The prothrombotic nature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been well established since the onset of the 2019 global coronavirus disease (COVID-19) pandemic. Thrombosis of the mesenteric artery and acute mesenteric ischemia are rare events in their own right and often associated with fatal gastrointestinal (GI) pathologies that require prompt identification and intervention by the physician to improve clinical outcomes. SARS-CoV-2 infection may present with acute GI pathologies and warrants further investigation regarding anticoagulant therapy in COVID-19 positive patients. We report on a 64-year-old female infected with SARS-CoV-2 who presented with superior mesenteric thrombosis and acute intestinal ischemia.
Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing 2019 coronavirus disease (COVID-19) is increasingly associated with coagulopathy and thrombotic complications. While pulmonary presentations of the disease have prevailed, extrapulmonary complications have also been reported in individuals with confirmed COVID-19 [1,2]. Acute mesenteric ischemia (AMI) is a less common thrombotic complication and is described in only a few case reports but with high morbidity and mortality [1,2,4]. This report describes a patient affected by COVID-19 presenting with superior mesenteric artery (SMA) thrombosis and acute intestinal ischemia.
A 64-year-old woman with a medical history of hypertension and diabetes mellitus presented to the emergency department after two days of constipation, abdominal pain, and distention. While waiting in the triage, the patient collapsed and became unresponsive. She was found to be hypotensive with a Glasgow Coma Scale (GCS) of 5 and was rushed to the trauma ward, intubated and started on vasopressors. Laboratory testing was significant for lactic acidemia of 9.6 mmol/L, a predominant neutrophilic leukocytosis of 19.37 x 10^3 cells/L, elevated D-dimer of >20 µg/ml and SARS-CoV-2 detected on a BioFire® -respirator. panel (BioFire Diagnostics, Salt Lake City, Utah, United States). ECG showed sinus tachycardia and there was a slight elevation of troponin consistent with type II myocardial infarction (MI). A CT abdomen and pelvis with contrast was significant for diffuse pneumatosis in the small bowel loops in left lower quadrant and pelvis (Figures 1, 2) as well as diffusely reduced caliber of the celiac axis and superior mesenteric artery with air sacs in the mesenteric vessels of the left lower quadrant (Figures 3, 4).
These findings were highly suggestive of non-occlusive bowel ischemia and the patient was taken for an urgent exploratory laparotomy. At that time, it was discovered that the patient had a large area of ischemia in the distribution of the SMA, which was removed, along with significant ischemia to the colon, leading to total colectomy; the patient was left with an estimated 150 cm remaining viable small intestine at closure. An ABTHERA™ Vacuum Assisted Wound Closure (VAC) (Acelity LP Inc., San Antonio, Texas, United States) was placed and the patient was returned to the ICU for ongoing monitoring and care. Over the next two postoperative days on high-dose vasopressors, the patient with progressive multi-organ failure continued to deteriorate. The patient was taken for a second urgent exploratory laparotomy, which was significant for a 1 cm area of necrosis on the anterior aspect of the rectal stump. As a result, the rectal stump was resected, effectively removing the area of ischemia; however, the patient continued to deteriorate clinically. Nine days after hospitalization, the patient’s family decided only on comfort care measures, after which the patient died quickly.
It has been suggested that the coagulopathy caused by SARS-CoV-2 is due to changes in the microcirculation. One hypothesis proposes that viral replication causes inflammatory cells to infiltrate the endothelium, leading to endothelial apoptosis and subsequent microvascular prothrombotic events. . In addition, SARS-CoV-2 has been shown to act on angiotensin-converting enzyme 2 receptors in the lungs, which are also found in vascular endothelium and in small intestine enterocytes, and SARS-CoV-2 supports microvascular thrombotic effects on small intestine. . The presentation of pulmonary embolism is responsible for most COVID-19 related coagulopathies; however, cases have been reported including venous thromboembolism, arterial thrombosis, MI, stroke, and microvascular thrombosis .
Infection with SARS-CoV-2 occurs by inhalation of aerosol droplets and is mainly characterized by respiratory symptoms. GI manifestations of COVID-19 such as nausea, vomiting, diarrhea and abdominal pain are well documented; however, the true prevalence of GI symptoms among COVID-19 positive patients is unknown, ranging from less than 10% to 70% in various reports [3,7]. While AMI is rare with an overall incidence of less than 1%, AMI in the setting of COVID-19 justifies a high index of suspicion to prevent harmful, potentially fatal complications . The recent medically ill hospitalized patients for COVID-19 thrombosis extended prophylaxis with rivaroxaban therapy (MICHELLE) randomized controlled trial suggests improved clinical outcomes with long-term use of rivaroxaban anticoagulants in high-risk patients after hospital discharge, to support thromboprophylaxis for patients at increased risk of thrombotic events .
With the SARS-CoV-2 virus still a significant burden on the healthcare system, several unforeseen pathological manifestations are still described. Thromboembolic presentations of the virus, such as AMI, pose significant clinical challenges to physicians due to its unpredictable and catastrophic nature. Early recognition of AMI and identifying those at highest risk are important for rapid clinical diagnosis and treatment, which can lead to better clinical outcomes. Future research on prophylactic anticoagulant therapy in COVID-19 positive patients is warranted, given the individual patient risk and high morbidity and mortality associated with AMI.