Aortic and Renal Artery Thrombosis as the First Clinical Manifestation of COVID-19 in a Heart Transplant Recipient

INTRODUCTION: The relation between coronavirus 2019 disease (COVID-19) and thrombotic events is well established, and both arterial and venous thrombotic events are described. Although arterial events occur in about 3.6 to 10.5% of critically ill patients, they are usually stroke or acute myocardial infarction. Arterial thrombosis of other sites is rare. CASE REPORT: We report a case of a 28-year-old male heart transplant recipient admitted into emergency department presenting right flank pain associated with fever, chills, nausea and vomiting for three days. Apart from diabetes mellitus and dyslipidemia, he had no other comorbidity and he was on regular immunosuppression. Physical exam revealed right costovertebral angle tenderness. Blood tests showed C-reactive protein of 317mg/dL, lactate dehydrogenase of 1827U/L, D-dimer of 4126ng/mL, ferritin of 651ng/mL and leukocytosis of 16100/mm³. An abdominal and thoracic computed tomography scan (CT scan) revealed sparse luminal peripheral thrombi in the descending thoracic aorta. One of the thrombi extended to right renal artery ostium and caused subocclusion of the proximal segment of this artery. Right kidney presented multiple renal infarcts. Also ground-glass opacities were found in 25% of pulmonary parenchyma. COVID-19 was suspected and nasopharynx real-time fluorescence polymerase chain reaction result for SARS-CoV-2 was positive. Coagulopathy tests were performed because of atypical presentation and lupus anticoagulant (LAC) was positive. Hydration, antibiotics and anticoagulation with enoxaparin were prescribed. The patient recovered and became asymptomatic. Warfarin was prescribed and patient was discharged after 15 days of hospitalization. SUMMARY: This case report illustrates the heterogeneity of clinical presentation of COVID-19 and reinforces the existence of a prothrombotic state, even in the outpatient setting. Moreover, it adds information to the recent reports regarding the presence of antiphospholipid antibodies in COVID-19, although their importance in the pathophysiology of thromboembolic events in this setting is still not clear. The implication of these findings in transplant recipients is even less established, and this case report highlights the need for further research.