Acute Limb Ischemia: A Rare Complication of COVID-19

A 60-year-old male with a history of primary hypertension presented to the emergency department of a tertiary care hospital, in Pakistan, with complaints of fever, cough, and shortness of breath. He tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction, with bilateral infiltrates found in chest X-ray. At admission, oxygen saturation was 80% on room air; hence, he was immediately put on non-invasive ventilation. Laboratory investigation revealed elevated D-dimer, international normalized ratio, and total leukocyte count. C-reactive protein was markedly elevated (82.5 mg/L), indicating the state of a cytokine release syndrome (CRS). Treatment started with antibiotics, prophylactic enoxaparin (40-mg subcutaneous once daily), methyl prednisone 60 mg BD and multivitamins. Intravenous tocilizumab (TCZ) 6 mg/kg was started from Day 1 to address the CRS. On Day 3, he complained of pain in the right lower limb with signs of hypothermia, numbness, and slight blackening of the right foot. Peripheral pulses were not palpable, and vascular ultrasound showed no vascular flow in the popliteal, anterior and posterior tibial, and dorsalis pedis artery. The Vascular Surgery department declared the limb unsalvageable and right limb above-knee amputation. On Day 9, the right foot was blackened and atrophied extending up to the knee. Above-knee amputation was done, and he was discharged on rivaroxaban after 48 hours of observation. We conclude that heparin is effective in treating coronavirus disease 2019-associated coagulopathy, while TCZ, simultaneously, decreases the severity of CRS. Our case suggests that the concomitant use of TCZ and anticoagulation therapy can be beneficial in patients presenting with arterial and venous thrombosis.