Presentation
COVID-19 ICU patient presented with progressive abdominal distension and pain with clinical signs suggestive of bowel obstruction.
Patient Data
Complete occlusion of the celiac trunk and its main branches (splenic, hepatic and left gastric). Subsequent infarctions and ischemic injuries to the following:
- Massive splenic infarction, with sparing of a small area located medially underneath the splenic capsule (less than 10% of splenic volume)
- The tail of the pancreas infarction (the distal-most 4cm). The pancreatic duct is minimally dilated throughout the body and proximal tail.
- The gastric mucosa shows linear enhancement, with high suspicion of a solitary tiny gas density underneath, raising the possibility of developing gastric pneumatosis. The stomach itself is markedly dilated, with an air-fluid level.
- The portal vein and its branches are well enhanced in the arterial phase. The hepatic artery didn’t show up.
- The SMA looks patent. The small bowel shows mild diffuse wall thickening, possibly reflecting an element of hypo-perfusion. Multiple small gas densities are seen within, but no evidence of pneumatosis.
- Mild to moderate ascites.
Other findings:
- Right lower ureteric stones with subsequent mild hydronephrosis and hydro ureter.
- Calcified uterine fibroid noted.
- A nasogastric tube was seen in place.
- A urinary catheter is seen.
- L4/5 and L5/S1 posterior disc protrusions.
- Lower chest cuts show a mixture of ground glass and consolidative areas with atelectatic bands and pleural effusions.
Case Discussion
In the current era of COVID-19, there are strong associations with thromboembolic vascular events in up to 30% of ICU patients, even with pharmacological thromboprophylaxis.
In some cases, it may be the first presentation, including pulmonary arterial embolism, peripheral circulation of limbs, and/or mesenteric vascular occlusion, as in this case. Thrombotic events are associated with 5.4 times higher risk of mortality.
A recent post-mortem examination has demonstrated severe endothelial injury (inflammatory mediators storm-induced -vascular intima injury and vasculitis) and the intracellular virus within lung autopsies with thrombosis of small and middle-sized pulmonary vessels.
Usually, developing thromboembolic events in COVID cases carries a bad prognosis and is considered a sign of deteriorating clinical condition.
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