• Irena Gigovska Dimova Department of Urgent medicine and Intensive Care, Faculty of Medicine, University of Cyril and Methodius in Skopje, R.of North Macedonia
  • Daniela Buklioska Ilievska Department of Pulmology, Faculty of Medicine, University of Cyril and Methodius in Skopje, R.of North Macedonia
  • Natasha Nedeska Minova Department of Endocrinology, General Hospital 8th September, Faculty of Medical Sciences, University "Goce Delcev" Shtip, R.of North Macedonia
  • Keti Terzievska Department of Urgent medicine and Intensive Care, Faculty of Medicine, University Ss. Cyril and Methodius in Skopje, R.of North Macedonia


With no ideal specific therapy confirmed by the science community, and many low income countries barely being able to obtain a sufficient number of vaccines, as well as the long-term mental health impact, the COVID-19 infection makes for a worldwide health and global problem. A COVID-19 positive patient was admitted due to poor condition, malaise and bilateral interstitial pneumonia with borderline oxygen saturation of 94%, hypoxemia with pO2 of 64mmHg, and elevated C reactive protein (CRP) of 70. The patient was put on oxygen support of 3l/min, and started parenteral antibiotic and LMWH in prophylactic doses - a combination that primarily improved the patient’s condition.  Three days after hospitalization marked shortness of breath with a drop in oxygen saturation of 62% referred. With further increasing of the oxygen flow, and a transfer to ICU, gas pressures showed significant worsening and the patient was put on mechanical support with a CPAP mask. Despite adding pulsed doses of potent corticosteroid, rapid acting insulin for blood glucose control, and administerring convalescent plasma and parenteral nutrition, the CRP levels were increasing and oxygen was decreasing. Hypotensive, tachycardic and with reduced urine output, the patient was intubated and set up on IPPV mechanical support. Vasopressor stimulation didn’t improve the diuresis and elevation of degradation products followed, as well as elevation of the troponin and cardiospecific enzymes - non of which was caused by sepsis. Eight days after admission, the left arm presented as pale, cool and cyanotic. Fully deteriorated laboratory findings of multiple organ system failures (MOFS) were undoubtable; with the oxygen levels incompatible of life, and a CT scan with ARDS presentation, a continuous heparin infusion was the only solution. At the beginning, nothing indicated the deleterious outcome; however, with a highly unusual presentation of arterial thrombosis, the upper limb gangrene became too much and the patient died. COVID-19 is primary a respiratory infection, but the virus can affect other organs and systems, with some very rare presentations and deleterious outcomes.

Keywords: COVID 19, limb ischemia, thromboembolism, COVID-19-associated coagulopathy, multiple organ system failure.


1. Zheng J. SARS-CoV-2: an Emerging Coronavirus that Causes a Global Threat. Int J Biol Sci. 2020;16(10):1678-1685. Published 2020 Mar 15. doi:10.7150/ijbs.45053.
2. Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges. Int J Antimicrob Agents. 2020;55(3):105924. doi:10.1016/j.ijantimicag.2020.105924.
3. Coronavirus disease (COVID-19). World Health Organization. https://www.who.int/emergencies/diseases/novel-coronavirus-2019 . Updated July 1, 2021. Accessed July 2, 2021.
4. COVID-19 pandemic in Europe. Wikipedia. https://en.wikipedia.org/wiki/COVID-19 pandemic in Europe Updated July 1, 2021. Accessed July 2, 2021.
5. Corona Virus. Ministry of Health of Republic of North Macedonia. http://zdravstvo.gov.mk/korona-virus/ Updated July 1, 2021. Accessed July 2, 2021.
6. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. World Health Organization. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations . Updated March 29, 2021. Accessed July 2, 2021.
7. David J Cennimo. Coronavirus Disease 2019 (COVID-19) Clinical Presentation. Medscape Drugs & Diseases. https://emedicine.medscape.com/article/2500114-clinical. Updated June 29, 2021. Accessed July 2, 2021.
8. Clinical Spectrum of SARS-CoV-2 Infection. National Institutes of Health COVID-19 Treatment Guidelines. https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/. Updated April 21, 2021. Accessed July 2, 2021.
9. Williamson, E., Walker, A., Bhaskaran, K., Bacon, S., Bates, C., Morton, C., Curtis, H., Mehrkar, A., Evans, D., Inglesby, P., Cockburn, J., McDonald, H., MacKenna, B., Tomlinson, L., Douglas, I., Rentsch, C., Mathur, R., Wong, A., Grieve, R., Harrison, D., Forbes, H., Schultze, A., Croker, R., Parry, J., Hester, F., Harper, S., Perera, R., Evans, S., Smeeth, L. and Goldacre, B., 2020. Factors associated with COVID-19-related death using OpenSAFELY. Nature, 584(7821):430-436. doi: 10.1038/s41586-020-2521-4.
10. Hewitt J., Carter B., Vilches-Moraga A., Quinn TJ, Braude P., Verduri A., Pearce L., Stechman M., Short R., Price A., Collins JT, Bruce E., Einarsson A., Rickard F., Mitchell E., Holloway M., Hesford J., Barlow-Pay F., Clini E., Myint PK, Moug SJ, McCarthy K., 2020. The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study. Lancet Public Health. Lancet Public Health. 5(8):444-451.
11. Iqbal FM, Lam K, Sounderajah V, Clarke JM, Ashrafian H, Darzi A. Characteristics and predictors of acute and chronic post-COVID syndrome: A systematic review and meta-analysis. EClinicalMedicine. 2021;36(100899):100899.
12. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in pat. with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-847.
13. Al-Jahdhami I, Al-Naamani K, Al-Mawali A. The Post-acute COVID-19 Syndrome (Long COVID). Oman Med J. 2021;36(1):e220. Published 2021 Jan 26. doi:10.5001/omj.2021.91.
14. Post-COVID Conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html . Updated April 8, 2021. Accessed July 2, 2021.
15. Know Your Treatment Options for COVID-19. U.S. Food & Drug Administration. https://www.fda.gov/consumers/consumer-updates/know-your-treatment-options-covid-19 . Updated March 11, 2021. Accessed July 2, 2021.
16. William F. Marshall, III M.D. COVID-19 (coronavirus) drugs: Are there any that work? Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/coronavirus/expert-answers/coronavirus-drugs/faq-20485627 . Updated June 2, 2021. Accessed July 2, 2021.
17. COVID-19 advice for the public: Getting vaccinated. World Health Organization. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/advice . Updated June 22, 2021. Accessed July 2, 2021.
18. COVID-19. Wikipedia. https://en.wikipedia.org/wiki/COVID-19 . Updated July 2, 2021. Accessed July 2, 2021.
19. Chisari, Alberto & Pistritto, Anna-Maria & Bellosta, Raffaello & Ferraresi, Roberto & Danzi, Gian. (2016). Upper limb Ischemia from arterial thromboembolism: A comprehensive review of incidence, etiology, clinical aspects, diagnostic tools, treatment options and prognosis. Minerva cardioangiologica. 64.
20. Jean Deguara, Tahir Ali, Bijan Modarai, Kevin G. Burnand. Upper Limb Ischemia: 20 Years Experience from a Single Center. Vascular. 2005;13(2):84-91.
21. E. Jane H. Turner, Alexander Loh, Adam Howard. A Conservative Approach to Acute Upper Limb Ischemia. Vascular Disease Management. https://www.hmpgloballearningnetwork.com/site/vdm/content/conservative-approach-acute-upper-limb-ischemia . Published November, 2010. Accessed July 2, 2021.
22. Mondal S, Quintili AL, Karamchandani K, Bose S. Thromboembolic disease in COVID-19 patients: A brief narrative review. J Intensive Care. 2020;8(1):70.
23. Di Micco P, Núnez Fernández MJ, Riviere AB, Brenner B. Editorial: Thrombotic disorders, prothrombotic abnormalities and COVID-19. Front Med (Lausanne). 2021;8:676137.
24. Kohansal Vajari M, Shirin M, Pourbagheri-Sigaroodi A, Akbari ME, Abolghasemi H, Bashash D. COVID-19-related coagulopathy: A review of pathophysiology and pharmaceutical management. Cell Biol Int. 2021;(cbin.11623). doi:10.1002/cbin.11623.
25. Colling ME, Kanthi Y. COVID-19-associated coagulopathy: An exploration of mechanisms. Vac Med. 2020;25(5):471-478.
26. Malas MB, Naazie IN, Elsayed N, Mathlouthi A, Marmor R, Clary B. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis. EClinicalMedicine. 2020;29(100639):100639.
27. Full-dose blood thinners decreased need for life support and improved outcome in hospitalized COVID-19 patients. National Heart, Lung, and Blood Institute (NHLBI). https://www.nih.gov/news-events/news-releases/full-dose-blood-thinners-decreased-need-life-support-improved-outcome-hospitalized-covid-19-patients . Published January 22, 2021. Accessed July 2, 2021.
28. Casini A, Alberio L, Angelillo-Scherrer A, et al. Thromboprophylaxis and laboratory monitoring for in-hospital patients with COVID-19 - a Swiss consensus statement by the Working Party Hemostasis. Swiss Med Wkly. 2020;150:w20247.
29. Yao Y, Cao J, Wang Q, et al. D-dimer as a biomarker for disease severity and mortality in COVID-19 patients: a case control study. J Intensive Care. 2020;8(1):49.
30. Antithrombotic Therapy in Patients With COVID-19. National Institutes of Health COVID-19 Treatment Guidelines. https://www.covid19treatmentguidelines.nih.gov/therapies/antithrombotic-therapy/ . Updated February 11, 2021. Accessed July 2, 2021.
31. Christian Hoffmann, Bernd Sebastian Kamps. Covid Reference. The Covid Textbook. https://covidreference.com/clinical. Published January 20, 2021. Accessed July 2, 2021.
32. Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with Coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020;158(3):1143-1163.
33. Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(23):2950-2973Al-Zoubi N, Shatnawi N, Jarbo H. Acute lower limb ischemia in patients infected with COVID-19. Int J Gen Med. 2021;14:833-839.
34. Topcu AC, Ariturk C, Yilmaz E. Acute limb ischemia in a COVID-19 patient. Thrombosis Update. 2021;2:100031. doi:10.1016/j.tru.2020.100031
35. Bellosta R, Luzzani L, Natalini G, et al. Acute limb ischemia in patients with COVID-19 pneumonia. J Vasc Surg. 2020;72(6):1864-1872.
36. Max Wohlauer, RPVIYana Etkin. COVID-19: Acute limb ischemia. UpToDate. https://www.uptodate.com/contents/covid-19-acute-limb-ischemia . Updated May 10, 2021. Accessed July 2, 2021.
37. Kaur P, Qaqa F, Ramahi A, et al. Acute upper limb ischemia in a patient with COVID-19 [published online ahead of print, 2020 May 13]. Hematol Oncol Stem Cell Ther. 2020;S1658-3876(20)30096-0. doi:10.1016/j.hemonc.2020.05.001
38. Shao T, In-Bok Lee C, Jabori S, Rey J, Duran ER, Kang N. Acute upper limb ischemia as the first manifestation in a patient with COVID-19. J Vasc Surg Cases Innov Tech. 2020;6(4):674-677.
39. Lari E, Lari A, AlQinai S, et al. Severe ischemic complications in Covid-19-A case series. Int J Surg Case Rep. 2020;75:131-135.
40. Erkul GSA, Erkul S, Parlar AI, Cekirdekci A. A probable covid-19 case presented with acute upper limb İschemia. Ann Vasc Surg. Published online 2021. doi:10.1016/j.avsg.2021.05.003
41. Galanis N, Stavraka C, Agathangelidis F, Petsatodis E, Giankoulof C, Givissis P. Coagulopathy in COVID-19 infection: a case of acute upper limb ischemia. J Surg Case Rep.2020;2020(6):rjaa204.
42. de Roquetaillade C, Chousterman BG, Tomasoni D, et al. Unusual arterial thrombotic events in Covid-19 patients. Int J Cardiol. 2021;323:281-284.
43. Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and antiphospholipid antibodies in patients with covid-19. N Engl J Med. 2020;382(17):e38.
44. Woehl B, Lawson B, Jambert L, Tousch J, Ghassani A, Hamade A. 4 cases of aortic thrombosis in patients with COVID19. JACC Case Rep 2020;2(9):1397-1401. doi:10.1016/j.jaccas.2020.06. 003.
45. Han H, Yang L, Liu R, et al. Prominent changes in blood coagulation of patients with SARS-CoV-2 infection. Clin Chem Lab Med. 2020;58(7):1116-1120.
46. Fournier M, Faille D, Dossier A, et al. Arterial thrombotic events in adult inpatients with COVID-19. Mayo Clin Proc. 2021;96(2):295-30.
47. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China [published correction appears in Lancet. 2020 Jan 30;:]. Lancet. 2020;395(10223):497-506. doi:10.1016/S0140-6736(20)30183-5.
How to Cite
GIGOVSKA DIMOVA, Irena et al. UNUSUAL PRESENTATION OF THROMBOEMBOLIC DISEASE IN A HOSPITALIZED PATIENT WITH A COVID-19 INFECTION: A CASE REPORT. Journal of Morphological Sciences, [S.l.], v. 4, n. 3, p. 94-105, dec. 2021. ISSN 2545-4706. Available at: <https://jms.mk/jms/article/view/278>. Date accessed: 21 jan. 2022.