Life and Limb: a Case of COVID-19-Associated Multisystem Thrombosis and Review of the Literature

Excerpt

A 63-year-old non-smoking woman with a past medical history of hypertension and myasthenia gravis status post thymectomy presented for care at our institution with a 9-day history of cough, fever, and weakness. On presentation, she was hypoxic with an oxygen saturation of 85% on ambient air and had a positive nasopharyngeal polymerase chain reaction assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Due to rapidly progressive respiratory failure and hypotension, she was admitted to the Intensive Care Unit (ICU) and was intubated on the same day and an internal jugular central venous catheter was inserted for vasopressor infusion. A right radial arterial catheter was also placed for hemodynamic monitoring. On admission, she was treated with prophylactic anticoagulation for venous thromboembolism (VTE), with dalteparin 5000 units subcutaneously daily. In the ICU, her condition rapidly deteriorated. Her oxygenation and lung mechanics worsened, and she developed circulatory collapse, consistent with acute respiratory distress syndrome (ARDS) with systemic hyperinflammation. Empiric antimicrobial therapy with intravenous piperacillin-tazobactam and vancomycin as well as intravenous hydrocortisone 100 mg every 8 h was initiated. Initial investigations revealed an elevated C-reactive protein (637 mg/L, normal 0–4) as well as an elevated D-dimer level (1498 μg/L, normal < 500). Platelets and fibrinogen were within normal limits. Within 72 h of admission, the patient required high doses of vasopressors including a norepinephrine infusion at 25 mcg/min and vasopressin at 0.04 unit/min as well as ionotropic support with dobutamine 5 mcg/kg/min. She was started on inhaled nitric oxide at 20 parts per million for refractory hypoxia. On the fourth day of admission, the interleukin-6 serum level was elevated at 2948 ng/L and she received a dose of intravenous tocilizumab 8 mg/kg. …