Case presentation
A 40-year-old male without any past medical history admitted in the covid 19 ICU with complaint of fever, myalgia and progressive dyspnea over 4 days. vital signs in the day of admission revealed blood pressure of 110/60 mmhg, heart rate of 87, respiratory rate 25, low grade fever and oxygen saturation of 85% on room air. Chest computerized tomography scan (CT scan) showed peripheral bilateral patchy ground glass infiltrations which is suggestive for covid 19 pneumonia and venous blood gas information (ph:7/41 po2:54 mmhg pco2: 35 mmhg hco3:20 mmol/dl) and o2 saturation of 85% revealed the patient was in moderate to severe acute respiratory distress syndrome (ARDS) according to Berlin ARDS criteria. Initial laboratory evaluations showed: hemoglobin 14 g/dl, total leukocyte count 9800 per microliter, absolute neutrophil count 7100 per microliter absolute lymphocyte count 2100 per microliter, platelets 330000 per microliter, BUN 28 mg/dl, serum creatinine 0.9 mg/dl, prothrombin time 12s, international normalized ratio 1s, partial thromboplastin time 38s, lactate dehydrogenase 1200 u/land C-reactive protein was 86 mg/dl. Electrocardiogram showed sinus tachycardia of 106 beats per minute. The patient was started on remdesivir, dexamethasone, heparin for prophylaxis.
On second day of hospitalization, the patient complained about a sudden severe pain in his right leg. On examination, he had profound weakness in the right leg, mild weakness in the left leg, and absent pulses. The findings of laboratory data (complete blood counts and PT, PTT, INR and liver and kidney function tests) were unremarkable. Doppler ultrasonography reported intraluminal thrombus with in the distal part of right common iliac artery. CT angiography showed thrombotic occlusion at right common iliac artery, right external iliac artery and common femoral artery (Fig 1 , 2).
Lupus anticoagulant antibody, antiphospholipid antibody, anticardiolipin antibodies, anti beta2 glycoprotein, anti-nuclear antibody (ANA), P-ANCA, C-ANCA and c3, c4, CH50 complement level were in normal range.
The patient was started on therapeutic anticoagulation with unfractionated heparin. Angiography of bilateral iliac and lower extremity arteries showed thrombotic occlusion of right common iliac artery, right external iliac artery, right superficial femoral artery, right popliteal artery and a partial thrombolysis at left common iliac artery.
Revascularization and thrombolysis by injecting tissue plasminogen activator was not sufficient and the patient underwent leg amputation one day after angiography.