Case 1
A 56-year-old woman with diabetes referred to the emergency department,
with complaints of cough, headache, high-grade fever, dyspnea, and
hypoxemia on April 2020. Chest computed tomography (CT) showed bilateral
ground-glass opacities. Laboratory results revealed normal complete
blood count, high CRP titer, LDH (904 IU/L), while PT, INR, and PTT were
in the normal range. Nasopharyngeal sampling was positive for SARS-CoV-2
using real-time PCR method. Supplemental oxygen, prophylactic
unfractionated heparin, and hydroxychloroquine were initiated. On day 5
of admission, she was intubated due to respiratory distress and sedative
drugs were used to control the condition. On day 6, ecchymosis and
patchy skin lesions appeared on her extremities. Owing to the
probability of bacterial superinfection, blood and tracheal secretion
cultures were performed and meropenem and vancomycin were added to
Hydroxychloroquine. On day 7, she was transferred to designated COVID-19
center. At the admission, she was unconscious and still intubated under
mechanical ventilation using SIMV+PS mode. The blood pressure and heart
rate were 90/65 mmHg and 87/min, respectively. Atrial blood gas (ABG)
evaluation revealed that pO2 was 61 mmHg and oxygen saturation was 90%
with 50% FIO2. Meanwhile, cyanosis was seen at the end of her upper and
lower extremities, toes (Figure 1 a) and fingers (Figure 1 b) and spO2
with digital pulse oximeter was about 87%. Blood sampling showed
leukocytosis (16,200 per mm3), lymphopenia (1,200 per
mm3), thrombocytopenia (91,000 per
mm3), Hb (7.8 g/L), high CRP titer (107 mg/l), LDH
(1117 IU/L), D-dimer (7780 µg/ml), ferritin (1650 ng/ml), and IL-6 (359
pg/ml). Additional laboratory findings indicated negative PANCA, CANCA,
anticardiolipin, lupus anticoagulant, and
β2microglobulin. Echocardiographic was normal while
electrocardiogram showed inverted T in V1 to V5. Atorvastatin and
aspirin were added to the treatment regimen and the dose of heparin was
increased to the therapeutic dose. For improvement of blood flow on
extremities, nitroglycerin ointment was also applied. In spite of the
multiple treatment modalities, her clinical condition deteriorated and
she ultimately demised.