The COVID-19 pandemic is constantly evolving. Fever, myalgia, cough, and dyspnea are common clinical manifestations of SARS-CoV-2 infection, along with headache, diarrhea, nausea, and vomiting [3]. The state of hypercoagulability caused by SARS-CoV-2 has been shown to manifest in a wide range of presentations ranging from asymptomatic infection to critical disease. Although respiratory symptoms predominate in patients with COVID-19, thrombosis can also occur. There have been reports of ALI observed mostly among adults with comorbidities [2,3,4,5, 7] and only one case has been reported in an adolescent [6], but to our knowledge, no cases at the time of writing of this case has been reported in younger age groups. This is the first reported case of a four-year-old with ALI due to COVID-19.
ALI is defined as a sudden decrease in arterial perfusion of a limb that threatens its viability. If the symptom duration is less than two weeks, the clinical presentation is considered acute [8]. Pain, pallor, paralysis, decreased pulse rate, paresthesia, and poikilothermia are the classic clinical features of patients with ALI. Symptoms range from new or worsening intermittent claudication to severe pain at rest, paresthesia, muscle weakness, paralysis, and even gangrene, and may become apparent within minutes, hours, or days [9]. We discovered acute ALI symptoms in this patient, including cyanosis and paralysis. Based on Rutherford classification, the patient was diagnosed with Rutherford stage IIb disease.
Similar case was reported in Pakistan, Lahore, where an elderly patient with comorbidities presented with fever and lower leg discoloration in which became a non-salvageable limb and required subsequent amputation of the affected limb [2].
Several recently published articles have reported the occurrence of arterial thrombotic events in COVID-19-positive patients with no history of peripheral arterial disease [2, 3].
The mechanism underlying ALI in patients with COVID-19 is complex. It is attributed to the angiotensin-converting enzyme 2 receptor, which is found in almost all tissues of the body, that the virus can use to enter the host cells leading to the release of damage-associated molecular pattern, which results in the release of the inflammatory cascade and proinflammatory cytokines, eventually triggering a thromboinflammatory process [10].
The therapeutic strategy is based on the presence of a neurological deficit, location, Rutherford class, duration of ischemia, comorbidities, and risks and outcomes associated with the therapy. Patients with clinically suspected ALI should be admitted to the ED for immediate diagnosis and treatment. Anticoagulation therapy with Enoxaparin is administered promptly to prevent thrombus propagation and preserve microcirculation. Enoxaparin inhibits the development of cytokine storm and has competitive binding activity to the coronavirus, significantly reducing pathogen activity by inhibiting cell penetration [3]. Depending on the Rutherford classification, revascularization was required. Our patient had class II ALI, in which the limb was saved with immediate intervention using fasciotomy and Enoxaparin. However, in a case reported in Indonesia, the Rutherford classification was IIb, and the patient was treated with anticoagulant therapy with unfractionated Enoxaparin and referred to other hospital to perform a thrombectomy [3].
However, in a case report in Greece, the authors attempted to combine thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) and immunosuppressive therapy with IL-6 (tocilizumab) in a patient who was admitted with acute respiratory failure secondary to COVID-19 pneumonia, who later developed ALI in his lower limb digits. However, after starting the management patient showed poor prognosis and had major amputations in which he died due to respiratory failure [11]. The patient, wherein we used a combination of Enoxaparin, tocilizumab, and pulse steroid therapy, later showed complete resolution of symptoms in all previously involved digits [12]. To our knowledge, this is the first report on the use of a combination of thrombolytic and anti-inflammatory therapy for treating COVID-19-induced ALI in pediatric patients reported in the international literature.
The variety of COVID-19 symptoms has increased rapidly since 2020. Initially, attention was focused on respiratory problems; however, other symptoms have recently surfaced, including COVID-19-induced myocarditis, arthritis, liver damage, and encephalitis. ALI is challenging to treat because the limb cannot be saved beyond a certain period. Since everyone focuses on the patient’s respiratory condition, especially pediatric patients, such complications may be overlooked. By sharing this, we hope to share our experience and contribute to the research on how a case of COVID-19-induced ALI in pediatric patients was handled in a developed country.
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