Bilateral Spermatic Vein Thrombosis Following COVID-19 Infection

A 35-year-old male attended the emergency department complaining of bilateral inguinoscrotal pain.

Two weeks prior to presentation, he had been diag- nosed with coronavirus disease-2019 (COVID-19). On day 11 following COVID-19 diagnosis he developed bilateral groin pain.

The patient’s scrotal examination was remarkable for clinical grade 3 varicoceles, a finding he reported as new. There was moderate bilateral inguinal tenderness but no hernias. His blood tests showed a raised platelet count of 426 x109/L (normal:150 to 400), white cell count of 9.7 x 109/L (4 to 11) and haemoglobin of 146g/L. JAK2 V617F was not detected. An inguinoscrotal ultrasound demonstrated absence of f low in his spermatic veins bilaterally, with echo- genic material within the vessel lumen consis- tent with spermatic vein thrombosis (Figure 1). A CT abdomen demon- strated an incidental 18mm right renal angio- myolipoma.

The patient was dis- charged with a 3-month course of rivaroxaban. At a follow-up call one month later, his pain had resolved.

Bilateral spermatic vein thrombosis is a rare diagnosis with this being only the third case reported. All previ- ous reported cases were associated with an underlying coagulation disorder and were managed with a course of anticoagulant therapy. In our patient, the likely predis- posing factor was COVID-19 infection. Myeloprolifera- tive neoplasia was considered; however, the resolution of the mild thrombocytosis and negative JAK2 study were not supportive.

COVID-19 is associated with a pro-thrombotic state postulated to arise from the high pro-inflammatory cytokine levels. Increased platelet activation and reac- tive hyperfibrinogenemia contribute to the prothrombotic state. Guidelines on the management of spermatic vein throm- bosis are lacking. In view of the symptoms, embolic risk and the transient nature of the thrombotic risk factor, our patient was treated with a course of 15mg rivaroxaban twice daily for 3 weeks, and then 20mg daily for a total of 3 months.