Incidence, Characteristics, Laboratory Findings and Outcomes in Acro-Ischemia in COVID-19 Patients
Authors Alonso MN, Mata-Forte T, García-León N, Vullo PA, Ramírez-Olivencia G, Estébanez M, Álvarez-Marcos F
Received 17 August 2020
Accepted for publication 5 November 2020
Published 24 November 2020 Volume 2020:16 Pages 467—478
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 3
Editor who approved publication: Dr Takashi Kajiya
María Noelia Alonso,1,2 Tatiana Mata-Forte,3 Natalia García-León,2,4 Paula Agostina Vullo,2,5 Germán Ramirez-Olivencia,3 Miriam Estébanez,3 Francisco Álvarez-Marcos6
1Vascular Surgery Department, Central Defense Gómez Ulla Hospital, Madrid, Spain; 2Thrombosis and Anticoagulation Committee, Central Defense Gómez Ulla Hospital, Madrid, Spain; 3Infectious Diseases Department, Central Defense Gómez Ulla Hospital, Madrid, Spain; 4Hematology Department, Central Defense Gómez Ulla Hospital, Madrid, Spain; 5Anesthesiology Department, Central Defense Gómez Ulla Hospital, Madrid, Spain; 6Vascular Surgery Department, Asturias University Central Hospital (HUCA), Oviedo, Spain
Correspondence: María Noelia Alonso
Vascular Surgery Department, Central Defense Gómez Ulla Hospital, Glorieta Del Ejército 1, Madrid 28047, Spain
Tel +34 914 222 000 ext: 22365
Aim: In addition to its respiratory impact of SARS-CoV2, skin lesions of probable vascular origin have been described. This study intends to quantify the incidence of acro-ischemic lesions in COVID-19 infected adult subjects in our population, describing clinical patterns and associated findings.
Methods: All adult confirmed cases of COVID-19 infection who presented with acro-ischemic lesions and received care in our institution were prospectively enrolled up to May 15th, 2020. The variables included demographics, comorbidities, analytical parameters, clinical presentations and COVID-19 treatment.
Results: We enrolled 24 patients. The overall rate of acro-ischemic findings in COVID-19 patients was 1.2% [0.6% for outpatients and 2.9% for hospitalized (ICU and non-ICU patients)], but the observed incidence for acro-ischemia in ICU patients was remarkably higher (23.0%, p< 0.001). We have described four different clinical patterns of acroischemia: atypical Raynaud´s phenomenon (ARP), (4); pseudo-pernio (PP), (5); severe microcirculatory ischemia with preserved pulse (SMI), (6); and dry gangrene with arteriosclerosis obliterans (AO), (9). Kendall´s τ correlation with lung disease severity was 0.877 (95% CI, 0.756 to 0.968); p< 0.01). ARP individuals were predominantly female, while SMI appeared lately in elderly hospitalized subjects with better prognosis. AO occurred in patients with more comorbidity and younger than those with SMI. We observed other associated lesions of suggestive ischemic nature in other organs in all groups (15 patients of total sample). Plasma procalcitonin was significantly higher in patients who developed SMI (median and interquartile range: 9.99 (4.2, 12.3) mg/mL vs 0.26 (0.11, 0.89) mg/mL; p< 0.001), and D-dimer level at hospital admission was significantly higher in AO patients (median and interquartile range: 1166 (1050, 2111) mg/L vs 502 (448, 777) mg/L; p< 0.001).
Conclusion: The observed risk for acroischemia in COVID-19 is high in ICU patients (23%). We have described four different clinical patterns of acroischemia (ARP, PP, SMI and AO) associated with lung disease severity. Authors have communicated various lesions of suggestive ischemic nature in other organs. Raynaud-like pattern is reported as a ”novelty”.
Keywords: acro-ischemia, COVID-19, Raynaud´s phenomenon, ischemia reperfusion injury, hypercoagulability, thromboinflammation