Global haemostatic tests in rapid diagnosis and management of COVID-19 associated coagulopathy in acute limb ischaemia
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LETTER TO THE EDITOR
Global haemostatic tests in rapid diagnosis and management of COVID‑19 associated coagulopathy in acute limb ischaemia Bingwen Eugene Fan1,2,9,10 · Yew Woon Chia3,9,10 · Christina Lai Lin Sum4 · Ponnudurai Kuperan1,2,9,10 · Stephrene Seok Wei Chan1,2,9,10 · Li Min Ling5,6,9,10 · Glenn Wei Leong Tan7,9,10 · Serene Si Ning Goh7 · Lai Har Wong4 · Shu Ping Lim4 · Kian Guan Eric Lim4 · Hwee Tat Tan4 · Mui Kia Ang4 · Soon Lee Lau4 · Kiat Hoe Ong1,2,9,10 · Jensen Ng8,9,10
© Springer Science+Business Media, LLC, part of Springer Nature 2020
To the editor, COVID-19-associated coagulopathy [1] has recently been described with a globally observed increased incidence of venous thromboembolism (VTE) and arterial thrombosis which manifests as acute myocardial infarction, ischaemic stroke and acute ischaemic limb [2]. The exact pathophysiology of COVID-19 large vessel thrombosis is still under investigation and can be attributed to three plausible causes: firstly, endothelial injury by the SARS-CoV-2 virus that binds via ACE2 receptors on endothelial cells, secondly, a hypercoagulable state from an uncontrolled hyperinflammatory response and thirdly, stasis due to immobilization in critically ill patients. All three causes comprise Virchow’s triad of thrombosis. * Bingwen Eugene Fan [email protected] 1
Department of Haematology, Tan Tock Seng Hospital, Singapore, Singapore
2
Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
3
Department of Cardiology, Tan Tock Seng Hospital, Singapore, Singapore
4
Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore, Singapore
5
Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
6
National Centre for Infectious Diseases, Singapore, Singapore
7
Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
8
Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore, Singapore
9
Lee Kong Chian School of Medicine, Singapore, Singapore
10
Yong Loo Lin School of Medicine, Singapore, Singapore
We describe a case of a 39-year-old Bangladeshi male migrant worker with no significant past medical history, who presented with fever, cough, and central abdominal discomfort. The patient required supplemental intranasal oxygen of 1.5 l/min on admission. SARS-CoV-2 PCR from nasopharyngeal swab returned positive and chest X-ray showed bilateral infiltrates. A diagnosis of COVID-19 pneumonia was made, and he was started on intravenous (IV) Remdesivir as part of a clinical trial. He remained ambulant in the general isolation ward and was not commenced on prophylactic anticoagulation upon the managing physician’s discretion. On Day 13 of illness, he developed acute right foot pain, with absent distal pedal pulses, decreased warmth, and duskiness of his toes. An acute ischaemic limb was suspected, and urgent vascular surgery consult was obtained. Global haemostatic tests [3], namely thromboelastography (TEG) (Haemoneti
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