Introduction

As is the case for so many aspects of COVID-19 pandemic, information on clinical complications caused by this virus continues to emerge and evolve in real time. The majority of patients who have tested positive for COVID-19 present with symptoms of an acute respiratory illness including fever, body aches, lethargy, dry cough and breathing difficulties. However, it appears that the novel coronavirus may impact more than just the lungs, especially in severe cases.

Citation: Hlaihel AF. Deep vein thrombosis as sole presentation of COVID-19 infection. J Clin Images Med Case Rep. 2021; 2(1): 1007.

Case presentation

A 56 years old male presented with left leg A and pain and low grade fever few days ago no history of Joint pain or swelling.

No history of cough or dyspnea or chest pain or dyspnea
No relevent symptoms in other systems
He had history of DVT few years ago with complete recovery
History of DM and hypertension
No recent history of immoblity or surgery
No history of drug or ilicit medication
No smoker and no history of alcohol injestion
Physical examination
Normal viral signs
Tense swelling of left calf with tenderness
Normal systemetic examination
Normal blood sugar and Renal function
Normal PT PTT and INR
Doppler ultrasound of veins showed acute DVT of left popliteal and femoral veins
Normal CBC
Increased CRP 43
Serum Ferritin 543
LDH 170
D-dimer test 1500
Hyperglycemia RBS 260
ECG normal
Chest x-ray lung infliterate
CT typical radiogical finding of COVID-19
Pulse oxumetry 94% oxygen saturation
Put on noval oral anticoagulant(apxiban 5mg)
Antibiotic
Antiviral
Support treatment
Control of DM
Close follow up
Good response to DV

Discussion

The symptoms most commonly reported by patients affected by COVID-19 include fever, dry cough, and shortness of breath [1]. There were no typical and distinguished symptoms of COVID-19 in our patient, and the patient presented with typical symptoms of DVT, such as swelling, pain and tenderness. While he had no risk factor for DVT, laboratory tests and chest X-ray tests showed COVID-19. The most stable hemostatic abnormalities with COVID19 include mild thrombocytopenia5 and increased D-dimer levels [6]. There have been reports of thrombotic disorders with organ dysfunction in patients with COVID-19 resulting in higher mortality [7] but there are few reports of DVT in patients with COVID19. In a study by Zhou et al, a patient with COVID-19 presented with symptoms of acute cerebral infarction. After CT angiography, acute cerebral infarction and DVT in both lower limbs were confirmed [8]. In our case, DVT was suspected due to, pain, and tenderness at the leg veins, which was seen by color Doppler ultrasound in external iliac, common iliac, small saphenous, and large saphenous. Seeing this lesion on the leg, our patient was initially suspected of having thromboembolism, which, after a CT scan, revealed a person with COVID-19, with no evidence of pulmonary thromboembolism. However, in some studies, respiratory deterioration with other clinical evidence of venous thrombosis should lead to suspected pulmonary embolism (PE) [9,10]. In a study by Fu et al, [2] middle-aged patients with a history of acute ischemic stroke in middle age developed COVID-19 with neurological symptoms of acute ischemic stroke, including paralysis of the tongue, dysarthria, and weakness of the limb muscles. Despite high levels of D-dimer, they showed no signs of DVT [11], which was different from our study. Eventually, CT of the head and neck showed blockage of cerebral arteries, blockage of small vessels, and an acute ischemic stroke was confirmed [11]. In a study by Klok et al, 128 patients with COVID-19 symptoms were admitted to the intensive care unit. The cumulative incidence of thrombotic disorders was 31%. Using CT pulmonary angiogram or ultrasonography, venous thromboembolism was detected at 27% and arterial thrombotic events at 3.7%. PE was the most common thrombotic complication (81%). DVT was also diagnosed in 3 patients. These disorders occurred after the diagnosis of COVID-19 in patients due to hospitalization [12], which was different from our patient. Also in some patients with COVID-19, nonspecific myocardial damage, renal dysfunction (leading to troponin accumulation), myocarditis, PE, and myocardial infarction type I and II due to hospitalization and, as a result, coagulation disorders were observed [7].

Conclusion

The exact mechanism of DVT formation due to COVID-19 is unknown despite thrombocytopenia and has not been investigated but it resolved as COVID-19 symptoms, tenderness, and leg pain improved. Although COVID-19 presented with DVT is a rare condition, in middle-aged people with sudden onset of manifestations, we should recognize DVT from other symptoms as an important and treatable symptom for COVID-19 diagnosis. Rapid diagnostic assays, efficient treatment, and prudent use of CT scan are important to control future COVID-19 spread.

References

1. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records. Lancet. 2020; 395: 809-815.
2. Shen K, Yang Y, Wang T, et al. Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: Experts’ consensus statement [published online February 7, 2020]. World J Pediatr.
3. World Health Organization. Coronavirus disease (COVID-19) pandemic. Accessed May 16, 2020.
4. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol. 2020; 17: 259-260.
5. Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. Clin Chim Acta. 2020; 506: 145-148.
6. Terpos E, Ntanasis-Stathopoulos I, Elalamy I, et al. Hematological findings and complications of COVID-19 [published online April 13, 2020]. Am J Hematol.
7. Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up [published online April 15, 2020]. J Am Coll Cardiol.
8. Zhou B, She J, Wang Y, Ma X. A case of coronavirus disease 2019 with concomitant acute cerebral infarction and deep vein thrombosis. Front Neurol. 2020; 11: 296.
9. Xie Y, Wang X, Yang P, Zhang S. COVID-19 complicated by acute pulmonary embolism. Radiology. 2020; 2: e200067.
10. Danzi GB, Loffi M, Galeazzi G, Gherbesi E. Acute pulmonary embolism and COVID-19 pneumonia: a random association?. Eur Heart J. 2020; 41: 1858.
11. Fu B, Chen Y, Li P. The 2019 novel coronavirus disease
12. Klok FA, Kruip MJHA, Endemen H. Incidence of thrombotic complications in critically ill ICU patients with COVID-19.