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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 5  |  Page : 45-49

Left renal vein thrombosis in a COVID-19 patient


Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission26-Jun-2021
Date of Decision12-Jan-2022
Date of Acceptance25-Jan-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
R Ram
Professor and Head, Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcsr.jcsr_39_21

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  Abstract 


The multiorgan deleterious effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) are now well known. Although COVID-19 disease is a hypercoagulable state and thrombotic complications occur in about one-third of critically ill patients with COVID-19, thrombosis is not typically a presenting symptom. We report the case of a patient presented with the complaints of abdominal pain due to renal vein thrombosis as the first feature of the COVID-19.

Keywords: COVID-19 patient, left renal vein thrombosis, severe acute respiratory syndrome-coronavirus-2


How to cite this article:
Vaghdevi CN, Sindhu D, Jahnavi B, Chowdary DP, Gaddam SL, Aishwarya PL, Murali M, Mathani S, Kumar P, Ram R, Kumar V S. Left renal vein thrombosis in a COVID-19 patient. J Clin Sci Res 2022;11, Suppl S1:45-9

How to cite this URL:
Vaghdevi CN, Sindhu D, Jahnavi B, Chowdary DP, Gaddam SL, Aishwarya PL, Murali M, Mathani S, Kumar P, Ram R, Kumar V S. Left renal vein thrombosis in a COVID-19 patient. J Clin Sci Res [serial online] 2022 [cited 2022 Oct 6];11, Suppl S1:45-9. Available from: https://www.jcsr.co.in/text.asp?2022/11/5/45/355061




  Introduction Top


The multiorgan deleterious effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) are now well known. Presenting symptoms of COVID-19 reported to date in otherwise 'asymptomatic' patients (i.e., patients without reported respiratory symptoms) include diarrhoea, vomiting, loss of appetite and skin lesions.[1],[2] Although COVID-19 infection is a hypercoagulable state[3] and thrombotic complications occur in about one-third of critically ill patients with COVID-19,[4] thrombosis is not typically a presenting symptom.

We report the case of a patient who presented with the complaints of abdominal pain due to renal vein thrombosis as the first feature of the COVID-19. The patient reported no other symptoms.


  Case Report Top


A 46-year-old woman, who was not known to have diabetes mellitus or hypertension, presented with sudden-onset left lumbar and umbilical pain. The patient was awakened from sleep at approximately 03:00 am with dull abdominal pain. The pain had worsened over the next few hours. She had an associated episode of diarrhoea. Contrast-enhanced computerized tomography (CT) of abdomen revealed hypoenhancement of the left kidney in corticomedullary and nephrogenic phases. A non-enhancing filling defect in the left renal vein [Figure 1] and intrarenal segments that extended into the inferior vena cava [Figure 2] and left lumbar vein were also noted. Minimal left perinephric fat stranding was noted with thickening of the anterior pararenal fascia. Multiple simple cortical cysts were noted in the left kidney. Pulmonary thromboembolism was evident in bilateral lower lobe segmental arteries, right more than left [Figure 3]. Laboratory investigations are listed in [Table 1]. Hypercoagulability workup was drawn and the patient was started on therapeutic doses of (1 mg/kg body weight, subcutaneously twice-daily) low-molecular-weight heparin.
Figure 1: Contrast-enhanced computerized tomography (venous) axial image, non-enhancing filling defect noted in the left renal vein suggestive of thrombosis (arrow). The left kidney is comparatively less attenuating on post-contrast images indicating impaired renal function

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Figure 2: Contrast-enhanced computerized tomography (venous) axial image, non-enhancing filling defect noted in the inferior vena cava suggestive of thrombosis (arrow)

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Figure 3: Contrast-enhanced computerized tomography (venous) axial image, non-enhancing filling defect noted in the left inferior segmental pulmonary artery suggestive of pulmonary artery thrombosis (arrow)

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Table 1: Investigations

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Two days after admission, the patient developed breathlessness. Arterial oxygen saturation mesured by pulse oximetry (SpO2) at admission was 98% on room air which had declined to 94%. Oxygen was administered through face mask. Nasopharyngeal swab real time polymerase chain reaction tested positive for COVID-19. CT of the chest showed features of COVID-19 disease [Figure 4]. She also received intravenous remdesivir, 200 mg on day 1, followed by 100 mg for 4 more days, dexamethasone 6 mg/day for 10 days and azithromycin 500 mg/day for 5 days. She was discharged after 10 days. Low-molecular-weight heparin was substitute with oral acenocoumarol. The dosage was adjusted to maintain the international normalised ratio between 2.0 and 2.5. Vitamin K-free diet had also been prescribed. After 4 weeks, the Doppler ultrasonography revealed a shrunken left kidney with minimal flow in the left renal vein. Serum creatinine remained normal at 1 mg/dL. [Table 2][5],[6],[7],[8],[9],[10],[11],[12] presents important data of other reported patients of renal vein and renal artery thrombosis attributed to COVID-19.
Figure 4: Computerized tomography axial image of the chest (lung window), patchy ground-glass opacities noted in periphery of the lung parenchyma (arrows)

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Table 2: Published reports of the renal artery and renal vein thromboses

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  Discussion Top


This patient underscored that a high index of suspicion is needed for thrombotic complications as presentations of COVID-19. Our patient lacked the conventional respiratory symptoms of COVID-19 and was not acutely ill like the commonly seen COVID-19 patients when he developed renal vein thrombosis. The diagnosis became evident serendipitously. CT of the chest done incidentally revealed the features of COVID-19, thereby enabled institution of specific therapy and isolation. It reduced the chances of staff exposure and a poor patient outcome.

Renal vein thrombosis attributed to COVID-19 infection has seldom been reported.[5]

The negative results for hypercoagulable pathogenesis in our patient differentiated our patient from others in which thrombotic events are attributable to the development of lupus anticoagulant or other prothrombotic factors secondary to COVID-19 infection.[3] In turn, these results also suggested that COVID-19 infection can induce coagulation independent of the prothrombotic intermediaries tested on hypercoagulable investigations. A potential paradigm for the cause of COVID-19-related thrombus had also been proposed, which may explain the development of thrombus in critically ill patients.[13]

This patient and few other reports hint us that COVID-19 disease could be a possibility in patients with unexplained thrombosis. Recognition of thrombosis as a potential initial sign of COVID-19 disease is critical for timely isolation and initiation of COVID-19 therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors are faculty members/Undergraduate/postgraduate students/residents of Sri Venkateswara Institute of Medical Sciences, Tirupati, of which Journal of Clinical and Scientific Research is the official Publication. The article was subject to the journal's standard procedures, with peer review handled independently of these faculty and their research groups.



 
  References Top

1.
Parasa S, Desai M, Thoguluva Chandrasekar V, Patel HK, Kennedy KF, Roesch T, et al. Prevalence of gastrointestinal symptoms and fecal viral shedding in patients with coronavirus disease 2019: A systematic review and meta-analysis. JAMA Netw Open 2020;3:e2011335.  Back to cited text no. 1
    
2.
Wollina U, Karadağ AS, Rowland-Payne C, Chiriac A, Lotti T. Cutaneous signs in COVID-19 patients: A review. Dermatol Ther 2020;33:e13549.  Back to cited text no. 2
    
3.
Bowles L, Platton S, Yartey N, Dave M, Lee K, Hart DP, et al. Lupus anticoagulant and abnormal coagulation tests in patients with COVID-19. N Engl J Med 2020;383:288-90.  Back to cited text no. 3
    
4.
Klok FA, Kruip MJ, van der Meer NJ, Arbous MS, Gommers DA, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.  Back to cited text no. 4
    
5.
Mui LW, Lau JF, Lee HK. Thromboembolic complications of COVID-19. Emerg Radiol 2021;28:423-9.  Back to cited text no. 5
    
6.
Acharya S, Anwar S, Siddiqui FS, Shabih S, Manchandani U, Dalezman S. Renal artery thrombosis in COVID-19. IDCases 2020;22:e00968.  Back to cited text no. 6
    
7.
Varner KB, Cox EJ. COVID-19 as the cause of thrombosis: Recognising COVID-19 infection in apparently asymptomatic patients. BMJ Case Rep 2021;14:e241027.  Back to cited text no. 7
    
8.
Post A, den Deurwaarder ES, Bakker SJ, de Haas RJ, van Meurs M, Gansevoort RT, et al. Kidney infarction in patients with COVID-19. Am J Kidney Dis 2020;76:431-5.  Back to cited text no. 8
    
9.
Deshmukh SB, Upadhyay KM, Kulkarni A, Deshpande S, Purohit R, Kulkarni M. Renal artery thrombosis: A post COVID-19 sequel. J Adv Res Med 2020;7:22-4.  Back to cited text no. 9
    
10.
Philipponnet C, Aniort J, Chabrot P, Souweine B, Heng AE. Renal artery thrombosis induced by COVID-19. Clin Kidney J 2020;13:713.  Back to cited text no. 10
    
11.
El Shamy O, Munoz-Casablanca N, Coca S, Sharma S, Lookstein R, Uribarri J. Bilateral renal artery thrombosis in a patient with COVID-19. Kidney Med 2021;3:116-9.  Back to cited text no. 11
    
12.
Mukherjee A, Ghosh R, Furment MM. Case report: COVID-19 associated renal infarction and ascending aortic thrombosis. Am J Trop Med Hyg 2020;103:1989-92.  Back to cited text no. 12
    
13.
Du F, Liu B, Zhang S. COVID-19: The role of excessive cytokine release and potential ACE2 down-regulation in promoting hypercoagulable state associated with severe illness. J Thromb Thrombolysis 2021;51:313-29.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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