Unit of Vascular and Endovascular Surgery, 18560Azienda Ospedaliero Universitaria di Ferrara - Arcispedale S.Anna, Ferrara, Italy.
Department of Translational Medicine for Romagna, and Vascular Diseases Center, University of Ferrara, Ferrara, Italy.
Vascular. 2023 Feb;31(1):189-195. doi: 10.1177/17085381211053695. Epub 2021 Dec 17.
Since October 2019, SARS-CoV-2 pandemic represents a challenge for the international healthcare system and for the treatment and survival of patients. We normally focus on symptomatic patients, and symptoms can range from the respiratory to the gastrointestinal system. In addition, we consider patients without fever and respiratory symptoms, with both a negative RT nasopharyngeal swab and lung CT, as a "Covid-19 negative patient." In this article, we present a so called Covid-19 "negative" patient, with an unsuspected vascular clinical onset of the viral infection.
An 80 y.o. man, who previously underwent endovascular aortic repair for an infrarenal abdominal aortic aneurysm, presented to our department with an atypical presentation of an aorto-enteric fistula during the pandemic. While in hospital, weekly nasopharyngeal swab tests were always negative for SARS-CoV-2. However, the absence of aortic endograft complications, the gross anatomy of duodenal ischemic injury, and the recent history of the patient who lived the last months in Bergamo, the Italian city with the highest number of COVID-19 deaths, lead the senior Author to suspect an occult SARS-CoV-2 infection. The patient underwent to resection of the fourth portion of the duodenum and the first jejunal loop, with subsequent duodenum-jejunal latero-lateral anastomosis and the direct suture of the aortic wall. The intestinal specimen was investigated as suspected SARS-CoV-2 bowel infection by the means of immune-histochemistry (IHC). An ileum sample obtained in the pre-COVID-19 era was used as a control tissue.
The histological analysis of the bowel revealed sustained wall ischemia and liponecrosis of the duodenal wall, with intramural blood vessels thrombosis. Blood vessel endotheliitis and neo-angiogenesis were also observed. Finally, the IHC was strongly positive for SARS-CoV-2 RNA and for HLA-G presence, with a particular concentration both in blood vessels and in the intestinal villi. The control tissue sample was not positive for both SARS-CoV-2 and HLA-G.
Coronavirus pandemic continues to be an international challenge and more studies and trials must be done to learn its pathogenesis and its complications. As for thromboembolic events caused by SARS-COV-2, vascular surgeons are involved in treatment and prevention of the complications of this syndrome and must be ready with general surgeons to investigate atypical and particular cases such as the one discussed in this article.
自 2019 年 10 月以来，SARS-CoV-2 大流行对国际医疗体系以及患者的治疗和生存构成了挑战。我们通常关注有症状的患者，症状范围从呼吸系统到胃肠道系统。此外，我们还将没有发热和呼吸道症状、鼻咽拭子 RT-PCR 检测和肺部 CT 均为阴性的患者，视为“新冠病毒阴性患者”。在本文中，我们报告了一例疑似 COVID-19“阴性”患者，其病毒感染的血管临床发病隐匿。
一名 80 岁男性，因腹主动脉下段腹主动脉瘤行血管内修复术，在大流行期间出现不典型的肠-主动脉瘘。住院期间，每周鼻咽拭子 SARS-CoV-2 检测均为阴性。然而，主动脉覆膜支架内移植物并发症不明显，十二指肠缺血损伤的大体解剖结构，以及患者最近的病史，他在过去几个月里一直住在意大利 COVID-19 死亡人数最多的贝加莫市，这都使资深作者怀疑存在隐匿性 SARS-CoV-2 感染。患者接受了十二指肠第四段和空肠第一段切除术，随后进行了十二指肠空肠侧侧吻合术和主动脉壁直接缝合术。通过免疫组织化学（IHC）检测怀疑存在 SARS-CoV-2 肠道感染，对肠标本进行研究。使用 COVID-19 前时期获得的回肠样本作为对照组织。
肠道的组织学分析显示，十二指肠壁持续缺血和脂肪坏死，伴有血管内血栓形成。还观察到血管内皮炎和新生血管形成。最后，IHC 对 SARS-CoV-2 RNA 和 HLA-G 存在呈强阳性，在血管和肠绒毛中均有特殊浓度。对照组织样本对 SARS-CoV-2 和 HLA-G 均为阴性。
冠状病毒大流行仍然是一个国际挑战，必须进行更多的研究和试验，以了解其发病机制及其并发症。至于由 SARS-CoV-2 引起的血栓栓塞事件，血管外科医生参与治疗和预防这种综合征的并发症，并且必须与普通外科医生一起调查这种不典型和特殊的病例，如本文讨论的病例。
