Complex Combination of Pulmonary Embolism, Stroke, and ST-Segment Elevation Myocardial Infarction in Young Patient with Recent COVID-19 Infection and Newly Diagnosed Lung Carcinoma

Abstract

BACKGROUND: Ischemic stroke, pulmonary embolism (PE), and acute ST-segment elevation myocardial infarction (STEMI) are very rarely all present in younger patients without classical risk factors or a family history of dyslipidemia or cardiovascular disease. They  represent a medical emergency and necessitate fast diagnosis, treatment, and search for etiology, not explained purely by atherosclerosis. Thrombophilia testing should be considered in younger patients with several major thrombotic episodes, although there is much disagreement concerning the importance of homocysteine level testing in patients with arterial and venous thrombotic events, including PE. COVID-19 infection may trigger several thrombotic complications caused by unique immunothrombotic processes. CASE PRESENTATION: A 44-year-old patient complaining of chest pain was admitted at our clinic due to acute anterior STEMI. He has a previous  medical history of ischemic stroke, COVID-19 infection, and PE in the past 2 months. Newly, diagnosed lung adenocarcinoma was confirmed by biopsy 10 days before STEMI admission, without surgical or previous hemotherapy. The patient was on regular anticoagulant therapy with rivaroxaban 20 mg OAD and antiplatelet therapy with Aspirin due to previous PE and ischemic stroke. Patient denied standard risk factors, family history for cardiovascular disease or any previous minor or major bleedings, history of anemia, liver, or renal dysfunction. Acute stroke was confirmed by brain computed tomography imaging. Thrombophilia panel testing revealed  homozygote  mutations for MTHFR 677 gene, heterozygote mutation for integrin subunit alpha 2, and fibrinogen B beta chain) genes. The patient was treated with low molecular weight heparin, aspirin, clopidogrel, and heart failure therapy in the acute phase. Clinical consultations were performed with a team of doctors which included a cardiologist, neurologist, and oncologist. Patients have a high bleeding risk, assessed by HAS-BLEED score of 4. CONCLUSION: Our patient is a rare case of serious multi-vascular thrombotic events with underlying thrombophilia, lung cancer, and past COVID-19 infection complicated by pulmonary embolism, ischemic stroke, and STEMI.