Acute upper limb ischemia as initial presentation of COVID-19 infection in a 49-year-old male: A case report

ABSTRACT

Background: Coronavirus disease-19 (COVID-19) is an emerging threat because of its significant damage to the lungs and its risk of thrombosis in microvascular, venous, and arterial beds. Moreover, thrombosis in patients with the COVID-19 infection may also be more extensive, leading to limb loss and death. One of the thrombotic complications reported in COVID-19 is acute limb ischemia (ALI), which is characterized with an abrupt decrease in the arterial perfusion of a limb, threatening its viability and integrity. In this report, we describe an unusual case of an unvaccinated patient who presented with acute unilateral upper extremity ischemia as the initial manifestation of COVID-19. Case presentation A 49-year-old man, unvaccinated for COVID-19, presented to the emergency room due to worsening left hand and forearm pain of one week duration. The brachial, radial, and ulnar pulses were absent. Emergency arterial duplex scan of the left arm showed acute thrombi totally occluding the lumen of axillary artery and extending to the proximal to distal brachial, proximal to distal radial and ulnar arteries. Anticoagulant infusion in the form of heparin was immediately started was titrated accordingly depending on aPTT. Surgical embolectomy was offered but could not be immediately done within 6 hours of presentation due to positive result for SARSCoV2. Patient denied history of respiratory symptoms and was also noted to have normal lung findings. During surgical embolectomy, a significant amount of large, elongated acute thrombi were retrieved. Anticoagulation was resumed post-operatively and no signs and symptoms of compartment syndrome were noted. Patient slowly recovered his sensory and motor functions within a month from onset of ALI. Conclusion(s) Thrombotic events such as acute limb ischemia may be the initial manifestation of COVID-19 infection. In this patient, what we found particularly peculiar was that he had no respiratory symptoms despite being unvaccinated during the time that the Delta variant was the prevailing strain of coronavirus. This case underscores the fact that clinicians should have high index of suspicion of COVID-19 infection as a cause of thrombotic events, especially in patients with no or very few risk factors.