Catastrophic acute bilateral lower limbs necrosis associated with COVID-19 as a likely consequence of both vasculitis and coagulopathy.

Case report

A‐83‐year‐old man was admitted on the 3 of April 2020 for respiratory distress. He had presented with fever the 20th of March. On the 2nd of April, he had an acute pain of both legs associated with discolouration. He was admitted to the emergency room on the following day. His temperature was 38°C, and he was dyspnoeic despite oxygen. He had bilateral and symmetrical well limited black skin on both legs (Fig. 1).

Figure 1

Acute bilateral lower limb necrosis.

The patient had multiple comorbidities including obesity, type 2 diabetis mellitus, hypertension, mesenteric ischaemia in 2007, distal arteriopathy and ischaemic cardiopathy treated by coronary bypass in 2015. He had the following treatment: acetylsalicylic acid, fluindione, ramipril, bisoprolol, furosemide and prednisolone 7.5 mg per day (for pseudopolyarthritides rhizomelic).

Laboratory tests showed a C‐reactive protein concentration of 246 mg/L (normal range, <5 mg/L). Complete blood count showed white blood cell count 19 × 109/L (normal range, 4–12 × 109/L) and neutrophils 16 × 109/L (1.5–8.5 × 109/L), and a lymphopenia 0.92 × 109/L (1–4 × 109/L). D‐dimer was 7650 ng/L (normal range < 500 ng/L), and platelet count down to 148 × 109/L (normal range 150–500 × 103/L). Nasal tests for influenza A and B viruses were negative. Bacterial blood cultures were negative. The computed tomography scan presented multiple ground‐glass opacities with 80% of the lung affected. There was no sign of pulmonary embolism. The patient was diagnosed with COVID‐19 on the basis of positive RT‐PCR analysis of sputum.

During the hospitalization, we observed a coagulation degradation with disseminated intravascular coagulation (DIC) with decrease of platelet 100 × 109 and a decrease of fibrinogen 0.52 g/L normal range 2–3.93 g/L and DDIMERE 6900 ng/L was also increased normal <500 ng/L. There was no antiphospholipid syndrome (lupus anticoagulant, anticardiolipin and anti‐beta2‐glycoprotein1 antibodies were negative). His condition worsened and the patient died.

Our patient had a catastrophic acute bilateral legs and foot necrosis during the course of COVID‐19 infection. Zhang et al. reported 7 critical COVID‐19 patients with acro‐ischaemia in a single centre in Wuhan. All had acro‐ischaemia presentations including finger/toe cyanosis, skin bulla and dry gangrene. D‐dimer, fibrinogen and fibrinogen degradation product were significantly elevated in most patients, and 4 patients were diagnosed with definite DIC. Zang et al. proposed antiphospholipid antibodies as the source of coagulopathies. A few cases of digital ischaemia and necrosis have also been reported in association with coagulopathy. , Bellosta et al., who conducted an observational study of 20 patients infected by COVID‐19 and treated for acute lower limb ischaemia, suggested a higher incidence of acute limb ischaemia in COVID‐19 positive patients. The literature strongly supports a link between severe COVID‐19 and coagulopathy. , , , Our patient had coagulopathy abnormalities similar to DIC but no antiphospholipid antibodies. It is likely that the distal arteriopathy of our patient played an important role in the severity of the clinical evolution.

In contrast to such severe lesions, acrosyndromes consisting of acral eruptions of erythemato‐violaceous papules and macules, with possible bullous evolution, or digital swelling localized on the feet, hands or both reported as chilblain lesions have been reported in non‐severe or paucisymptomatic patients. , ,

This observation led authors such as Suarez‐Valle et al. to conclude that « there is a continuum spectrum related to acro‐ischaemic lesions, ranging from mild chilblain‐like lesions to dry gangrene». However, we postulate that these lesions are not a continuum but are distinct in one important point. Both Chilblain‐like and acro‐ischaemic lesions share a vasculitis. Indeed, Varga et al. demonstrated that COVID 19 could cause viral endotheliitis. However, acro‐ischaemic lesions are the consequence of the malignant synergy of the vasculitis and severe coagulopathy.

Conflicts of interest

This manuscript has not been published and is not under consideration for publication elsewhere. We have no conflicts of interest to disclose.