Acute upper limb ischemia in a patient with COVID-19.

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection mainly present with upper and lower respiratory tract symptoms, with complications related to cytokine storm syndrome and acute respiratory distress syndrome. It has also been described to predispose to venous and arterial thromboembolism; however, limited published data is available regarding thrombosis in coronavirus disease 2019 (COVID-19). Here we are presenting a case of arterial thrombosis in a patient with COVID-19 and a systematic review on coagulopathy associated with COVID-19.

COVID-19 Presenting as Acute Limb Ischaemia.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic that developed in late 2019 and early 2020 has caused thousands of deaths and has had an enormous impact on our health systems and economies. Coronavirus disease 2019 (COVID-19) complications include disseminated coagulation and thrombosis, but, to the best of our knowledge, the literature to date on these manifestations has been limited. Herein, we report an unusual presentation in a 43-year-old man with a medical history of diabetes and hypertension who presented with dyspnoea and acute pain in his right leg and was found to have acute limb ischaemia and diabetic ketoacidosis. Our case adds to the literature regarding arterial thrombosis in COVID-19. LEARNING POINTS: Arterial thrombosis in the form of acute limb ischaemia can occur in COVID-19.A high index of suspicion should be maintained for acute limb ischaemia, which is a vascular emergency.

Pulmonary embolism: A complication of COVID 19 infection.

The Coronavirus Disease 2019 (COVID 19) has been reported in almost every country in the world. Although a large proportion of infected individuals develop only mild symptoms or are asymptomatic, the spectrum of the disease among others has been widely variable in severity. Additionally, many infected individuals were found to have coagulation markers abnormalities. This is especially true among those progressing to severe pneumonia and multi-organ failure. While the incidence of venous thromboembolic (VTE) disease has been recently noted to be elevated among critically ill patients, the incidence among ambulatory and non-critically ill patients is not yet clearly defined. Herein, we present six patients who didn't have any hypercoagulable risk factors yet presented with pulmonary embolism in association with COVID 19 infection. Furthermore, we discuss the possible underlying mechanisms of hypercoagulability and highlight the possibility of underdiagnosing pulmonary embolism in the setting of overlapping symptoms, decreased utilization of imaging secondary to associated risks, and increased turnover times. In addition, we emphasize the role of extended thromboprophylaxis in discharged patients.

Conquering the pneumococcal nemesis with oral antibiotics.

Introduction: Streptococcus pneumoniae endocarditis (SPE) occurs in <3% of all EI cases due to the evolution of penicillin and vaccination. However, immunocompromised and unvaccinated patients are still at grave risk. Case: A 58-year-old African American male who used alcohol and intravenous (IV) drugs presented with confusion, fever, and hemoptysis. He had coarse rhonchi with a grade 2/5 holosystolic apical murmur. CT chest showed diffuse bilateral infiltrates. Blood cultures were positive for pansensitive Streptococcus pneumoniae. Echocardiogram demonstrated large vegetations on the anterior and posterior leaflets of the mitral valve with flail leaflet and severe eccentric mitral regurgitation. Patient was started on IV ceftriaxone, but after 3 weeks of therapy, he wished to leave against medical advice. He was discharged on combination oral therapy with successful resolution of SPE on follow-up. Discussion: Invasive pneumococcus is highly virulent causing irreversible valvular destruction or death. IV beta-lactams are first-line treatment, but there are currently no guideline-recommended alternatives for oral therapy. Recent data suggest partial oral therapy may be noninferior to IV only therapy. Conclusion: Switching to oral combination antibiotics after at least 2 weeks of IV therapy is an acceptable alternative to treat SPE.

Primum Non Nocere: A Rare Case of Amplatzer Erosion and Cardiac Pseudoaneurysm with Multimodality Imaging.

Complications of septal-occluder devices include erosion, perforation, and embolization, which are most commonly caused by oversized devices or thin rim margins. Cardiac pseudoaneurysm is a rare phenomenon that forms as a result of device erosion into the myocardium. Although this is often an incidental finding, they are at risk for rupture. (Level of Difficulty: Intermediate.).

Warfarin-induced leukocytoclastic vasculitis and proteinuria.

Warfarin is typically prescribed for patients with thromboembolic diseases and atrial fibrillation. In addition to the complications of bleeding, allergic skin reaction is one of its rare adverse effects. We herein report a case of a 79 year old male patient with leukocytoclastic vasculitis and proteinuria secondary to warfarin. The warfarin was discontinued and oral prednisone therapy was initiated. The cutaneous lesions and the proteinuria resolved thereafter.