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.