MESENTERIC ISCHEMIA AND COVID-19. A CASE REPORT
..................
Ana
María Pérez Murcia ¹, Paula
Daniela Nieto-Zambrano ², Carlos
Alfonso Madariaga Carocci ³
,
Héctor Fabio Restrepo ²,
Adriana Rojas-Villarraga ²
Abstract
Introduction. Coronavirus
disease 2019 (COVID-19) is characterized by generating adult
respiratory
distress syndrome and multi-organ dysfunction, but it also has a
prothrombotic effect that must be
considered for the correct approach with patients.
Clinical case.
50-year-old patient who consulted
due to a 4-day clinical febrile syndrome and pain in the lower abdomen.
In the review by systems, he
referred dysgeusia, anosmia and occasional dry cough. Initial
paraclinical tests showed, polyglobulia,
thrombocytosis, elevated D-dimer, and arterial gases with respiratory
alkalemia. Chest computed tomography (CT) was compatible with viral
pneumonia and the contrast abdominal CT had evidence of
mesenteric ischaemia. Intraoperative findings of multiple thrombi at
the mesentery level.
Discussion.
The prothrombotic state induced by COVID-19 has been predominantly
described in the venous system, but we must not ignore its arterial
involvement even in unusual sites, since if it is not suspected it
can generate fatal consequences for patients.
Keywords: Mesenteric Ischemia; COVID-19; SARS-CoV-2
..............
¹ Servicio de Medicina Interna, Hospital de San José.
Especialista Docencia Universitaria. Fundación Universitaria de
Ciencias de
la Salud.
² Vicerrectoría de investigaciones. Fundación Universitaria de
ciencias de la Salud.
³ Servicio de Medicina Interna, Hospital de San José.
Fundación Universitaria de Ciencias de la Salud.
ISQUEMIA MESENTÉRICA Y COVID-19.
REPORTE DE CASO
Resumen
Introducción. La enfermedad por
coronavirus 2019 (COVID-19) se caracteriza por generar
síndrome de dificultad respiratoria del adulto y disfunción
multiorgánica, sin embargo, tiene
un efecto protrombótico que se debe tener en cuenta para un adecuado
abordaje de los pacientes.
Presentación
del caso:
Individuo masculino de 50 años, asiste por clínica de 4 días de
fiebre y dolor en hemiabdomen inferior. En la revisión por sistemas
reveló disgeusia, anosmia
y tos seca ocasional. Exámenes paraclínicos iniciales reportaron
poliglobulia, trombocitosis,
dímero D elevado y gases arteriales con alcalemia respiratoria. La
tomografía de tórax compatible con neumonía viral y tomografía de
abdomen contrastada con evidencia de isquemia
mesentérica. Los hallazgos intraoperatorios fueron múltiples trombos a
nivel del mesenterio.
Discusión. El estado
protrombótico inducido por la COVID-19 se ha descrito predominantemente
en el sistema venoso, pero no se debe dejar de lado su compromiso
arterial, ya que si
no se sospecha puede generar consecuencias fatales para los pacientes.
Palabras clave: Isquemia Mesentérica; COVID-19;
SARS-CoV-2.
..................
Introduction
The first pandemic of the century; COVID-19 (Coronavirus 2019) caused
by the new SARS-CoV-2 (severe acute
respiratory syndrome coronavirus 2), a virus belonging
to the
Coronaviridae family
of the B-coronavirus subgroup
(1), is currently recognized worldwide for the high mortality secondary
to the systemic inflammatory reaction
and the adult respiratory distress syndrome that it generates.
Following the Middle East respiratory syndrome
(MERS-CoV) and the severe acute respiratory syndrome
(SARS-CoV), SARS-CoV-2 is the third coronavirus to
cause infection worldwide in the last 20 years.
In a study conducted in Milan, Italy, a general decrease in emergency
surgical procedures was identified
in 2020 compared to 2019, however, an increase was
identified in certain procedures, within which a significant increase
was found (p= 0,002) in the interventions
secondary to acute mesenteric ischaemia. Although
the authors do not describe a clear explanation (2),
they propose as possible hypotheses, the participation
of the thrombogenic effect of COVID-19 or the possible dietary changes
during the pandemic. To date, there is some data on mesenteric
ischaemia in COVID-19,
extracted from several published cases and grouped
through systematic reviews (3,4).
The following is a case of an unusual thromboembolic
event manifested by mesenteric thrombosis in a patient
with positive reverse transcription-polymerase chain
reaction (RT-PCR) for SARS-CoV-2.
Clinical Case
A 50-year-old overweight male from a rural area
with otherwise unremarkable past medical history,
consulted due to a four day history of fever with
peaks quantified up to 39° Celsius (C), unresponsive
to antipyretics. At 48 hours after the onset of fever,
he presented continuous abdominal pain, located in
the lower quadrants of moderate intensity, aggravated with food intake,
and without improvement after self-prescribed intramuscular
administration of
non-steroidal anti-inflammatory drugs. Additionally,
presented numerous foamy and non-bloody diarrheal
stools, that spontaneously resolved. Later the pain
intensifies and generalizes to the entire abdomen,
for which he consults to the emergency department.
When inquiring into the systems review, the presence
of anosmia, dysgeusia, and occasional non-cyanotic
or emetizing dry cough were established, which began two days before
the consultation.
Physical examination on admittance, revealed the
patient was tachycardic (120 beats per minute), normotensive, with a
fever of 37.5 °C axillary, tachypneic
(25 breaths per minute), with adequate oxygen saturation at room air,
and a regular general condition with
grimacing. Cardiopulmonary without alterations, flat
abdomen, gastrointestinal sounds present, normotympanic, painful on
deep and superficial palpation, with
generalized muscular defense, and a rebound tenderness in all four
quadrants.
Laboratory values indicated polyglobulia and thrombocytosis in the
hemogram, elevated D-dimer, arterial
gases with respiratory alkalemia, without oxygenation
disorder, and hyperlactatemia, with amylase levels
three times higher than the normal value, and positive
RT-PCR for SARS-CoV-2. Imaging studies with high
resolution chest computed tomography (CT) identified predominantly
peripheral ground glass pattern
in both lung fields compatible with viral pneumonia
(Figure 1) and; the contrast abdominal CT showed
diffuse hepatic steatosis, concentric and diffuse thickening of the
proximal ileum walls reaching a maximum
thickness of 12 millimeters (mm) in a long segment
of approximately 30 centimeters (cm), engorgement
of mesenteric vessels, inflammatory changes in fat,
opacification defects corresponding to thrombi in the
mesenteric artery, 1 cm above from its origin occluding
approximately 60% of the vessel’s lumen in a segment
with a length of 12 mm and another more distal at the
height of the ileal arteries branching that occludes approximately 80%
of the vessel’s lumen, and dilation of
jejunal and ileal thin intestinal loops reaching a maximum transverse
diameter of 38 mm, no transitional
areas were observed (Figure 2).
The patient was taken to emergency laparotomy, with
intraoperative findings of 200 cubic centimeters of peritoneal fluid
with evidence of perforation, additionally a 40 cm area of ischaemia at
the level of the ileum
at 80 cm from the ligament of the Treitz angle, with
multiple thrombi to level of the mesentery, for which
they performed a 40-cm intestinal resection with an
end-to-end ileal ileus anastomosis plus peritoneal lavage and abdominal
wall closure. He required surveillance in the intensive care unit (ICU)
and later in a
general ward, with analgesia and from the respiratory
point of view only required oxygen through a nasal
cannula at 2 liters per minute. He was discharged after
7 days, with indication of outpatient anticoagulation
with low molecular weight heparins.
Discussion
This study describes the clinical evolution of a case
of mesenteric ischaemia in a patient who underwent
RT-PCR for SARS-CoV-2 with a positive result during
hospitalization. Upon admission, COVID-19 infection
was not suspected, however, upon review of systems,
symptoms suggestive of mild respiratory infection
were found. This proposes that in the context of a pandemic, it is
necessary to systematically carry out
a complete interrogation and physical examination
to guide a possible positive case and to avoid possible
complications associated with thrombosis.
Figure 1. High-resolution chest computed tomography. Axial view.
The arrows show areas in both lung fields of
subpleural ground glass pattern and basal subsegmentary atelectasis.
Findings are suggestive of viral pneumonia
secondary to COVID-19.
Figure 2. Contrast abdominopelvic computed angiotomography A. Axial
view. The arrow indicates the location of
the opacification defect, which corresponds to thrombi in the
mesenteric artery, 1cm above its origin, occluding
approximately 60% of the vessel’s lumen. B. Coronal Cut. The arrow
indicates branching of the ileal arteries where
the thrombi occludes approximately 80% of the vessel’s lumen.
During the course of the current pandemic, a great
effort has been devoted to recognize and manage
SARS-CoV-2 infection, dedicating greater impetus
to respiratory symptoms. However, various systemic
complications have been demonstrated, highlighting
that there is currently wide evidence suggesting a state
of hypercoagulability (5). COVID-19 has been considered a phenomenon
that induces autoimmune response associated with higher titers of
antiphospholipid
antibodies, suggesting a theory of latent autoimmunity
accountable for clinical outcomes(6).
Ignat et al. (7) reported a series of 3 cases of hospitalized patients
(2 men and 1 woman), positive for
SARS-CoV-2 who developed intestinal ischaemia,
in which two of them had normal clinical examination, but because of
deterioration in the clinical
course, they decided to perform a contrast abdomen
CT, which corroborated the diagnosis. Cheung et al.
(8) reported one of the first cases of mesenteric ischaemia in a
patient with COVID 19, which, like the
present case, was a man who exhibited absence of
respiratory symptoms and acute abdominal pain. Vulliamy et al. (9)
display another case in a man, who,
unlike the present case, debuted with mild respiratory
compromise in the two weeks prior to abdominal
symptoms, subsequently documenting aortic thrombosis with embolism to
the mesenteric artery, also requiring extraction surgery of the
ischaemic segment
of the intestine. Kaafarani et al. (10) in a series that
included 141 SARS-CoV-2 positive patients who described
gastrointestinal complications of which 3.5%
were intestinal ischaemia.
It is interesting how in a systematic review carried out
by Pirola et al.(3) revealed that none of the evaluated
studies reported a history of systemic atherosclerosis
or any condition that explained mesenteric ischaemia,
similar to that reported by Patel et al., who suggested
the need to increase research regarding the classification of patients
with COVID-19 and suspected intestinal ischaemia(4).
Several hypotheses have been proposed to explain why
SARS-CoV-2 infection can cause vascular and / or gastrointestinal
injury, which appear to be related to the
inflammatory response and intrinsic properties of the
virus (11,12). Angiotensin converting enzyme 2 is the
functional receptor of the virus, present in the lung, cardiovascular
system, intestine, placenta, among others
is overexpressed by the virus, which allows greater
penetration of this in digestive cells. The pathophysiological
mechanisms involved are a pro-coagulant, proinflammatory and
anti-fibrinolytic state, a consequence
of damage at the cellular level; as well as the secondary
anti-phospholipid syndrome (13).
This is explained by the infection of the pulmonary
vascular bed, the subsequent massive endothelial apoptosis and the
activation of the immune response, where
monocytes, macrophages and neutrophils participate,
with the release of cytokines (Interleukin [IL] 6, IL 1
and Tumor Necrosis Factor). In a series of autopsies
performed during SARS-CoV in 2003, showed signs
of diffuse alveolar damage with atypical pneumocytes,
as well as signs of diffuse micro-thrombosis at the peripheral level.
On the other hand, autopsies carried out
in Germany on positive cases for COVID-19 evidenced a prevalence of 21%
of pulmonary arterial embolism; establishing this entity as the second
cause of
death in this population after pneumonia (14). Other
triggers linked to thromboembolic events have been
identified, including the hypoxic state, which activates
transcription factors such as Activator Protein-1 complex, Early growth
response-1 protein, Nuclear Factor
kappa-light-chain-enhancer of activated B cells, and
Hypoxia-Induced factors (15).
Table 1. Risk factors associated with COVID-19 and thrombosis
**(19)No associations were identified with thromboprophylaxis, cancer
VTE history, ICU admission, and mean length of hospitalization.
Abbreviations: Acute cerebrovascular disease (CVD); Confidence Interval
(CI); Pneumonia Severity Score (CURB-65): score 0-1: ambulatory
treatment, score 2-3: inpatient treatment, score 4-5: ICU treatment;
Lactic dehydrogenase (LDH); Odds ratio (OR); Padua Prediction
Score (PPS); Venous Thromboembolism (VTE); Without acute
cerebrovascular disease (WCVD)
The understanding of this pro-coagulant cascade
added to the knowledge of the markers evaluated in
clinical practice (fibrinogen, D-dimer, platelet count,
clotting times), allow us to suspect a possible outcome
in the management of these patients. Several studies
have described that the presence of these high markers or in the upper
limit usually have a fatal outcome (Table 1). It has been described
that patients with
COVID-19 who have high D-dimer values are more
likely to require admission to the ICU, non-invasive
mechanical ventilation or death and it is attributed to a
hyperimmune response of the host (12,16).
Acute mesenteric ischaemia secondary to thrombosis in the presence of
SARS-CoV-2 infection can be
explained by the hypercoagulable state attributed to
the infection and should be suspected in patients with
confirmed or suspected infection and gastrointestinal
symptoms (5), to give prompt treatment and avoid fatal consequences.
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Recibido: 27 de enero de 2022
Aceptado: 7 de marzo de 2022
Correspondencia:
Paula Daniela Nieto-Zambrano
pdnieto@fucsalud.edu.co