A 40-year-old male with no known comorbidities, brought from a quarantine facility due to positive throat PCR swab for COVID- 19 pneumonia complains of fever and severe left sided abdominal pain since 3 days. Laboratory studies were notable for lymphopenia, mildly increased prothrombin time and activated partial prothromboplastin time. Vital signs unremarkable except for low grade fever. No respiratory complains were reported.
CT of abdomen and pelvis was done with intravenous contrast and showed completely occluding continuous filling defect in the inferior mesenteric vein along its whole length up to portosplenic confluence extending slightly to splenic vein. The wall the veins appear hyperdense. Marked mesenteric congestion is noted predominantly around the course of inferior mesenteric vein. Mild circumferential wall thickening of rectum including recto sigmoid junction measuring approximately 8.2 mm associated with perirectal fat stranding seen. Mild pericolic fat stranding also seen in adjacent to descending colon. No evidence of pneumatosis intestinalis. Ground glass opacities are noted in the visualized basal segments of the lungs.
The causative agent of COVID-19, Coronavirus SARS-CoV-2 is characterized by an exaggerated inflammatory response that can lead to severe manifestations such as adult respiratory syndrome, sepsis, coagulopathy, and death in a proportion of patients (1). Severe acute respiratory syndrome CoV 2 parades a huge threat to the world that goes far beyond the spread and risks of SARS-CoV. Like wise high incidence of thrombotic complications are also reported in critically ill patients with COVID -19 which is described in up to 50% of patients with severe manifestation (2). Coagulopathy in COVID-19 is triggered by increase in the vasoconstrictor angiotensin II, decrease in the vasodilator angiotensin and sepsis-induced release of cytokines. Increase in d-dimer is the most significant change in coagulation parameters in such patients and recorded more frequently than other coagulation parameters such as prothrombin time (PT) or aPTT (3)
The usual clinical manifestations of COVID-19 include fever, cough and myalgia. Severe patients may develop dyspnoea, lymphopenia and/or hypoxemia several days later and progress rapidly to acute respiratory distress syndrome. Recent studies have reported higher number of venous thrombotic complications in patients with pneumonia related to SARD-CoV2 infection. (4) Clinical symptoms of mesenteric venous thrombosis are nonspecific and are mainly characterized by abdominal pain,
Signs of peritonitis on physical examination is an indicator of irreversible ischemia and bowel necrosis
Plain abdominal radiograph may show thumbprinting suggestive of intestinal wall edema. Pneumatosis, portal venous gas and pneumoperitoneuym point to infarcted bowel. Multidetector computed tomography is the modality of choice in this setting, especially for early diagnosis. Key findings in these patients include partial or complete venous filling defect, increase in the expected caliber of the vein, sharply defined vein wall with a rim of increased density, engorgement of mesneteric veins due to congestion. Late findings include persistance enhancement of the bowel wall, penumatosis intestinalis, portal vein gas.(5,6). Mesenteric fat edema is more pronounced in venous thrombosis than arterial occulsions (7). Late findings include bowel dilataion from ischemia, free intraperitoneal air in perforation of an infarcted bowel segment
Mesenteric venous thrombosis diagnosis is often delayed. Early diagnosis with early treatment with anticoagulation or combination with surgery is necessary to prevent bowel infarction.
Take-Home Message / Teaching Points
 Wolfgang Miesbach , Michael Makris (2020) COVID-19: Coagulopathy, Risk of Thrombosis, and the Rationale for Anticoagulation. Clin Appl Thromb Hemost. 2020 Jan-Dec;26:1076029620936776. doi: 10.1177/1076029620936776. (PMID: 32687449)
 Zhou, F, Yu, T, Du, R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054–1062. doi:10.1016/S0140-6736(20)30566-3
 Ang, N, Li, D, Wang, X, Sun, Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844–847. doi:10.1111/jth.14768
 Helms J., Tacquard C., Severac F. High risk of thrombosis in patients with severe SARS-COV-2 infection: A multicenter prospective cohort study. Intensive Care Med.2020: 1-10. doi:10.1007/s00134-020-06062-x
 Boley SJ, Kaleya RN, Brandt LJ. Mesenteric venous thrombosis. Surg Clin North Am 1992;72:183-201
 Wiesner W, Mortelé KJ, Glickman JN, Ji H, Ros PR. Pneumatosis intestinalis and portomesenteric venous gas in intestinal ischemia: correlation of CT findings with severity of ischemia and clinical outcome. AJR Am J Roentgenol 2001;177(6):1319–1323
 Whitehead R. The pathology of ischemia of the intestines. Pathol Annu 1976;11:1–52.
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