Discussion and conclusion:
We report here a case of a hypertensive and diabetic patient presenting a severe form of COVID 19 associated with an ischemia of the left lower limb with an extremely high d-dimer level.
High D-dimer value is associated with severe infection and high risk of thromboembolic events during COVID-19 [6]. Arterial occlusion can be life threatening or can lead to significant disabilities. Our patient had a history of hypertension, previous smoking and type 2 diabetes. According to the literature, these comorbidities are significantly associated with the occurrence of arterial thrombosis during COVD-19 [5]. He was diagnosed with a severe form of COVID-19 and presented at the same time an ischemia of the left lower limb secondary to an extensive thrombosis of several arteries in the left lower limb. Our patient had a D-dimer up to 514 times the upper normal level. The d-dimer level correlates with the severity of the disease and is a reliable prognostic marker of in-hospital mortality in those admitted with COVID-19 [6–8]. The risk of death is therefore high for our patient. In COVID-19, arterial thrombosis mainly involves the heart, the brain, the kidney and the bowels. There were only few reported cases of arterial thrombosis involving limbs including the left arm, the left leg, the right arm and the right leg [5]. However, our case involved the entire left lower limb (thigh, leg, foot).
Gold DD. et al. reported a series of cases of arterial thrombosis. The first case had a thrombosis of the two renal arteries, the superior mesenteric artery and the celiac trunk. The second case had a thrombosis of the aorta, the celiac trunk, hepatic and the splenic arteries. The third case had a cerebral, pulmonary, splenic and renal thrombosis. The fourth case had a thrombosis of the lung, the spleen and the kidney. The last case was a peripheral thrombosis with an occlusion of the radial and ulnar arteries [9]. All five patients had arterial occlusions that were life-threatening or disabling, and four of the five patients did not survive. Despite the severity of the COVID-19 and the arterial occlusion, our case had survived. However, the delay in the management led to a total obstruction of the artery causing ischemia which resulted in amputation. The outcome was unexpected given the severity of COVID-19 and the extensive arterial occlusions in a country like Madagascar with limited technical platform and resources.
One limitation associated with this case report is that we have not been able to perform any serology test for covid 19 to strengthen the diagnosis made by chest CT scan, due to unavailability of this test.
We report a case of an extensive peripheral arterial thrombus with an extremely high D-dimer during COVID-19. Arterial thrombosis can occur during COVID-19, causing peripheral or central ischemia with increased morbidity and mortality. The occurrence of these events is related to the D-dimer value [10]. Thus, this report underlines the potential role of anticoagulation in COVID-19 especially in severe forms and furthermore in patient with cardiovascular comorbidities, or in the case of a high D-dimer value in order to limit the occurrence of thromboembolic diseases.