INTRODUCTION:
Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, is well-known for its diverse systemic manifestations. The virus utilizes its spike protein to bind to angiotensin-converting enzyme 2 (ACE2) receptors, which are found in multiple organs including the lungs, kidneys, and vascular endothelium. This interaction can trigger a cascade of events, leading to various complications. We present a case of a 73-year-old male who developed COVID pneumonia and acute respiratory distress syndrome (ARDS), further complicated by compartment syndrome and rhabdomyolysis. These severe conditions arose as a consequence of extensive arterial thrombosis in his right lower extremity, directly linked to a COVID-induced hypercoagulable state. This case underscores the importance of considering less common, yet critical, complications like compartment syndrome in patients with severe COVID-19.
CASE PRESENTATION:
A 73-year-old male with a significant cardiac history, including coronary artery disease and a triple coronary artery bypass graft ten years prior, along with type 2 diabetes mellitus, presented to the emergency department. His chief complaint was progressively worsening dyspnea over the course of a week. Upon evaluation, he was diagnosed with COVID-19 pneumonia via nasopharyngeal swab. His initial assessment revealed an oxygen saturation of 85% on room air, necessitating supplemental oxygen. A chest X-ray (CXR) confirmed bilateral diffuse alveolar infiltrates, leading to his hospital admission.
His respiratory status deteriorated over the next five days, requiring escalation of respiratory support to maximum supplementation via high flow nasal cannula (HFNC). He was subsequently transferred to the medical Intensive Care Unit (ICU). Due to worsening severe ARDS, he was intubated and placed on mechanical ventilation for the remainder of his hospitalization.
Three days into his ICU stay, a critical vascular event was noted. His right lower extremity became cold, and pulses were neither palpable nor detectable via bedside Doppler from the femoral artery down to the pedal arteries. A formal ultrasound Doppler confirmed extensive arterial thrombosis, spanning from the right external iliac artery to the posterior tibial arteries. Immediate interventions included embolectomy, stenting, and initiation of therapeutic heparin.
Despite these interventions, within 24 hours, the patient’s condition worsened. While his initial creatinine kinase levels were normal, he developed significantly elevated myoglobin and lactate levels, along with worsening acidosis. Compartment syndrome was suspected and confirmed, necessitating an emergency fasciotomy of the right lower extremity.
The subsequent day, the patient developed anuria, further compounding his critical state with severe acidosis, hyperkalemia, and hypotension. Continuous Renal Replacement Therapy (CRRT) and vasopressor support were initiated to manage these complications. After three days on dialysis, with no signs of clinical improvement and facing a poor prognosis, the family opted for comfort measures. Compassionate extubation was performed, and the patient passed away.
DISCUSSION:
Compartment syndrome is a serious condition characterized by elevated pressure within enclosed muscle compartments. This increased pressure compromises blood flow, leading to cellular necrosis and rhabdomyolysis, the breakdown of muscle tissue that releases harmful substances into the bloodstream. In this particular case, the hypercoagulable state induced by the COVID-19 infection played a central role. The viral impact on the coagulation system resulted in extensive arterial thrombosis, which in turn precipitated compartment syndrome and subsequent acute renal failure requiring CRRT.
The pathophysiology of COVID-19-related hypercoagulability remains an area of ongoing research and debate. However, clinical observations consistently reveal a spectrum of thromboembolic manifestations in COVID-19 patients. These range from more commonly recognized conditions like deep venous thrombosis (DVT) and pulmonary embolism (PE) to more severe arterial events, including stroke and, as highlighted in this case, acute limb ischemia leading to compartment syndrome. This case emphasizes that while respiratory complications are the hallmark of severe COVID-19, vascular complications, such as compartment syndrome stemming from arterial thrombosis, must be considered, especially in critically ill patients.
CONCLUSIONS:
COVID-19 is undeniably a complex and aggressive viral illness with wide-ranging effects on various organ systems and the vasculature. This case serves as a stark reminder of the diverse and sometimes unexpected complications that can arise in critically ill COVID-19 patients. When managing these complex cases, clinicians must maintain a high index of suspicion for all forms of vascular thromboembolism, including the potential for compartment syndrome, to ensure prompt diagnosis and intervention and improve patient outcomes.
REFERENCES:
- Jamal M, Bangash HI, Habiba M, et al. Immune dysregulation and system pathology in COVID-19. Virulence. 2021;12(1):918-936. doi:10.1080/21505594.2021.1898790
- Hu Y, Meng X, Zhang F, Xiang Y, Wang J. The in vitro antiviral activity of lactoferrin against common human coronaviruses and SARS-CoV-2 is mediated by targeting the heparan sulfate co-receptor. Emerg Microbes Infect. 2021;10(1):317-330. doi:10.1080/22221751.2021.1888660
- Bibbo C. Reconstruction of COVID-19-Related Compartment Syndrome With Massive Soft Tissue Necrosis. Wounds. 2021;33(4):99-105.
DISCLOSURES:
No relevant relationships by Kendall Creed, source=Web Response
No relevant relationships by Navkiran Randhawa, source=Web Response
No relevant relationships by Sima Shahbandar, source=Web Response
No relevant relationships by Sabrina Siddiqui, source=Web Response
No relevant relationships by Victor Test, source=Web Response
