Discussion and conclusion:
We report here a case of a hypertensive and diabetic patient presenting
a severe form of COVID 19 associated with an ischemia of the left lower
limb with an extremely high d-dimer level.
High D-dimer value is associated with severe infection and high risk of
thromboembolic events during COVID-19 [6]. Arterial occlusion can be
life threatening or can lead to significant disabilities. Our patient
had a history of hypertension, previous smoking and type 2 diabetes.
According to the literature, these comorbidities are significantly
associated with the occurrence of arterial thrombosis during COVD-19
[5]. He was diagnosed with a severe form of COVID-19 and presented
at the same time an ischemia of the left lower limb secondary to an
extensive thrombosis of several arteries in the left lower limb. Our
patient had a D-dimer up to 514 times the upper normal level. The
d-dimer level correlates with the severity of the disease and is a
reliable prognostic marker of in-hospital mortality in those admitted
with COVID-19 [6–8]. The risk of death is therefore high for our
patient. In COVID-19, arterial thrombosis mainly involves the heart, the
brain, the kidney and the bowels. There were only few reported cases of
arterial thrombosis involving limbs including the left arm, the left
leg, the right arm and the right leg [5]. However, our case involved
the entire left lower limb (thigh, leg, foot).
Gold DD. et al. reported a series of cases of arterial thrombosis. The
first case had a thrombosis of the two renal arteries, the superior
mesenteric artery and the celiac trunk. The second case had a thrombosis
of the aorta, the celiac trunk, hepatic and the splenic arteries. The
third case had a cerebral, pulmonary, splenic and renal thrombosis. The
fourth case had a thrombosis of the lung, the spleen and the kidney. The
last case was a peripheral thrombosis with an occlusion of the radial
and ulnar arteries [9]. All five patients had arterial occlusions
that were life-threatening or disabling, and four of the five patients
did not survive. Despite the severity of the COVID-19 and the arterial
occlusion, our case had survived. However, the delay in the management
led to a total obstruction of the artery causing ischemia which resulted
in amputation. The outcome was unexpected given the severity of COVID-19
and the extensive arterial occlusions in a country like Madagascar with
limited technical platform and resources.
One limitation associated with this case report is that we have not been
able to perform any serology test for covid 19 to strengthen the
diagnosis made by chest CT scan, due to unavailability of this test.
We report a case of an extensive peripheral arterial thrombus with an
extremely high D-dimer during COVID-19. Arterial thrombosis can occur
during COVID-19, causing peripheral or central ischemia with increased
morbidity and mortality. The occurrence of these events is related to
the D-dimer value [10]. Thus, this report underlines the potential
role of anticoagulation in COVID-19 especially in severe forms and
furthermore in patient with cardiovascular comorbidities, or in the case
of a high D-dimer value in order to limit the occurrence of
thromboembolic diseases.