Published online Jun 26, 2024. doi: 10.12998/wjcc.v12.i18.3561
Revised: April 9, 2024
Accepted: May 6, 2024
Published online: June 26, 2024
Processing time: 141 Days and 8.4 Hours
It is well-described that the coronavirus disease 2019 (COVID-19) infection is associated with an increased risk of thrombotic complications. While there have been many cases of pulmonary emboli and deep vein thrombosis in these patients, reports of COVID-19 associated portal vein thrombosis (PVT) have been uncommon. We present a unique case of concomitant PVT and splenic artery thrombosis in a COVID-19 patient.
A 77-year-old-male with no history of liver disease presented with three days of left-sided abdominal pain. One week earlier, the patient was diagnosed with mildly symptomatic COVID-19 and was treated with nirmatrelvir/ritonavir. Physical exam revealed mild right and left lower quadrant tenderness, but was otherwise unremarkable. Significant laboratory findings included white blood cell count 12.5 K/μL, total bilirubin 1.6 mg/dL, aminoaspartate transferase 40 U/L, and alanine aminotransferase 61 U/L. Computed tomography of the abdomen and pelvis revealed acute PVT with thrombus extending from the distal portion of the main portal vein into the right and left branches. Also noted was a thrombus within the distal portion of the splenic artery with resulting splenic infarct. Hypercoagulable workup including prothrombin gene analysis, factor V Leiden, cardiolipin antibody, and JAK2 mutation were all negative. Anticoagulation with enoxaparin was initiated, and the patient’s pain improved. He was discharged on apixaban.
It is quite uncommon for PVT to present simultaneously with an arterial thrombotic occlusion, as in the case of our patient. Unusual thrombotic manifestations are classically linked to hypercoagulable states including malignancy and hereditary and autoimmune disorders. Viral infections such as Epstein-Barr virus, cytomegalovirus, viral hepatitis, and COVID-19 have all been found to increase the risk of splanchnic venous occlusions, including PVT. In our patient, prompt abdominal imaging led to early detection of thrombus, early treatment, and an excellent outcome. This case is unique in that it is the second known case within the literature of simultaneous PVT and splenic artery thrombosis in a COVID-19 patient.
Core Tip: Thromboembolism is a severe but clinically common complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Thrombotic events classically occur in infected patients who are critically ill, and typically present as deep vein thrombosis or pulmonary embolism. We report a rare case of a patient with SARS-CoV-2 infection complicated by simultaneous portal vein thrombosis and splenic artery thrombosis. A presentation of moderate to severe abdominal pain in SARS-CoV-2 patients should trigger prompt abdominal imaging, as early diagnosis and treatment of splanchnic thrombosis with anticoagulation leads to favorable outcomes.