Case presentation:
A 69-year-old man was hospitalized with febrile dyspnea at the military
hospital of Antananarivo. He reported a close contact with a confirmed
case of COVID-19 5 days before the onset of symptoms. His history
included hypertension treated with Losartan 100mg per day, type 2
diabetes treated with Metformin 1500mg/day, alcoholism and smoking
cessation for 10 years (9.5 pack-years). He has no known history of
peripheral artery disease. For 13 days prior to his admission, he
presented with a dry cough, shortness of breath at rest without
orthopnea, fever, asthenia and anorexia. Two days before
hospitalization, he felt a spontaneous severe pain with swelling of the
left lower limb. Physical examination revealed a body mass index of
28.7 kg/m2, a pulsed oxygen saturation of 72% on room air, a
respiratory rate of 23 per minute, a high temperature of 38.9°C, a heart
rate of 117 beats per minute, a blood pressure of 135/80 mmHg and
bilateral clinical signs of pneumonia. He presented a cyanosis of the
left foot up to the mid-thigh (Figure 1), a hypoesthesia of the left
lower limb and the skin was cool. The left pedal, posterior tibial,
popliteal and femoral pulses were abolished.
The nasopharyngeal swab for SARS-CoV-2 reverse transcriptase-polymerase
chain reaction (rt-PCR) performed on admission was negative. The
complete blood count showed a haemoglobin level of 13.3 g/dl (13.5-17.5
g/dl) a white blood cells count of 11.81 G/L (5-10 G/L) and a platelet
count of 81 G/L (150-400 G/L). The C-reactive protein was 82.6 mg/L
(<6 mg/l). The creatinine was 187 µmol/L (65.4-119.3 µmol/L).
The blood sodium level was 141 mmol/L (135-145 mmol/l) and the blood
potassium level was 4.9 mmol/L (3.6-5.2 mmol/l). The glycated
haemoglobin was 7.5% (<6%). The D-dimer was 514 times the
upper normal limit (220-500 ng/mL). The troponin was normal. The
electrocardiogram showed a regular tachycardia with a heart rate of 103
bpm. Chest CT scan was in favour of COVID-19 showing ground glass images
with 50-75% involvement, without pulmonary embolism (Figure 2). The
arterial doppler ultrasound showed an extensive intraluminal thrombus
along the arterial axes of the left lower limb, completely obstructing
them, starting from the common iliac artery just after its bifurcation
with the aorta and extending distally (external iliac, common femoral,
superficial femoral, popliteal, anterior tibial, posterior tibial,
fibular and pedal), without any detectable collateral circulation
(Figure 3 a, b, c). The patient was diagnosed with a severe COVID-19
associated with acute ischemia of the whole left lower limb secondary to
an extensive arterial thrombosis. He was receiving oxygen therapy with a
high concentration oxygen mask at 15 L/min, corticosteroid therapy with
intravenous dexamethasone (12 mg/day), subcutaneous therapeutic
anticoagulation with enoxaparin at a curative dose (8000UI x2/day), oral
antibiotic therapy with levofloxacin (1g/day) and insulin therapy
(rapid-acting insulin 14UI x3/day and long-acting insulin 20 UI/day).
The patient was transferred to the surgical ward due to aggravation of
the ischemia with skin necrosis of extremities and underwent an
amputation of the ischemic left lower limb. The post-operative follow-up
was simple. The patient was discharged after 28 days of hospitalization
and was under long-term oxygen therapy at home. At one month follow-up,
he remained well and there was no recurrence of other ischemia.