A 54 y.o. woman with a hx of opiod dependence and schizophrenia presents with a painful hand.

The patient is a smoker

What is the problem

Our patient had COVID

So the question became: does she have microthrombi or microemboli.  And does she have Buerger’s disease? Pulses were intact at the radial and ulnar arteries and arteries were patent into the digits.

Covid has been shown to produce thrombi in the extremities with “covid toes”  being an example.  These microthrombi resolve without sequellae.  Most people who develop “covid toes” do not have other symptoms of COVID-19 such as fever or cough. These lesions are similar to chilblains.  In one study 73% of patients with “covid toes” had IgA antineutrophil cytoplasmic antibodies and elevated type I interferon .  This is interesting in that these patients will not test positive on commercial IgM or IgG antibody tests.

covid toes are common in younger people with covid

BUT WAIT…….

Our patient had a free-floating thrombus noted in the aortic arch on admission and was admitted to the ICU with cardiac surgery consult.  It was felt that she had microemboli to the fingers.  In general , it is uncommon to find an aortic thrombus in the absence of an aneurysm or atherosclerosis.

Another diagnosis in the initial differential is Buerger’s disease.  This is also known as thromboangiitis obliterans It is a disease of smokers first described in 1908.  It is thought to be a hypersensitivity to tobacco products with a possible genetic component since it is more common in people of Israeli, Indian or Japanese descent. This disease affects the distal extremities since it is a disease of small and medium-sized arteries..

Buerger’s disease is a small to medium sized artery vasculits caused by smoking

Our patient was positive for lupus anticoagulant but was B-glycoprotein and cardiolipin negative. Cardiothoracic surgery recommended she be on anticoagulation for one month being closely observed for more emboli.  If any new embolic events occurred she was to be imaged immediately. Her lupus anticoagulant was due to be rechecked in 12 weeks.  Her fingers continue to be painful.

Frumholz L  Type I interferon response and vascular alteration in chilblain-like lesions during the COVID- 19 outbreak. 2021 British Journal of Dermatology DOI:10.1111/bjd.20707

Ohta Takashi, Ishibashi H, Sugimoto I, et al. The clinical course of Buerger’s disease.  2008 Ann Vasc Dis;1(2):85-90. 

Avelino M, Menders de Miranda C, Moreira de Sousa C, et al. Free-floating thrombus in the aortic arch. 2017 Radiol Bras . Nov-Dec; 50(6):406-407.

Kim S, Hwang J, Lee J, et al. Free floating thrombus of the aorta an unusual cause of peripheral embolization J Korean surg Soc.  2011;80:204-211.