Portal vein thrombophlebitis is a rare complication that can occur in various hypercoagulable states, including COVID-19. We are presenting a 74-year-old female with a history of hypertension, diabetes, and lymphoma who contracted the COVID-19 infection and presented with persistent fever, leukocytosis, and mild epigastric tenderness. She developed hypotension, acute hypoxic respiratory failure, and worsening leukocytosis with bandemia and was diagnosed with portal vein thrombosis (PVT) and superior mesenteric vein thrombosis. The patient received broad-spectrum IV antibiotics and full anticoagulation therapy with heparin and was discharged on oral Warfarin after completing 14-day antibiotic therapy. She presented again with recurrent watery diarrhea, fever, abdominal pain, and fatigue and was diagnosed with pylephlebitis and multiple small liver abscesses. The patient was treated with antibiotics for six weeks and was discharged on warfarin, furosemide, and spironolactone with close outpatient follow-up. Prolonged fever in COVID-19 patients can indicate extensive thrombosis at unusual sites, which can lead to major morbidity and mortality in patients.

Coronavirus disease 2019 (COVID-19) has been primarily linked to respiratory complications, including acute respiratory distress syndrome (ARDS). However, several systemic manifestations of the disease may also occur. One of the emerging complications that is being increasingly reported in the literature is the hypercoagulable and intense inflammatory state in COVID-19 patients, which leads to venous and/or arterial thrombosis, vasospasm, and ischemia. Despite the recent advances in diagnostic and treatment modalities, the diagnosis and management of vascular ischemia in this patient population remain a challenge, resulting in increased morbidity and mortality. In this case report, we highlight the etiology and potential treatment of limb ischemia in COVID-19 patients.

A 44-year-old male with a history of deep venous thrombosis (DVT) and pulmonary embolism (PE) with the inferior vena cava (IVC) filter in place and peripheral vascular disease (PVD) status post lower extremity vascular stenting presented from a COVID-19 rehabilitation center with bilateral phlegmasia cerulea dolens and no palpable popliteal or dorsalis pedis pulses, at risk for venous gangrene and loss of limbs. The patient was anticoagulated and taken emergently to the operating room for vascular surgery where thrombolysis with alteplase and mechanical thrombectomy were performed. Bilateral thrombolysis infusion catheters were placed for two days. The patient had a return of arterial signals in the feet and decreasing clot burden. The patient is expected to make a full recovery.

BACKGROUND: Coronavirus disease 2019 (COVID-19) infection is associated with an increased risk of arterial thromboembolic events (ATE) and venous thromboembolic events (VTE). Hypercoagulability associated with COVID-19 infection is multifactorial, and underlying pathogenic mechanisms potentially responsible for thrombosis include inflammation resulting in endothelial damage, platelet activation and the presence of antiphospholipid antibodies (APAs). Antiphospholipid antibody syndrome is one of the very few causes which is associated with venous and arterial thromboembolic events. COVID-19 patients have a high prevalence of APAs as well as both ATE and VTE, but their clinical significance in COVID-19 patients is not fully understood yet.
OBJECTIVE: In this study, we intend to find the prevalence of APAs in hospitalized COVID-19 patients at the time of diagnosis and determine whether their presence has any clinical significance.
METHODS: This is a retrospective single-institution study involving patients hospitalized for the management of COVID-19 infection at The University of Toledo Medical Center. After obtaining approval from the biomedical institutional review board at The University of Toledo, antiphospholipid antibody (APA) testing was done on pre-stored blood samples of these patients and hospital charts were reviewed till six months from the positive COVID-19 test result. Two groups were created based on the patients\' APA testing results (APA positive and APA negative) and used for statistical comparison. Any patients with positive lupus anticoagulant (LA) or abnormal titers APA antibodies were labeled as positive. Demographic data, prognostic outcomes and laboratory values were compared either using Mann-Whitney U-test for continuous variables or Fisher\'s exact test for categorical variables.
RESULTS: The prevalence of APAs in hospitalized COVID-19 patients at the time of diagnosis was 39.3% in this study. There was no difference in demographic variables between the APA-positive and APA-negative groups. The prevalence of APAs was higher in smokers, where 91% of the APA-positive patients were smokers. There was no statistically significant difference in prognostic outcomes including six-month mortality between APA-positive and APA-negative patients. The comorbidity profile was the same in the two groups. APA-positive patients were found to have lower nadir of absolute lymphocyte count and higher nadir levels of C-reactive protein during hospitalization.
CONCLUSIONS: The prevalence of APA positivity in hospitalized COVID-19 patients is higher in our study than in historical studies involving non-COVID-19 hospitalized patients, particularly in smokers. However, there is no correlation between APA positivity and prognostic outcomes including six-month mortality. At this point, it is unclear whether APAs are just bystanders or have a pathogenic role. Routine testing of APA in COVID-19 patients is not indicated. Further prospective studies to elucidate the persistence and clinical implications of APAs are needed.

A 46-year-old male with a history of SARS-CoV-2 infection one month ago presented to the hospital due to acute onset left flank pain. He was found to have an acute left renal embolic infarction from a large 15mm ascending aortic thrombus, which may have formed due to a transient hypercoagulable state from his recent SARS-CoV-2 infection along with tobacco use. He was medically managed with anticoagulation for six months. Subsequent imaging after three months of therapeutic anticoagulation showed complete resolution of the ascending aortic thrombus.

Coronavirus disease 2019 (COVID-19) was thought to mainly affect the respiratory system. However, studies have shown that it can be associated with hypercoagulability leading to thromboembolism. Although venous thromboembolism is a common complication associated with COVID-19, arterial thrombosis and intracardiac thrombosis are not frequently described. We herein report a case of a 54-year-old male with a past medical history of end-stage renal disease, diabetes mellitus, hypertension, heart failure, chronic obstructive pulmonary disease who presented to the emergency department with shortness of breath and was found to have intracardiac thrombus in post-recovery COVID-19 state.

This is a case report of a 47-year-old male with a history of hypertension and pre-diabetes who presented to the emergency department with dyspnea, progressive unilateral leg swelling and pain. The patient tested positive for coronavirus disease 2019 (COVID-19) infection about a week earlier. The patient was found to have an extensive clot burden of his lower extremity veins, both deep and superficial, which extended to his inferior vena cava (IVC). Based on the patient\'s clinical exam and ultrasound findings, the patient was diagnosed with impending phlegmasia cerulea dolens. Due to his renal failure, the patient was taken for a ventilation/perfusion (V/Q) scan which found widespread V/Q mismatch highly suggestive of pulmonary embolism. Interventional radiology took the patient for lower extremity venogram, catheter-directed alteplase administration, and IVC filter placement. The patient was admitted to the intensive care unit (ICU) for further management and had a stable recovery.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or coronavirus disease 2019 (COVID-19), first identified in December 2019 in Wuhan, China, has rapidly spread worldwide, is now a public health emergency, and has been declared a pandemic. While SARS-CoV-2 is known to cause significant pulmonary disease, ranging from pneumonia to acute respiratory distress syndrome (ARDS), various extrapulmonary manifestations of COVID-19 have also been reported. Growing evidence suggests that COVID-19 leads to a hypercoagulable state leading to micro and macro-vascular angiopathies. We present a case of an 80-year-old male without a previous history of prothrombotic disorders who developed descending aortic thrombosis, approximately 40% stenosis, at the level of the diaphragmatic hiatus and acute limb ischemia secondary to COVID-19 requiring emergent surgical intervention. After 12 days of persistent ischemic left lower extremity imaging despite thrombectomy, bypass, and therapeutic heparin, the patient\'s limb was deemed non-salvageable and underwent left above-knee amputation. Transthoracic echocardiogram revealed normal left ventricular function, moderate pulmonary hypertension, and no evidence of atrial septal defect, aortic root abnormalities, or intraventricular thrombi. Evaluation of autoimmune and inflammatory vasculitis was negative. While further study into the prothrombotic nature of this condition still needs to be pursued, the thromboembolic risk of COVID-19 represents an urgent need for appropriate anticoagulation for venous thrombosis. Arterial thrombosis requires other kinds of management to avoid the severe adverse effects of emboli and related ischemia. This current case highlights the need for randomized control trials testing different prophylactic strategies. Further evidence is also required for the role of amputation surgery when initial interventions for revascularization fail to restore blood flow.