How can inflammation caused by COVID-19 lead to upper limb blood clots and how best to treat them?

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Researchers at Rutgers Robert Wood Johnson Medical School are reporting the first instance of COVID-19 triggering a rare recurrence of potentially serious blood clots in people’s arms.

The discovery, published in the journal Viruses, improves the understanding of how inflammation caused by COVID-19 can lead to upper extremity blood clots and how best to treat them.

The case study is part of a larger Rutgers study of 1,000 hospitalized patients diagnosed with COVID-19 who were admitted and discharged between March and May 2020.

While there have been reports of lower extremity deep vein thrombosis following COVID-19, this is the first study in which COVID-19 triggered a recurrence in the upper arm of an active 85-year-old man who had a prior diagnosis of upper extremity blood clots.

“The patient presented to his primary care physician with complaints of swelling in his left arm and was sent to the hospital for further management where he was diagnosed with an upper arm blood clot and an asymptomatic COVID-19 infection,” said Payal Parikh, an assistant professor of medicine at Rutgers Robert Wood Johnson Medical School, who led the study along with Martin Blaser, director of the Center for Advanced Biotechnology and Medicine and a professor at Rutgers Robert Wood Johnson Medical School.

“While his oxygen levels were not diminished, he was hospitalized for the management of the upper extremity deep vein blood clot. Often, blood clots are preceded by chronic inflammatory conditions exacerbated by immobility, and rarely do they occur in patients who are otherwise healthy and active at baseline.

Most cases of deep vein thrombosis occur in the legs. Only about 10 percent of blood clots occur in the arms and of those cases only 9 percent recur.

“This is of concern since in 30 percent of these patients, the blood clot can travel to the lung and be possibly fatal,” said Parikh. “Other disabling complications include persistent swelling, pain and arm fatigue.”

The study suggests that clinicians should consider testing for deep vein thrombosis and COVID-19 in patients who present with complaints of unexplained swelling. People who test positive for COVID-19 should seek medical attention if they have declining oxygen levels, shortness of breath and any unexplained swelling.

“If you have been previously diagnosed with deep vein thrombosis or have chronic medical illness that predisposes you to blood clots, you have a higher risk for recurrence of a deep vein thrombus in the setting of a COVID-19 infection and thus, should be vigilant,” said Parikh.


he COVID-19 pandemic, due to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has had worldwide consequences [1]. The clinical and pathological features of the infection are gradually becoming better understood [2]. While COVID-19 infects the respiratory tract and presents as pneumonia in most patients, others also suffer from severe neurological, cardiovascular, and/or gastrointestinal complications due to hyperinflammatory and hypercoagulable states [3,4,5,6].

Coagulation disorders have been noted in 23–49% of COVID-19 patients regardless of the use of heparin or low-molecular-weight heparin [7]. Arterial and venous thromboembolic events are more common than bleeding disorders, with the highest rates described in ICU settings [8,9,10,11,12]. COVID-19 hospitalized patients have had much higher DVT rates (31% in one New York study) than in hospitalized patients without COVID-19 (19%) [13].

Most DVTs occur in the lower extremities (LEDVT), due to increased gravitational stress and decreased endothelial fibrinolytic activity compared to upper extremity veins [14]. Only 4–10% of DVTs occur in the upper extremities (UEDVT), which may be primary (20%) or secondary (80%) [15,16,17]. Primary UEDVTs, identified as two events per 100,000 patients, are either idiopathic or due to effort-induced injuries or anatomical variation, like Paget–Schroetter syndrome or cervical rib [16,17,18,19].

Secondary UEDVTs may be caused by malignancy or, more commonly, by intravenous catheters or pacemaker wires, especially after their insertion [16,17,18,19,20].

Although UEDVT incidence is low, severe complications include pulmonary embolism, post-thrombotic syndrome, and death. Pulmonary embolism (PE) may occur in up to 30% of patients following a UEDVT and may be fatal [15,17]. The mortality rate in patients with UEDVT varies from 15–50%, chiefly related to underlying conditions including malignancy, infection, or organ failure [15,17]. Another disabling complication, post-thrombotic syndrome, presents as swelling, pain, and limb fatigue with exertion in 27–50% of UEDVT patients [17].

UEDVTs recur in 9% of patients, usually in the ipsilateral extremity, whereas LEDVT recurrence may reach 97% [16,21].
While both UEDVTs and LEDVTs secondary to COVID-19 infection have been reported [22,23], there is little information on COVID-19 as a risk factor for recurrent UEDVT and how to optimize management. We present the case of an 85-year-old patient, who to our knowledge, was the first to develop recurrent UEDVT as the presenting sign of an asymptomatic COVID-19 infection.

reference link: https://www.mdpi.com/1999-4915/13/5/878/htm


More information: Yesha H. Parekh et al, Recurrence of Upper Extremity Deep Vein Thrombosis Secondary to COVID-19, Viruses (2021). DOI: 10.3390/v13050878

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