Case Report: COVID-19-associated gangrene of fingers in a patient with autoimmune haemolytic anaemia

Abstract

Introduction: This case report describes a 50-year-old man with a 12-year history of long-standing warm-antibody autoimmune haemolytic anaemia (AIHA) who developed peripheral digital gangrene following COVID-19 infection. Although COVID-19-associated AIHA and COVID-19-associated digital ischaemia have each been reported separately, this case is notable for their coexistence with both venous and arterial thrombosis, resulting in tissue loss. Main symptoms and important clinical findings: The patient presented with a 3-day history of fever, cough, and shortness of breath. On examination, his temperature was 39.2 °C, radial pulse 120/min and regular, respiratory rate 25 breaths/min, blood pressure 148/88 mmHg, and oxygen saturation 82% on room air. Chest examination revealed bilateral basal and mid-zone crepitations. Main diagnoses therapeutic interventions and outcomes: /μL. High-resolution computed tomography (CT) of the chest revealed bilateral multilobar ground-glass opacities with subpleural atelectatic bands, interlobular septal thickening, and a crazy-paving pattern, consistent with COVID-19 pneumonia. He was treated with non-invasive ventilation, corticosteroids, intravenous immunoglobulin, therapeutic anticoagulants, insulin glargine, and moxifloxacin. During admission, he received 6 units of packed RBCs and 34 units of platelets. His respiratory condition improved after 1 week, and therefore non-invasive ventilation was discontinued and he became stable on room air, with modest improvement in hemoglobin and platelet counts. Follow-up CT pulmonary angiography demonstrated a bilateral peripheral pulmonary embolism with regressing COVID-19 pneumonia. CT angiography of the upper extremities showed complete cessation of radial artery flow at both wrists. The patient subsequently developed dry gangrene affecting the right thumb and index finger and the distal parts of the left thumb and index finger. Six weeks post-admission, he underwent surgical amputation of the gangrenous digits. Conclusion: This case highlights a rare but serious coexistence of long-standing warm-antibody AIHA, COVID-19-associated thrombo-inflammatory disease, and combined venous and arterial thrombosis leading to peripheral digital gangrene. Although the exact mechanism cannot be established with certainty, the clinical course suggests that COVID-19 may have aggravated an already vulnerable haematologic and prothrombotic state, resulting in severe thrombotic complications and tissue loss.