A COVID-19 Patient with Simultaneous Renal Infarct, Splenic Infarct and Aortic Thrombosis during the Severe Disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with a high incidence of arterial and venous thrombotic complications. However, thromboembolic events in unusual sites such as limb and visceral arterial ischemia are reported rarely in the literature. Herein, we describe a rare case of a patient with severe coronavirus disease 2019 (COVID-19) infection who experienced severe abdominal pain during the hospitalization and presented simultaneously renal artery, splenic artery and vein as well as aortic thrombi despite prophylactic antithrombotic treatment. Information about his follow-up post discharge is also provided. This case report raises significant clinical implications regarding the correct dose of antithrombotic treatment during the acute phase of the severe COVID-19 infection and highlights the need for incessant vigilance in order to detect thrombosis at unusual sites as a possible diagnosis when severe abdominal pain is present in severe COVID-19 patients.

A rare case of renal infarction due to heroin and amphetamine abuse: case report

Background Renal infarctions as a result of recreational drug use are rare and are commonly associated with cocaine use. Although amphetamines have a similar mechanism of action as cocaine, there are few reports linking them to ischemic events, and only one to renal infarction. Similarly, few reports link heroin use with infarcts, but never in the kidney. Although uncommon, several mechanisms have been implicated in heroin and amphetamine-induced infarction, including vasculopathy, vasculitis and the activation of the coagulation cascade. Case Presentation 47-year-old female with a past medical history of non-intravenous heroin and amphetamine abuse, chronic obstructive pulmonary disease, hypertension, hyperlipidemia presented with right lower extremity swelling and rash, which was diagnosed as cellulitis and treated appropriately. Incidentally, the patient was found to have an acute kidney injury and further workup identified multiple renal infarcts in the right kidney. The patient had no past medical history of clotting disorders. Blood culture and urine cultures were sterile; autoimmune and hypercoagulable workup were negative. Urinalysis was unremarkable. Urine toxicology was only positive for opiates and amphetamines, which were thought to be the most likely cause of the renal infarct. Patient was lost to outpatient follow up due to noncompliance, but returned to the hospital for re-emergence of her cellulitis, during which no new infarcts were discovered, and the previous renal infarct had scarred over. Conclusion There are very few reports of heroin and amphetamine-induced infarctions. This case report describes a rare but important complication of heroin/amphetamine abuse that could be easily overlooked.

Multimodality cardiac imaging for management of a cardiac mass in the era of COVID-19: a case report

Background Atrial myxomas are the most common benign cardiac tumours. This case highlights an unusual presentation and complex management of a patient who was incidentally found to have a left atrial tumour concerning for a myxoma. Case summary A 54-year-old-woman presented with symptoms of nausea and vomiting and was found to have a left atrial mass incidentally in addition to a renal infarct. She was also found to have COVID-19 and the mass was initially thought to be a thrombus. With the help of multimodality imaging, it was determined that the mass was an atrial myxoma and she was started on short-term anticoagulation to prevent recurrent embolization. After 6 weeks of anticoagulation, she successfully underwent elective resection of the mass which was confirmed to be myxoma with superimposed thrombus. Discussion It is difficult to differentiate cardiac tumours from intracardiac thrombus and multimodality cardiac imaging is crucial to make an accurate diagnosis. While the treatment of atrial myxomas involves early surgical resection, it becomes more complicated with concurrent COVID-19 infection.

1563. Variations in the clinical spectrum of the Streptococcus anginosus group: a report of two rare presentations

Background The Streptococcus Anginosus Group (SAG) formerly Streptococcus Milleri Group is a subgroup of viridans streptococci including S. anginosus, intermedius, and constellatus. SAG are microaerophilic digestive tract commensals. They are associated with empyema and deep organ abscesses. We present 2 unusual cases: necrotizing fasciitis and aortic valve endocarditis with aortic root abscess, resulting in septic emboli causing renal infarction. Methods Review of the literature and reported cases of SAG. Results Case1) 48 year-old-male with history of HTN, T2DM, presented with swelling and erythema of the right arm of 2-day evolution. Exam: tender, erythematous indurated right deltoid. Significant labs: WBC 25k/uL and lactate of 2.5. CT of the RUE showed an extensive fluid collection. Vancomycin, levofloxacin and clindamycin were initiated, surgical debridement revealed extensive necrotizing fasciitis Wound cultures grew S. constellatus. Required multiple debridement and prolonged course of penicillin G. Case 2) 53-year-old male with history of COPD, Prior Splenectomy for a large splenic infarct, heterozygous factor V Leiden mutation, HCV infection, cirrhosis, presented with right flank pain, hematuria over 5 days. Labs: WBC 16.8 k/uL, CT abdomen with contrast: right renal infarct. Heparin drip, Vancomycin and Ceftriaxone were initiated. Blood cultures grew S. anginosus. TEE revealed new aortic valve vegetations with severe aortic regurgitation. His condition deteriorated, requiring aortic valve surgery, found to have aortic root abscess requiring aortic root replacement. Necrotizing Fascitis - Soft Tissue Air Post-Surgical Debridement Right Renal Infarct Conclusion SAG infections infections are unique from other S viridans, causing severe deep organ abscesses requiring combined surgical and antibiotic therapy. Isolation in clinical specimens should alert the possibility of severe life threatening infections. Here we highlight 2 unusual manifestations of necrotizing fasciitis and aortic valve endocarditis with aortic root abscess and possible large septic renal embolism. One patient had a splenectomy. We are not sure if this contributed to a severe SAG infection Disclosures All Authors: No reported disclosures

Idiopathic spontaneous extensive iliocaval thrombosis presenting with renal infarct

We describe an extremely rare case of idiopathic spontaneous extensive venous thrombosis in a young man involving the inferior vena cava, the iliac veins and both renal veins associated with right haemorrhagic renal infarction with non-functioning right kidney.