LAUSR

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Venous thromboembolism (VTE) and arterial thrombosis (AT) are known complications associated with critically ill COVID-19 patients. We report a case of a patient that developed an acute aortoiliac thrombosis and acute limb ischemia despite high-dose VTE prophylaxis and was subsequently found to have chronic lymphocytic leukemia (CLL). CASE PRESENTATION: A 62-year-old male with coronary artery disease and diabetes was admitted to the intensive care unit for acute hypoxemic respiratory failure from COVID-19 pneumonia. He was treated with Remdesivir, dexamethasone 6mg daily, and enoxaparin 30mg twice daily. On hospital day 5, he developed acute left lower extremity pain with sensory and motor loss and bilateral lower extremities became cold and pale. He had no palpable femoral or popliteal pulses and posterior tibial and dorsalis pedis pulses were not detected by doppler. A CTA demonstrated an acute, nearly occlusive thrombus at the level of the distal infrarenal aorta with extension to bilateral iliac and femoral arteries. The patient was taken emergently to the operating room and underwent percutaneous thrombectomy and left lower extremity fasciotomy. On further review, he was noted to have significant lymphocytosis (83% on admission), an unexpected finding for a patient with COVID-19. As a result, peripheral flow cytometry was performed and demonstrated CD5 positive B-cell leukemia. The patient eventually discharged to acute rehab after a 42-day hospitalization. DISCUSSION: Since the start of the pandemic, the thrombotic complications of COVID-19 have been a major research focus given the high incidence and associated increased risk of mortality. Most of the research has centered around VTE as the incidence among ICU patients with COVID-19 is estimated at 20-30%. The rate of AT is much less with an overall incidence between 2-4% and only 0.4% associated with acute limb ischemia. Our patient was at higher risk for thrombotic complications given his underlying but undiagnosed CLL. His lymphocytosis was striking, particularly because lymphopenia is the usual finding in patients with COVID-19, and further work up revealed the CLL diagnosis. CONCLUSIONS: Thrombotic complications are common and carry a higher risk of mortality in patients with COVID-19. While the rate of AT is much less compared with VTE, critical care practitioners must remain vigilant, particularly when patients are receiving mechanical ventilation and unable to report symptoms, and be mindful of other conditions, potentially undiagnosed, that may further predispose to thrombosis. REFERENCE #1: Jiménez D, García-Sanchez A, Rali P, Muriel A, Bikdeli B, Ruiz-Artacho P, Le Mao R, Rodríguez C, Hunt BJ, Monreal M. Incidence of VTE and Bleeding Among Hospitalized Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis. Chest. 2021 Mar;159(3):1182-1196. REFERENCE #2: Malas MB, Naazie IN, Elsayed N, Mathlouthi A, Marmor R, Clary B. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis. EClinicalMedicine. 2020 Dec;29:100639. REFERENCE #3: Tan BK, Mainbourg S, Friggeri A, Bertoletti L, Douplat M, Dargaud Y, Grange C, Lobbes H, Provencher S, Lega JC. Arterial and venous thromboembolism in COVID-19: a study-level meta-analysis. Thorax. 2021 Feb 23:thoraxjnl-2020-215383. DISCLOSURES: No relevant relationships by Amanda Jobe, source=Web Response No relevant relationships by Mohamed Ramez Mourad, source=Web Response