Elderly male with hypoxia.

An 89‐year‐old male with a past medical history of hypertension, hyperlipidemia, and dementia presented with hypoxia during the COVID‐19 pandemic. The patient's vital signs were heart rate (HR) 60, respiratory rate (RR) 21, oxygen saturation (SpO2) 90% on room air, blood pressure (BP) 123/84, and temperature 36°C. His examination was at baseline with no significant findings including extremities with normal perfusion. The patient tested positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and was discharged to continue oxygen at a skilled nursing facility. After 14 hours, the patient returned with acrocyanosis of the upper and lower extremities. Repeat vital signs were HR 73, RR 24, BP 165/71, temperature of 35.4°C, and SpO2 100% on oxygen. Physical examination was significant for bilateral upper and lower distal extremity cyanosis that were cool to the touch with diminished pulses (Figure 1, 2). Laboratory analysis revealed D‐dimer 58,017 ng/mL reference range (≤ 209 ng/mL); creatinine 6.10 mg/dL reference range (0.70‐1.30 mg/dL); and troponin 0.116 ng/mL reference range (0.010‐0.030 ng/mL). These rapid changes and acrocyanosis were owing to micro thrombosis and disseminated intravascular coagulopathy related to COVID‐19 disease.

FIGURE 1

Right hand skin visual exam with acrocyanosis from disseminated intravascular coagulation due to Coronavirus‐19

FIGURE 2

Bilateral soles of skin visual exam with acrocyanosis from disseminated intravascular coagulation due to Coronavirus‐19

DISCUSSION

This case report highlights a rare but known complication of diffuse microthrombosis and acrocyanosis associated with COVID‐19. Identifying signs of coagulopathy in COVID‐19 patients early could prevent end organ damage with initiation of anticoagulation. In COVID‐19 positive patients screening for skin changes, renal function, and testing for markers of disseminated intravascular coagulopathy may persuade clinicians to consider initiation of anticoagulation early.