Severe Acute Acrocyanosis and Digital Gangrene as a Sign of Catastrophic COVID-19 Infection

Abstract

Coronavirus Infection Disease-2019 (COVID-19) may present with different symptoms and complications during its course. Emerging evidence suggests that it induces a hypercoagulable state with micro and macroangiopathy. This hypercoagulopathy has been identified in a subset of critically ill COVID-19 patients. However, extremity ischaemia with acrocyanosis and digital gangrene has not been commonly reported with COVID-19. It is caused due to microangiopathic and immunothrombosis phenomenon, and may be accompanied by microvascular involvement of other organs. Here, a case of critically ill 67-year-old male COVID-19 patient is reported who developed digital acrocyanosis and gangrene in lower limbs while being mechanically ventilated for severe Acute Respiratory Distress Syndrome (ARDS) despite being haemodynamically stable (i.e., not needing vasopressor) and on therapeutic anticoagulation. He subsequently succumbed to his disease due to multiorgan dysfunction. This suggests that extremity ischaemia correlates with poor prognosis in this small subset of critically ill COVID-19 patients, and can have a prognostic role in the disease outcome. It may be the first clinical manifestation even in non-vasculopathic patients.

Keywords

• cytokine storm
• hypercoagulopathy
• immunothrombosis
• microangiopathy