Authors: Abdulhadi A Alali,¹Mohammed O Baqais,²Fayez M Albishi,³, et. al. Cureus. (11):19954. doi: 10.7759/cureus.19954PMCID: PMC8713302PMID: 34976537

Abstract

Thrombotic events are well-recognized complications of coronavirus disease 2019 (COVID-19). The incidence of such complications is highly related to the severity of COVID-19 pneumonia. Recent evidence suggests that the coagulopathy of COVID-19 may persist for some period even after the full recovery from pneumonia. We report the case of a 35-year-old man who presented with a 10-day history of fever and cough. His plain radiograph showed bilateral peripherally located opacities suggestive of COVID-19. The diagnosis was confirmed by the reverse transcriptase-polymerase chain reaction (RT-PCR) for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He was placed on a non-invasive ventilator but it failed to maintain normal oxygen saturation. Hence, the decision for intubation was made. He was extubated after 10 days in the ICU. The patient had a complete recovery. One week after discharge, the patient presented with severe abdominal pain that was out of proportion to the physical examination findings. He had an abdominal CT scan, which demonstrated a large thrombus occluding the superior mesenteric artery. There was no bowel dilatation or focal mural thickening to suggest bowel ischemia. The patient was resuscitated with intravenous fluid hydration. Opioid analgesics were administered to control the pain. After stabilizing the patient, he underwent laparotomy with thrombectomy. The patient tolerated the operation with no complications and had an uneventful recovery. The patient was discharged in good condition with no active issues after four days of hospitalization. The superior mesenteric thrombosis is an unusual complication of COVID-19 pneumonia. This case provides further evidence on the possibility of thrombotic events following the recovery from COVID-19. There is a pressing need for future studies to investigate the role of prophylactic antithrombotic and anticoagulants in patients who recovered from severe COVID-19.mesenteric artery occlusion, coronavirus disease 2019

Introduction

The coagulopathy and thrombotic complications of coronavirus disease 2019 (COVID-19) have been recognized in the early stages of the pandemic itself. The spectrum of thrombotic events in COVID-19 is very broad. For example, it has been reported that up to one-third of critically ill patients with COVID-19 develop deep venous thrombosis and pulmonary embolism [1]. The thrombotic events in COVID-19 are not restricted to venous complications alone. A retrospective study including over 3,000 patients with COVID-19 has shown that up to 9% of the patients developed coronary artery thrombosis [2]. The pathogenesis of coagulopathy in COVID-19 remains unclear. The pathophysiology of coagulopathy can be thought of in terms of Virchow’s triad, which includes endothelial injury, stasis, and hypercoagulable state. Several prothrombotic factors have been reported to have elevated levels in patients with severe COVID-19, such as factor VIII and fibrinogen [3]. A meta-analysis by Mitra et al. [4] involving over 5,000 patients with COVID-19 has demonstrated that the risk of coagulopathy is directly related to the severity of the disease. In this report, we present the case of a young male patient with unprovoked superior mesenteric artery thrombosis that developed after his recovery from severe COVID-19 pneumonia.Go to:

Case presentation

The patient was a 35-year-old man who presented to the emergency department with fever and cough for 10 days. The fever had been constant and partially relieved by over-the-counter medications. The fever had a peak measure of 38.5 ℃. It was not associated with night sweats. He reported that the cough had been dry initially, but it had become productive of yellowish sputum. The cough was associated with shortness of breath. The patient reported no history of chest pain or upper respiratory tract symptoms. He reported that these symptoms developed after his spouse was diagnosed with COVID-19 pneumonia. However, he had decided not to seek medical care and chosen to remain in home isolation. The patient had a long-standing history of gastroesophageal reflux disease for the last 10 years. He was on a maximum dose of proton pump inhibitors therapy. He did not have any other comorbidities. His surgical history was unremarkable for any previous surgeries. He had never been admitted to the hospital previously. He was a non-smoker and reported that he never consumed alcohol. The family history was remarkable for ischemic heart disease.

Upon examination, the patient appeared to be in respiratory distress. He was using his accessory muscles of respiration and the intercostal retraction was noted. The patient had difficulty speaking in full sentences. His vital signs showed tachycardia (110 bpm), tachypnea (24 bpm), low-grade fever (37.8 ℃), and normal blood pressure (122/84 mmHg). His oxygen saturation was 84% on room air. Respiratory examination revealed diffuse bilateral crepitations with decreased air entry. Examination of other systems was non-contributory. Initial laboratory investigations revealed leukocytosis, elevated C-reactive protein (19.2 mg/dL), elevated erythrocyte sedimentation rate (42 mm/hour), and elevated transaminases levels. The coagulation profile was within the normal range. A portable chest X-ray showed bilateral peripherally located opacities. The diagnosis of COVID-19 pneumonia was confirmed by the reverse transcriptase-polymerase chain reaction (RT-PCR) for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

The patient was admitted to the medical ward. He was placed on a non-invasive ventilator with the bi-level positive airway pressure (BiPAP), but it failed to maintain normal oxygen saturation. Hence, the decision for endotracheal intubation and mechanical ventilation was made. The patient was shifted to the ICU. He received multiple antibiotic therapies, including azithromycin, ceftriaxone, and vancomycin, during his stay. He did not require the use of inotropic agents. The patient received dexamethasone, tocilizumab, vitamin C, and zinc. Additionally, prophylactic low-molecular-weight heparin was administered. The patient showed gradual clinical improvement and his oxygen requirement decreased. He was weaned off the ventilator gradually and extubated after 10 days of stay in the ICU. He had a complete recovery and was discharged after 14 days of hospitalization.

One week after discharge, the patient presented to the emergency department again with a sudden-onset abdominal pain for five hours. He described the pain as stabbing in nature. The pain was constant and was aggravated by food intake. It was not related to posture. The pain was generalized with no radiation. He scored the pain as a 9 on the 10-point severity scale, and it was associated with vomiting. There was no history of fever, vomiting, or change in bowel habits. The pain was out of proportion to the abdominal examination findings. There was mild generalized tenderness with no signs of peritonitis. Further, the basic laboratory investigations were within normal limits (Table ​(Table11).

Table 1

Summary of the laboratory findings

Laboratory investigation	Unit	Result	Reference range
Hemoglobin	g/dL	14.2	13.0–18.0
White blood cells	1,000/mL	7.2	4.0–11.0
Platelet	1,000/mL	385	140–450
Erythrocyte sedimentation rate	mm/hour	18	0–20
C-reactive protein	mg/dL	9.7	0.3–10.0
Total bilirubin	mg/dL	1.0	0.2–1.2
Albumin	g/dL	3.8	3.4–5.0
Alkaline phosphatase	U/L	52	46–116
Gamma-glutamyltransferase	U/L	19	15–85
Alanine transferase	U/L	20	14–63
Aspartate transferase	U/L	16	15–37
Blood urea nitrogen	mg/dL	12	7–18
Creatinine	mg/dL	1.0	0.7–1.3
Sodium	mEq/L	135	136–145
Potassium	mEq/L	3.9	3.5–5.1
Chloride	mEq/L	105	98–107

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A plain radiograph of the abdomen was performed and demonstrated a normal bowel pattern with no free air under the diaphragm (Figure ​(Figure1).1). Then, an abdominal CT scan with intravenous contrast was performed. The scan demonstrated a large thrombus occluding the superior mesenteric artery. There was no bowel dilatation or focal mural thickening to suggest bowel ischemia (Figure ​(Figure2).2). The diagnosis of superior mesenteric artery thrombosis was made. Subsequently, 12-lead electrocardiography was performed, which showed a normal sinus rhythm. The bedside transthoracic echocardiography showed no intracardiac thrombus.

Figure 1

Abdominal radiograph demonstrating normal bowel loops pattern with no evidence of pneumoperitoneum

Figure 2

Coronal CT image demonstrating an obstructive thrombus (arrow) seen in the superior mesenteric artery

CT: computed tomography

Given the severity of his pain, the patient was given opioid analgesics to relieve it. He received a therapeutic dose of heparin. The patient experienced clinical improvement and was hemodynamically stable. Subsequently, the patient underwent a laparotomy with thrombectomy. He tolerated the operation with no complications and had an uneventful recovery. The patient was discharged in good condition with no active issues after four days of hospitalization. After three months of follow-up, the patient remained asymptomatic.Go to:

Discussion

We reported the case of a superior mesenteric artery thrombosis following the recovery from severe COVID-19 pneumonia in a young adult. It is becoming increasingly evident that the coagulopathy risk in COVID-19 is not limited to the active phase of the disease and may extend beyond the recovery from the disease. Several cases have been reported to support this finding. For example, Alqahtani et al. [5] reported the case of a middle-aged man with acute saddle aortic embolism after recovery from severe COVID-19 pneumonia, which required intubation and mechanical ventilation. They excluded any possible etiologies for the embolic disease. Similarly, Alfahhad et al. [6] reported a case of cerebral venous sinus thrombosis that developed one week following the recovery from severe COVID-19 pneumonia.

The superior mesenteric artery thrombosis in association with COVID-19 has been reported in several case reports [7–9]. However, the occurrence of thrombosis after the recovery from the COVID-19 is unusual with only one reported case in the medical literature so far [10]. Early diagnosis and management of mesenteric artery thrombosis are crucial because it is associated with a high rate of morbidity and mortality [11]. The risk factors for mesenteric thrombosis include cardiac arrhythmia, valvular disease, structural heart disease (e.g., ventricular aneurysm), atherosclerosis, abdominal aortic aneurysm, cardiac surgery, and infective endocarditis [12]. However, our patient did not have any of these risk factors, supporting the pathogenic role of COVID-19 in mesenteric thrombosis.

A high index of suspicion is essential to make the diagnosis of mesenteric thrombosis. The early signs and symptoms of mesenteric thrombosis are very non-specific. However, the diagnosis should be suspected in any patient with abdominal pain of sudden onset, especially if the pain is out of proportion to the physical examination findings. The laboratory findings may reveal metabolic acidosis. However, in the present case, all the laboratory parameters were within normal limits [13]. The definitive diagnosis of mesenteric thrombosis can be made by imaging studies. As in our case, CT angiography is very helpful for a correct diagnosis. The imaging findings can also help in planning the management approach [11].Go to:

Conclusions

The superior mesenteric thrombosis is an unusual complication of COVID-19 pneumonia. This case report provides further evidence on the possibility of patients developing thrombotic events following recovery from COVID-19. Further studies are warranted to investigate the role of prophylactic antithrombotic and anticoagulants in patients who recovered from severe COVID-19. A high index of suspicion is needed to make the diagnosis of mesenteric thrombosis and a CT scan is the best investigative modality to make an accurate diagnosis.Go to:

Notes

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.Go to:

Human Ethics

Consent was obtained or waived by all participants in this studyGo to:

References

1. Venous thromboembolism in hospitalized critical and noncritical COVID-19 patients: a systematic review and meta-analysis. Mansory EM, Srigunapalan S, Lazo-Langner A. TH Open. 2021;5:0–94. [PMC free article] [PubMed] [Google Scholar]

2. Thrombosis in hospitalized patients with COVID-19 in a New York City health system. Bilaloglu S, Aphinyanaphongs Y, Jones S, Iturrate E, Hochman J, Berger JS. JAMA. 2020;324:799–801. [PMC free article] [PubMed] [Google Scholar]

3. Hypercoagulability of COVID-19 patients in intensive care unit: a report of thromboelastography findings and other parameters of hemostasis. Panigada M, Bottino N, Tagliabue P, et al. J Thromb Haemost. 2020;18:1738–1742. [PubMed] [Google Scholar]

4. Severe COVID-19 and coagulopathy: a systematic review and meta-analysis. Mitra S, Ling RR, Yang IX, et al. Ann Acad Med Singap. 2021;50:325–335. [PubMed] [Google Scholar]

5. Saddle aortic embolism following recovery from severe COVID-19 pneumonia. Alqahtani SS, Altowygry SM, Alebiwani TE, et al. Cureus. 2021;13:0. [PMC free article] [PubMed] [Google Scholar]

6. Cerebral venous infarct after recovery from COVID-19 pneumonia. Alfahhad MF, Alghamdi SS, Alzahrani OA, et al. Cureus. 2021;13:0. [PMC free article] [PubMed] [Google Scholar]

7. Superior mesenteric artery thrombosis in COVID-19 pneumonia: an underestimated diagnosis-first case report in Asia. Karna ST, Panda R, Maurya AP, Kumari S. Indian J Surg. 2020;2:1–3. [PMC free article] [PubMed] [Google Scholar]

8. Superior mesenteric artery thrombosis for emergency laparotomy in Covid-19 patient: a case report. Hassan A, Desai P, Al Abady A, Baawain S. Oman Med J. 2021;36:0. [PMC free article] [PubMed] [Google Scholar]

9. Superior mesenteric arterial and venous thrombosis in COVID-19. Amaravathi U, Balamurugan N, Muthu Pillai V, Ayyan SM. J Emerg Med. 2021;60:0–7. [PMC free article] [PubMed] [Google Scholar]

10. Acute superior mesenteric artery thrombosis seven days after discharge for novel coronavirus pneumonia. Bannazadeh M, Tassiopoulos A, Koullias G. J Vasc Surg Cases Innov Tech. 2021;7:586–588. [PMC free article] [PubMed] [Google Scholar]

11. Determinants of mortality and treatment outcome following surgical interventions for acute mesenteric ischemia. Kougias P, Lau D, El Sayed HF, Zhou W, Huynh TT, Lin PH. J Vasc Surg. 2007;46:467–474. [PubMed] [Google Scholar]

12. Clinical implications for the management of acute thromboembolic occlusion of the superior mesenteric artery: autopsy findings in 213 patients. Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M. Ann Surg. 2005;241:516–522. [PMC free article] [PubMed] [Google Scholar]

13. Survival in nonocclusive mesenteric ischemia: early diagnosis by multidetector row computed tomography and early treatment with continuous intravenous high-dose prostaglandin E(1) Mitsuyoshi A, Obama K, Shinkura N, Ito T, Zaima M. Ann Surg. 2007;246:229–235. [PMC free article] [PubMed] [Google Scholar]