Arterial and venous abdominal thrombosis in a 79-year-old woman with COVID-19 pneumonia.

As coronavirus pandemic continue to spread over the world, we have to be aware of potential complications on hospitalized patients. We report a case of a 79-year-old woman with COVID-19 pneumonia complicated by combined arterial and venous thrombosis of upper mesenteric vessels. As unenhanced chest CT scan plays a key role in managing the COVID-19 pandemic, we should pay attention to indirect signs of thrombosis.

Introduction

Coronavirus disease (COVID-19), a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in Wuhan, Hubei Province, China, and rapidly spread to other domestic cities and many countries beyond China. Since chest CT scans are crucial for the diagnosis and management of COVID-19 patients [1], our activity as radiologists has changed drastically with the number of nonenhanced chest tomodensitometry increasing significantly [2]. Pulmonary manifestations are now widely described but few relate about abdominal and thromboembolic complications apart from pulmonary embolism. We report the imaging features of simultaneous arterial and venous thrombosis in a 79-year-old patient affected by COVID-19-induced pneumonia.

Clinical and radiologic observation

A 79-year-old woman, without known medical history, was suffering from fever, deterioration of her general condition, and abdominal pain located in the epigastric area associated with diarrhea over the previous 8 days. As acute dyspnea added to its symptoms, she went to the emergency room. Initially, the patient was hemodynamically stable (Blood pressure: 168/89 mm Hg), showed symptoms of acute respiratory insufficiency with polypnea (22 cycles per minutes with 86% of blood oxygen saturation in ambient air), and tachycardia (100 bpm). Blood tests revealed C-reactive protein (125 mg/L) increase and a hyperleukocytosis (12,600/mm3) with lymphopenia. Blood gas analysis showed compensated lactic acidosis (pH 7.43 with hyperlactatemia: 5.36 mmol/L). Nasopharynx PCR was negative for SARS-CoV-2.

Two hours after admission, an unenhanced chest CT scan displayed typical signs of COVID-19 pneumonia [13] (mostly ground-glass opacity without CT-backed evidence of another infection) with critical extent (>75% of pulmonary parenchyma; Fig. 1). The upper abdominal slices showed a spontaneous hyperdensity (71 Hounsfied units (HU) vs 38 HU in the portal vein) in the right portal vein (Figs. 2a and 4b). Further examination with enhanced CT scan of the chest, abdomen, and pelvis at the arterial and portal phases, performed at the same time, confirmed a right-portal vein thrombosis (Fig. 2b) originating from thrombosis of the distal part of the upper mesenteric vein extended to the spleno-mesaraic trunk. A proximal thrombosis of the upper mesenteric artery (Figs. 3a and b) and jejunal artery were also observed with subsequent features of bowel ischemia of the caecum and small intestine (Figs. 4a and b) with small amount of liquid in the peritoneal cavity. No pulmonary embolism was revealed. Laparotomy was undertaken few hours later and confirmed ischemia, where a meter of necrotic ileum and right colon were removed. Thrombolysis and thrombectomy of the upper mesenteric artery were also performed during the same procedure. Despite timely treatment, his medical condition stayed precarious because of extended bowel ischemia in addition to severe lung damage caused by COVID-19. Palliative cares was implemented and the patient passed away 4 days later.

Fig. 1

COVID-19 pneumonia. Transverse section of unenhanced chest CT scans showing typical lesions of COVID-19 pneumonia: ground glass associated with consolidation and intralobular lines, sometimes arcuate, with peripheral and declining predominance.

Fig. 2

Imaging features of venous thromboembolic disease in a 79-year-old COVID-19 patient. a: Native transverse upper abdominal slice of the unenhanced chest CT scan showing a spontaneous hyperdensity in the right portal vein (white arrowhead). b: Native transverse portal abdominal CT scan image showing an intraluminal thrombus of the right portal vein (white arrowhead).

Fig. 4

Imaging features of bowel ischemia in a 79-year-old COVID-19 patient. a: Oblique transverse reconstruction of portal abdominal CT scan. b: Oblique coronal reconstruction of portal abdominal CT scan image. Both images show a perfusion defect of the right large intestine—lower and middle third including caecum—(white arrowheads) relative to a normal loop of the small intestine (large white arrows) and a normal upper of the right large intestine (thin white arrow). Right-portal vein thrombosis can also be seen (black arrowhead).

Fig. 3

Imaging features of arterial thromboembolic disease in a 79-year-old COVID-19 patient. a: Sagittal reconstruction of arterial abdominal CT scan showing a thrombotic ostial occlusion of the upper mesenteric artery (thin arrow). b: Native transverse arterial abdominal CT scan image showing a thrombotic ostial occlusion of the upper mesenteric artery (thin arrow).

Discussion

COVID 19 is associated with a large and misleading field of symptoms [3] and complications including coagulopathy [4] as often seen in acute infection [5] including Influenza [6]. This hypercoagulation status, which results in diseases such as pulmonary embolism [7], [8], [9], is leading learned societies to ask themselves the question of an anticoagulation therapy at prophylaxis dose or even higher [10,11]. Gastrointestinal symptoms reported with COVID-19 are not specific and include nausea, vomiting, diarrhea, and raised liver enzyme [12].

In our case, Nasopharynx PCR was negative for SARS-CoV-2 although CT scan displayed typical signs of COVID-19 pneumonia. This scenario is frequently reported [1] and do not disprove the diagnosis.

As known, chest CT scan is an essential exam for the diagnosis, evaluation of extension and care management mostly in nonambulatory patients. Moreover, it could help in patient follow-up with worsening clinical conditions.

When CT scan control is needed, it seems reasonable to perform whole body enhanced CT scan at arterial and venous phases especially in case of pulmonary embolism suspicion or abdominal pain.

Conclusion

Chest CT scan is essential in managing the COVID-19 pandemic and allows to uncover potential complications such as thromboembolic diseases. Close attention should be payed to indirect signs of thrombosis on unenhanced CT scan.