An interesting case of multiple district vascular involvement related to the SARS-CoV2 infection

76-year-old man, hypertensive, suffering from permanent atrial fibrillation in treatment with Apixaban 5mg x 2/day. Hyperpiressia for a few days, treated with broad- spectrum antibiotic therapy. For the appearance of dyspnea and constricting retrosternal pain of about 20 minutes, he accessed to the emergency room of “San Paolo” Hospital in Bari. Electrocardiogram showed high ventricular response atrial fibrillation, while echocardiogram hypokinesia of the apical segments and moderate left ventricular dysfunction. Blood tests showed an increase in myocardial troponines. Chest angio CT highlited bilateral ground glass pulmonary thickening and pleural effusion, in the absence of signs of pulmonary thromboembolysm. The first molecular swab for SARS COV2 resulted negative. Subsequent admission to Cardiology Unit. During the hospitalization, coronary artery showed non-significant atheromasia of the epicardic branches and slow run-off of the anterior interventricular artery and right coronary artery. Subsequent pneumological evaluation made the indication to therapy with cephalosporins and corticosteroids and clinical- instrumental follow-up. The patient was discharged after a few days with a diagnosis of ACS-NSTEMI. After 8 days, new access to the emergency room due to worsening of dyspnea. For high D- dimer values, he underwent a new chest angio CT which showed pulmonary embolism and confirmed the presence of pulmonary parenchymal thickening already described. The new molecular swab documented positivity for SARS-COV2. Therefore, the patient wea hospitalized in the COVID department. After a few hours, weakness of the right arm appeared;skull CT and neurological evaluation concluded for probable cerebral ischemic episode. SARS-COV2 disease could lead to a multi-organ hyperergic inflammatory response. In this clinical case, there was the involvement of multiple vascular districts (cardiac, pulmonary), and in addition, a brain perfusion deficit of a probably cardioembolic nature, despite adequate oral anticoagulant therapy with DOAC that had been taken for some time. Currently, the effectiveness of DOACs is not known in patients with SARS-COV2 infection and, above all, whether these drugs are able to counteract the hypercoagulation tendency associated with systemic vasculitis that accompanies the most complex clinical infection.