# Acro-Ischemia Associated With SARS-CoV-2: A Case Report

## TL;DR

This case report describes a fatal acro-ischemic lesion in a severe COVID-19 patient despite anticoagulant therapy, suggesting alternative treatment approaches.

## Contribution

The paper presents a rare fatal case of acro-ischemia in SARS-CoV-2 infection and proposes novel treatment strategies based on immune mechanisms.

## Key findings

- Anticoagulant therapy failed to prevent necrosis in a patient with SARS-CoV-2-related acro-ischemia.
- The case suggests a potential role of immune clots and vasculitis in AIL pathogenesis.
- Behçet syndrome is proposed as a model for inflammation-induced thrombosis in AIL treatment.

## Abstract

COVID-19 is known to cause various cutaneous lesions, including acro-ischemic lesions (AIL), which are associated with poor prognosis. Anticoagulant therapy has shown positive responses in AIL patients. However, in this case study, we present a fatal AIL case despite anticoagulant therapy. We propose different treatment approaches based on the limited current data on acro-ischemia pathogenesis related to SARS-CoV-2. The clinical case involved a 59-year-old male with severe COVID-19 symptoms, including acrocyanosis and right hemiparesis. Despite receiving anticoagulant therapy, the patient's condition worsened, leading to necrosis in the left foot. The discussion focuses on the high-risk nature of AIL, the potential link between angiotensin-converting enzyme 2 (ACE2) receptors and vasculitis or thromboembolic manifestations, and the role of immune clots in AIL pathogenesis. Behçet syndrome is referenced as a model of inflammation-induced thrombosis, guiding the suggestion for immunosuppressant-based treatment in addition to anticoagulants. Additionally, three substances, N-acetyl cysteine, sulodexide, and hydroxychloroquine, are proposed.