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Concomitant aortic, inferior mesenteric artery thrombosis and sigmoid colon perforation in severe COVID-19 disease
Trombosis concomitante de la aorta, arteria mesentérica inferior y perforación del colon sigmoide en enfermedad COVID-19 severa
Ana Almeidaa, Jorge Baixaulia,b, Javier A. Cienfuegosa,b,c,
Corresponding author
fjacien@unav.es

Corresponding author.
, Víctor Valentía,b,c, Fernando Rotellara,b,c
a Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
b Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
c CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 31008 Pamplona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">One of the most striking features of infection by SARS-CoV-2 &#8211; unlike other Beta-coronavirus &#40;CoVs&#44; SARS&#44; MERS-coV&#41; &#8211; is the development of thromboembolic complications<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The gastrointestinal thromboembolic complications of SARS-CoV-2 are associated with high mortality &#40;32&#37;&#8211;86&#37;&#41;&#46; We present the case of a patient with severe COVID-19 who developed infrarenal thrombosis and perforation of the colon&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 79-year-old male was transferred to our center with severe bilateral pneumonia due to SARS-CoV-2 &#40;COVID-19&#41; and required mechanical ventilations&#46; He had a history of acute myocardial infarction&#44; hypertension&#44; obesity &#40;BMI 28&#41;&#44; dyslipidemia and chronic obstructive pulmonary disease&#46; On admission his ASA &#40;American Society of Anesthesiology&#41; score was IV&#46; Blood analyses revealed hemoglobin 11&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;Reference Range 13&#46;6&#8211;17&#46;0&#41;&#44; leucocytes 16&#46;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;RR 6&#8211;10&#41; with 91&#37; neutrophils&#44; platelets 251<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;RR 150&#8211;450&#41;&#44; <span class="elsevierStyleSmallCaps">d</span>-dimer 1250<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;RR 150&#8211;500&#41;&#44; C reactive protein 4&#46;6<span class="elsevierStyleHsp" style=""></span>ng&#47;dL &#40;RR 0&#46;0&#8211;0&#46;50&#41;&#44; ferritin 1171&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;L &#40;RR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;L&#41;&#44; lactic acid 2&#46;14 &#40;RR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">He was on antithrombotic prophylaxis with low molecular weight heparin &#40;LMWH&#41;&#44; 5000 UI&#47;1xd&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the deterioration in his neurological state on admission &#40;delirium&#44; mental confusion&#41;&#44; cranial and pulmonary computed tomographic angiography &#40;CTA&#41; was performed which revealed bilateral pneumonia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41; and pneumoperitoneum as a result of which an abdominal CTA was performed which showed pneumoperitoneum&#44; mural thrombosis of the inferior mesenteric artery &#40;IMA&#41; and infrarenal aorta respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient underwent surgery and perforation of the sigmoid colon with purulent peritonitis was identified and a Hartmann&#39;s procedure was performed&#46; The patient progressed favorably after days in intensive care&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The histologic analysis revealed perforation of the colon associated with diverticulosis and a marked inflammatory reaction&#46; A real time reverse-transcription polymerase chain reaction &#40;qRT-PCR&#41; of the RNA extracted from the formalin-fixed&#44; paraffin embedded tissue confirmed the presence of RNA from SARS-CoV-2&#44; N gene&#44; generic N&#58;30&#44;71 in the wall of the colon&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient signed the informed consent for the publication of his clinical information and images&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">One of the most striking phenomena in severe COVID-19 is the high incidence of venous and arterial thromboembolic complications in multiple locations&#44; even when prophylactic doses of low molecular weight heparin &#40;LMWH&#41; have been administered&#44; a phenomenon which has recently been termed &#8220;COVID-19-associated coagulopathy&#8221; &#40;CAC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> This abnormality is characterized by increases in <span class="elsevierStyleSmallCaps">d</span>-dimer&#44; fibrinogen&#44; von Willebrand factor &#40;VWF&#41; and factor VIII with normal platelet levels&#44; prothrombin time &#40;PT&#41; and activated partial thromboplastin time &#40;aPTT&#41; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Recent studies have reported thromboembolic complications in 31&#37; and 49&#37; of COVID-19 patients admitted to intensive care in spite of antithrombotic prophylaxis&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> In our case&#44; thrombosis of the aorta and IMA was associated with perforation of the sigmoid colon with the presence of SARS-CoV-2 in the colon wall&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Several pathogenic mechanisms associated with thromboembolic complications and intestinal ischemia have been proposed&#46; Firstly&#44; vascular thrombosis would be due to the endothelial damage caused by SARS-CoV-2&#44; thanks to the presence in the endothelium of angiotensin-converting enzyme 2 &#40;ACE2&#41; receptors and of type II transmembrane serine proteases &#40;TMPRSS-2&#41; which facilitate the binding of SARS-CoV-2 to the membrane of the cell endothelium a phenomenon known as immune-thrombosis or thrombo-inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;4</span></a> Apart from the binding of viral proteins to the heparan sulfate&#44; the endothelium loses its antithrombotic properties&#44; a reduction in the synthesis of nitric oxide &#40;NO&#41; and an increase in angiotensin-II&#44; which leads to procoagulant abnormalities&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Secondly&#44; direct injury of the mucosa of the intestine and colon has been reported by SARS-CoV-2&#44; which is facilitated by the presence of abundant ACE2 and TMPRSS-2 membrane receptors in the intestine and colon&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> The cell damage and necrosis would induce the innate immune response &#40;the so-called &#8220;cytokine storm&#8221;&#41; secondary to the release of damage-associated molecular patterns &#40;DAMPS&#41; and pathogen-associated molecular patterns &#40;PAMPS&#41;&#44; thus causing the synthesis of proinflammatory and prothrombotic cytokines&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5&#44;8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Finally&#44; it cannot be ruled out that the perforation of the sigmoid colon might be due to the perforation of a diverticulum secondary to occlusive intestinal ischemia or non-occlusive ischemia resulting from abnormalities in perfusion&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In spite of antithrombotic prophylaxis with LMWH and the recommendations of more than 70 scientific societies on antithrombotic prevention&#44; in severe COVID-19 very often oligo-symptomatic &#40;pauci-symptomatic&#41; thromboembolic complications occur which require early diagnosis and treatment given their high morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author contributions</span><p id="par0080" class="elsevierStylePara elsevierViewall">Study concept and design &#40;AA&#44; JAC&#44; JB&#44;&#41;&#44; data collection and analysis &#40;AA&#44; JAC&#41;&#44; manuscript preparation &#40;AA&#44; JAC&#41;&#44; manuscript review &#40;AA&#44; VV&#44; JAC&#44; FR&#41;&#46; All authors reviewed and approved the final draft&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">All authors have no relevant conflicts of interest to report&#46;</p></span></span>"
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es en pt

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