Case 1
An 80-year-old woman presented with acute onset of devastating pain in the right lower extremity since a day ago. The severe aching sensation intensified within a few hours and reached its highest intensity (resting pain) in less than 24 h. There was no previous history of fever, dyspnea, myalgia, or even cough; however, she had just been discharged from the hospital due to confirmed COVID-19 pneumonia 1 week ago and was hospitalized for 15 days. Other than her old age, she only had stage I hypertension and dyslipidemia as her past medical history. She consumed candesartan 1 × 8 mg and multivitamins daily.
Her vital signs in the initial examination were unremarkable (blood pressure 130/80 mmHg, heart rate 100 beats per minute/bpm, respiratory rate 20 times per minute, oxygen saturation 95% in room air). On general examination, we found cyanosed and cold right forefoot (Fig. 1). She had a slight difficulty moving (motoric) her toe and a slight numb (sensory) in her toe. Lower extremity palpation revealed weak pulsation at the posterior and dorsal pedis artery locations, but her popliteal artery was still palpable.
Other than a mild decrease in hemoglobin (11.9 gr/dL) and mild leukocytosis, her routine blood examination was normal. The absolute lymphocyte count was 2200/uL. Her PCR test for COVID-19 was negative since last week, and her current immune-serology anti-IgM and IgG SARS-CoV-19 results were non-reactive. Chest X-ray showed normal cardio-thoracic-ratio/CTR and clear lung interstitial. However, Chest CT scan found multiple bilateral honeycomb appearances and ground-glass opacity (Fig. 2). Unfortunately, coagulation markers such as D-dimer PT/aPTT, CRP, and INR were not performed due to the patient’s refusal.
Doppler ultrasound examination showed normal flow velocity and spectrum in the common right femoral arteries (triphasic curve). Unfortunately, we found an occlusion and thrombus in the 1/3 proximal right popliteal artery with a minimum flow at the distal part of the posterior tibial and dorsalis pedis arteries. There were no clear signs of collaterals and no evidence of thrombus in the vein (deep vein thrombosis) (Fig. 3).
Based on our examination, the patient was diagnosed with acute limb injury classification IIa. Unfortunately, the patient refused to be hospitalized because she was just discharged from the hospital due to COVID-19. We prescribed the patient with aspilet 80 mg, atorvastatin 20 mg, cilostazol 2 × 100 mg, pentoxifylline 2 × 400 mg, candesartan 8 mg, enoxaparin 2 × 0.4 mg subcutaneously, and analgetic drug. In her 1-month follow-up, there was remarkable progress in the clinical appearance. The toe edges appeared to be well-perfused, with complete relief from pain and minimal sign of ischemia. Functionally, she could walk actively with no claudication (Fig. 4).
Case 2
Another 54-year-old female presented to our hospital with a chief complaint of high-continuous fever for 1 week. She also had shortness of breath (dyspnea) in the last 7 days and had gradually worsened. She had a productive cough and high-intensity pain in her right leg. At the initial examination, she already had laboratory results with positive PCR result for COVID-19 and a raised D-dimer and fibrinogen. Our patient had many comorbidities such as obesity, type 2 diabetes mellitus, stage 2 hypertension, dyslipidemia, and chronic obstructive pulmonary disease (COPD). She routinely consumed amlodipine 10 mg, ramipril 5 mg, atorvastatin 20 mg, metformin 3 × 500 mg, and TSA capsule for COPD. Her initial vital signs suggested that her condition was unstable with tachypnea, tachycardia, elevated blood pressure 140/90 mmHg, and hyperpyrexia. Her peripheral oxygen saturation was 88-90% with non-rebreathing mask 10 L/min. Physical examination revealed no rhonchi and wheezing, yet chest X-ray indicated bilateral peripheral chest infiltrates. In further examinations of her lower extremities, we found tenderness of the right lower foot, weak pulsation at the posterior tibial and dorsalis pedis arteries. Distal toes were found to be cyanosed (Fig. 5).
Routine blood count (erythrocyte, leukocyte, hematocrit, hemoglobin, platelets) was showing within normal limits. Urea and creatinine serum level also indicated normal kidney function. Blood glucose level was also within the normal limit. Conversely, her absolute lymphocyte count was low, and neutrophil-lymphocytes-ratio (NLR) was > 3. Coagulation markers, including (D-dimer) and prothrombin time (PT), and activated partial thromboplastin time (aPTT) were dramatically increased. C-reactive protein, one of the markers believed to be associated with the severity of COVID-19 infection, was rapidly increased.
We performed a Doppler ultrasound examination, which was challenging in a pandemic situation. The Doppler ultrasound result showed normal flow velocity and spectrum in the common right femoral arteries (triphasic curve). Nevertheless, we discovered a significant occlusion and thrombus in the distal right popliteal artery, minimal flow in the distal posterior tibial and dorsalis pedis arteries. There was no clear sign of collaterals flow and no evidence of thrombus at vein (deep vein thrombosis).
The patient was hospitalized in the isolation ward with a diagnosis of COVID-19 and acute limb ischemia. She consumed aspilet 80 mg, atorvastatin 20 mg, cilostazol 2 × 100 mg, pentoxifylline 2 × 400 mg, amlodipine 10 mg, and ramipril 5 mg. She was also treated with unfractionated heparin (UFH) IV drip with a target control of 1.5×−2× of aPTT. The patient was prepared for further interventional-thrombolytic therapy; unfortunately, her condition worsened into acute respiratory distress syndrome, and our team decided to go on conservative treatment. She was intubated and ventilated. Two weeks later, her condition deteriorated, and she fell into septic shock. The patient had eventually passed away.
