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

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79-year-old woman with COVID-19 pneumonia

Olivier de Barry, Ahmed Mekki, Caroline Diffre, Martin Seror, Mostafa El

Hajjam, Robert Yves Carlier

To cite this version:

Olivier de Barry, Ahmed Mekki, Caroline Diffre, Martin Seror, Mostafa El Hajjam, et al.. Arterial

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

Case Reports, Elsevier, 2020, 15 (7), pp.1054-1057. �10.1016/j.radcr.2020.04.055�. �hal-02677114�

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Available

online

at

www.sciencedirect.com

journal

homepage:

www.elsevier.com/locate/radcr

Case

Report

Arterial

and

venous

abdominal

thrombosis

in

a

79-year-old

woman

with

COVID-19

pneumonia

✩

,

✩✩

Olivier

de

Barry,

Medical

intern

a ,b ,∗

_,

_Ahmed

_Mekki,

_MD

a ,b

_,

_Caroline

_Diffre,

_MD

a ,b

_,

Martin

Seror,

MD

a

_,

_Mostafa

_El

_Hajjam,

_MD

a

_,

_Robert-Yves

_Carlier,

_MD

a ,b ,c

a_DMU_Smart_Imaging,_Medical_Imaging_Department,_Assistance_{Publique-Hôpitaux}_de_Paris,_GH_Université

Paris-Saclay,AmbroiseParé TeachingHospital,9AvenueCharlesdeGaulle,92100Boulogne-Billancourt,France

b_DMU_Smart_Imaging,_Medical_Imaging_department,_Assistance_{Publique-Hôpitaux}_de_Paris,_GH_Université

Paris-Saclay,RaymondPoincaré TeachingHospital,Garches,France

c_UMR₁₁₇₉_End-icap,_{Université Versailles}_{Saint-Quentin-en-Yvelines/Paris-Saclay,}_Versailles,_France

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received16April2020 Revised21April2020 Accepted21April2020 Availableonline29April2020

Keywords:

COVID-19 coronavirus CTscan

Severeacuterespiratorysyndrome coronavirus2

Thrombosis

a

b

s

t

r

a

c

t

Ascoronaviruspandemiccontinuetospreadovertheworld,wehavetobeawareof poten-tialcomplicationsonhospitalizedpatients.Wereportacaseofa79-year-oldwomanwith COVID-19pneumoniacomplicatedbycombinedarterialandvenousthrombosisofupper mesentericvessels.AsunenhancedchestCTscanplaysakeyroleinmanagingthe COVID-19pandemic,weshouldpayattentiontoindirectsignsofthrombosis.

Introduction

Coronavirus disease(COVID-19), ahighlyinfectiousdisease causedbysevereacuterespiratory syndromecoronavirus2 (SARS-CoV-2),wasfirst reportedinWuhan,HubeiProvince, China,andrapidlyspreadtootherdomesticcitiesandmany countriesbeyondChina.SincechestCTscansarecrucialfor

✩ _Funding:_None.

✩✩_Declartion_of_Competing_Interest:_Authors_declare_that_they_have_no_competing_interest. ∗_{Corresponding}_author.

E-mail addresses: olivier.debarry@aphp.fr (O. de Barry), ahmed.mekki@aphp.fr (A. Mekki), caroline.diffre@aphp.fr (C. Diffre),

martin.seror@aphp.fr(M.Seror),mostafa.elhajjam@aphp.fr(M.El Hajjam),robert.carlier@aphp.fr(R.-Y.Carlier).

thediagnosisandmanagementofCOVID-19patients[1],our activityasradiologistshaschangeddrasticallywiththe num-berofnonenhancedchesttomodensitometryincreasing sig-nificantly[2].Pulmonarymanifestationsarenowwidely de-scribedbutfewrelateaboutabdominalandthromboembolic complicationsapartfrompulmonaryembolism.Wereportthe imagingfeaturesofsimultaneousarterialandvenous

throm-https://doi.org/10.1016/j.radcr.2020.04.055

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Fig.1– COVID-19pneumonia.Transversesectionof unenhancedchestCTscansshowingtypicallesionsof COVID-19pneumonia:groundglassassociatedwith consolidationandintralobularlines,sometimesarcuate, withperipheralanddecliningpredominance.

bosisina79-year-oldpatientaffectedbyCOVID-19-induced pneumonia.

Clinical

and

radiologic

observation

A79-year-oldwoman, withoutknown medicalhistory,was sufferingfrom fever,deteriorationofhergeneralcondition, andabdominalpainlocatedintheepigastricareaassociated with diarrheaover the previous 8days. As acute dyspnea addedtoitssymptoms,shewenttotheemergencyroom. Ini-tially,thepatient washemodynamicallystable(Blood pres-sure:168/89mmHg),showedsymptomsofacuterespiratory

insufficiencywithpolypnea(22cyclesperminuteswith86%of bloodoxygensaturationinambientair),andtachycardia(100 bpm).Bloodtestsrevealed C-reactiveprotein(125mg/L) in-creaseandahyperleukocytosis(12,600/mm3₎_with lymphope-nia.Bloodgasanalysisshowedcompensatedlacticacidosis (pH 7.43 withhyperlactatemia: 5.36 mmol/L).Nasopharynx PCRwasnegativeforSARS-CoV-2.

Twohoursafteradmission,anunenhancedchestCTscan displayedtypicalsignsofCOVID-19pneumonia[13](mostly ground-glass opacity without CT-backed evidence of an-other infection) with critical extent (>75% of pulmonary parenchyma;Fig. 1). Theupperabdominal slices showeda spontaneoushyperdensity(71Hounsfiedunits(HU)vs38HU intheportalvein)inthe rightportalvein(Figs.2aand4b). Further examination withenhanced CT scan of the chest, abdomen,and pelvisatthearterialand portalphases, per-formedatthesametime,confirmedaright-portalvein throm-bosis(Fig.2b)originatingfromthrombosisofthedistalpartof theuppermesentericveinextendedtothespleno-mesaraic trunk.Aproximalthrombosisoftheuppermesentericartery (Figs.3aand b)andjejunal artery werealsoobserved with subsequent featuresof bowel ischemiaof thecaecum and smallintestine(Figs.4aandb)withsmallamountofliquidin theperitonealcavity.Nopulmonaryembolismwasrevealed. Laparotomywasundertakenfewhourslaterandconfirmed ischemia,where ameterofnecrotic ileum andright colon were removed.Thrombolysisand thrombectomyofthe up-permesentericarterywerealsoperformedduringthesame procedure. Despitetimely treatment, hismedicalcondition stayedprecariousbecauseofextendedbowelischemiain ad-ditiontoseverelungdamagecausedbyCOVID-19.Palliative careswasimplementedandthepatientpassedaway4days later.

Discussion

COVID19isassociatedwithalargeand misleadingfield of symptoms[3]andcomplicationsincludingcoagulopathy[4]as

Fig.2– Imagingfeaturesofvenousthromboembolicdiseaseina79-year-oldCOVID-19patient.a:Nativetransverseupper abdominalsliceoftheunenhancedchestCTscanshowingaspontaneoushyperdensityintherightportalvein(white arrowhead).b:NativetransverseportalabdominalCTscanimageshowinganintraluminalthrombusoftherightportal vein(whitearrowhead).

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Fig.3– Imagingfeaturesofarterialthromboembolicdiseaseina79-year-oldCOVID-19patient.a:Sagittalreconstructionof arterialabdominalCTscanshowingathromboticostialocclusionoftheuppermesentericartery(thinarrow).b:Native transversearterialabdominalCTscanimageshowingathromboticostialocclusionoftheuppermesentericartery(thin arrow).

Fig.4– Imagingfeaturesofbowelischemiaina79-year-oldCOVID-19patient.a:Obliquetransversereconstructionofportal abdominalCTscan.b:ObliquecoronalreconstructionofportalabdominalCTscanimage.Bothimagesshowaperfusion defectoftherightlargeintestine—lowerandmiddlethirdincludingcaecum—(whitearrowheads)relativetoanormalloop ofthesmallintestine(largewhitearrows)andanormalupperoftherightlargeintestine(thinwhitearrow).Right-portal veinthrombosiscanalsobeseen(blackarrowhead).

oftenseeninacuteinfection[5]includingInfluenza[6].This hypercoagulation status,which results indiseases suchas pulmonary embolism [7–9], is leading learned societies to askthemselves the questionofan anticoagulationtherapy atprophylaxis dose oreven higher[10,11]. Gastrointestinal symptomsreported withCOVID-19arenot specificand in-clude nausea, vomiting, diarrhea, and raised liver enzyme

[12].

Inourcase,NasopharynxPCRwasnegativefor SARS-CoV-2althoughCTscandisplayedtypicalsignsofCOVID-19 pneu-monia.Thisscenarioisfrequentlyreported[1]anddonot dis-provethediagnosis.

Asknown,chestCTscanisanessentialexamforthe diag-nosis,evaluationofextensionandcaremanagementmostly innonambulatorypatients.Moreover,itcouldhelpinpatient follow-upwithworseningclinicalconditions.

When CTscancontrolisneeded,itseemsreasonableto performwholebodyenhancedCTscanatarterialandvenous phasesespeciallyincaseofpulmonaryembolismsuspicion orabdominalpain.

Conclusion

Chest CT scan is essential in managing the COVID-19 pandemic and allows to uncover potential complications suchasthromboembolicdiseases.Closeattentionshouldbe payed to indirect signs of thrombosis on unenhanced CT scan.

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