This month’s column begins with a 2-day-old ex 33-week gestational age female who was transferred to Cohen Children’s Medical Center of New York because of concerns about left forearm/hand ischemia due to a dusky color at birth. The patient had edema, erythematous scalding-like lesions, and weakness of the left upper extremity at birth. Radiographs revealed normal bones. The pregnancy was remarkable for maternal active herpetic lesions; therefore, cesarean section was performed. The mother had contracted severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection late in her second trimester. The result of the real time reverse transcription polymerase chain reaction (rRT-PCR) was positive. Physical examination at our facility revealed large necrotic areas over the left forearm and hand, surrounding erythema, edema, contractures of distal phalanges, and lack of a pulse at the wrist (Figure 1).
Initial evaluation revealed thrombocytosis and elevation in coagulation parameters. The patient’s D-dimer levels were very high (1270 ng/mL), antithrombin was low, partial thromboplastin time was elevated, and fibrinogen was normal. The patient was started on continuous heparin infusion and transitioned to subcutaneous enoxaparin twice a day as per vascular surgery. Plastic surgery and orthopedics services followed the case. Further coagulation evaluation revealed normal factors, including factor V Leiden, protein C, protein S, prothrombin time, anticardiolipin antibody, ß2 glycoprotein, negative work-up for neonatal lupus and pro-thrombotic inflammatory indices, such as interleukin-8 (IL-8), and normal clotting times. Her IL-10 level was elevated.
Doppler ultrasound confirmed a lack of radial arterial signal past the forearm and no evidence of deep venous thrombosis. Magnetic resonance imaging revealed no flow to the patient’s left hand, possibly indicating an arterial thrombus. Both radial and ulnar arteries were not visualized past the wrist. Etiology was not clear, but potentially could have originated from maternal placenta as pathology revealed a venous thrombus within 3 cm of insertion. Placental venous thrombi can embolize to the umbilical vein, travel to the inferior vena cava, and enter the heart, where they can be shunted to the aorta. Given the maternal COVID-19–positive status and current understanding of COVID-19 as a hypercoagulability disease, we could not exclude a COVID-19–related thromboembolic event causing patient hand ischemia, especially because extensive work-up of potential etiologies was negative. The infant had SARS-CoV-2 antibodies, likely from transplacental maternal transmission, and negative rRT-PCR for active COVID-19. Compartment syndrome and arterial malformation also were considered, but both were ruled out.