plasma therapy. His D-dimer had increased from 1.65 to 3.51 mg/L with worsening dyspnea. At this time, computed tomography angiogram (CTA) of the chest showed extensive ground-glass opacities and a 2.4 × 1.9 × 1.3 cm distal thoracic aortic intraluminal thrombus. He was started on a heparin drip. A follow-up CTA of the aorta showed thrombus or hypoattenuation within the splenic artery and wedge-shaped areas extending from the hilum with possible infarction and a 6 mm thrombus in the infrarenal abdominal aorta. He was transitioned to enoxaparin 1 mg/kg twice daily. He remained asymptomatic from his splenic infarction. This case adds more insight to splenic infarction associated with COVID-19 in addition to the 32 reported cases documented thus far. Management of thromboembolism includes a therapeutic dose of anticoagulation. To prevent thromboembolism, prophylactic anticoagulation is recommended for those hospitalized with COVID-19.

COVID-19 and Cavitary Lesion in Lung

“…For non-critically ill patients hospitalized with COVID-19, a high index of suspicion is necessary for detecting thromboembolism, especially when the patient presents with acute abdominal pain, chest pain, or lower extremity pain [ 17 , 18 ]. Therapeutic-dose heparin appears beneficial, with a high probability of reducing the need for organ support and the progression to intubation and death, regardless of D-dimer results [ 19 ].…”

Splenic Infarction with Myocardial Injury in a Diabetic Patient: A Case Report

“…10 Symptomatic arterial thrombosis is diagnosed clinically combined with imaging of CTA, which is preferable, while asymptomatic and atypical splenic infarction was discovered incidentally on CTA. 11 The causes of SI include atherosclerotic embolus, hypercoagulation-related diseases such as cancer, arterial damage, abnormal clotting factors, and inflammation. In a retrospective study of patients with SI, Wand et al suggested that SI could be the initial presentation of previously unknown medical conditions in 38% of patients.…”

“… 10 Symptomatic arterial thrombosis is diagnosed clinically combined with imaging of CTA, which is preferable, while asymptomatic and atypical splenic infarction was discovered incidentally on CTA. 11 …”

A Pictorial Essay Describing the CT Imaging Features of COVID-19 Cases throughout the Pandemic with a Special Focus on Lung Manifestations and Extrapulmonary Vascular Abdominal Complications

“…Splenic and renal infarction are rare ischemic abdominal complications in COVID-19 patients and have only been presented in case reports and a few case series [ 147 , 149 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 ]. Splenic and renal infarctions generally have a minor clinical impact compared to intestinal infarction.…”