A 64-year-old male with a past medical history of type 2 diabetes mellitus and essential hypertension presented in the emergency department with a history of intermittent fever of 102 degrees Fahrenheit for the last five days along with numbness and discoloration in his right leg for the last three days and shortness of breath. On examination, his Glasgow coma scale (GCS) score was 15/15 and his mental status was normal on gross neurological examination. His oxygen saturation (SpO2) at room air was 85% (indicative of severe disease) and 94% SpO2 at 15 L oxygen via a non-breather mask (NRM).\nOn physical examination, his right leg had a blackish discoloration (Figure ).\nIt was cold, clammy, with an absent femoral pulse. Arterial Doppler ultrasound of the right lower limb showed no flow in the femoral, popliteal, anterior tibial, posterior tibial, and dorsalis pedis arteries although no plaque or echogenic thrombus was seen. A CT angiogram of the lower limb was performed, which showed no contrast opacification beyond the right common femoral artery (Figure ).\nA Vascular surgeon was consulted and a diagnosis of acute limb ischemia was made. It was classified as Rutherford stage III, which was three days old. The limb was declared as non-salvageable. Keeping in view the clinical picture and CT angiogram findings, the Vascular surgeon advised an above-knee amputation of the affected limb.\nThe patient's real-time SARS-CoV-2 polymerase chain reaction (PCR) test was positive. His arterial blood gases (ABGs) showed metabolic acidosis with respiratory compensation with a pH of 7.4, bicarbonate (HCO3-) of 17.9, and pCO2 of 25.9. His high-resolution computerized tomography (HRCT) of the chest gave a severity score of 31/40 for COVID-19 pneumonia (Figure ), indicative of severe disease.\nHis serum ferritin levels were 1,279 ng/mL (N=15-200 ng/mL), serum D-dimer 1,650 ng/mL (N≤250 ng/mL), serum LDH 861 U/L (N=135-225 U/L), serum CK 4,252 U/L (N= up to 192 U/L), INR=1, IL-6=14.8 pg/mL (N≤7.0 pg/mL). CBC showed WBC count of 29.0 x 109/L with neutrophil-lymphocyte ratio (NLR) of 22.25 (N=1-3). His HbA1c was 12.4 (N=4.5%-6.5%).\nThe patient's above-knee amputation was done under spinal anesthesia, and he was subsequently moved to the COVID-19 Intensive Care Unit, where he was started on injection meronem, dexamethasone, and remdesevir, as per local protocol. He was also given intravenous fluids, pain medication, and insulin according to a sliding scale. After 12 hours of surgery, he was given therapeutic anticoagulation with enoxaparin.\nAfter eight days, the patient's clinical state improved, with oxygen saturation increasing to 94% on room air. His inflammatory markers were within the normal range following 12 days of sickness. On day 15, he was discharged with instructions for chest physiotherapy and incentive spirometry, as well as wound care and pulmonology, vascular surgery, and rehabilitation clinic follow-up.
A 48 year old male with a history of asthma presented to our institution with a cough, shortness of breath and a fever. The patient subsequently tested positive for Covid-19 and was intubated and admitted to the ICU with hypoxic respiratory failure after failure to improve with initial therapy. The patient was started on therapeutic enoxaparin treatment.\nOn the 10th day the patient was on high ventilator settings and minimal inotropic support. On examination, lower limbs showed unsalvageable ischemia with no palpable pulses (). Urgent CT angiography revealed complete occlusion of the left arterial tree from the aortic bifurcation descending down to the infra-popliteal arteries. Contralaterally, distal occlusion of the superficial femoral artery down to the infra-popliteal arteries. CT of the lung displayed ground glass appearance of the lungs associated with consolidation. After consulting the next of kin and the risk; benefit of proceeding to surgery. The joint decision to provide supportive care was made. The patient was declared dead on the same day.