RECURRENT HYPOXIA: ACUTE PULMONARY EMBOLI IN PATIENTS RECOVERING FROM COVID-19

Abstract

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: New York has been the epicenter of the COVID-19 pandemic in the United States. As potential treatment options are investigated, discussion revolves around the thrombotic nature of this novel virus. We present two COVID-19 positive patients in an NYC hospital, whose recoveries were complicated by pulmonary emboli despite receiving anticoagulation. CASE PRESENTATION: Patient 1: A 66-year-old female with coronary artery disease presented with dyspnea, cough, and fever. She was hypoxic, with labwork notable for elevated D-dimer of 1.83. She was initiated on hydroxychloroquine, dexamethasone, and prophylactic-dose enoxaparin. Initial CT angiogram (CTA) of the chest was negative for PE. Her symptoms improved, inflammatory markers down-trended, and she was discharged. Three days later, she returned with worsened dyspnea, tachycardia, hypoxia to 70%, and increased D-dimer, now greater than 20. Repeat CTA demonstrated a new saddle pulmonary embolus extending to lobar, segmental, and subsegmental branches bilaterally with evidence of right heart strain. She was treated with therapeutic enoxaparin, with gradual improvement in symptoms. Patient 2: A 48-year-old female with obesity presented with dyspnea, non-productive cough, and fever. She was hypoxic, with initial CTA showing bilateral ground-glass opacities and no evidence of PE. Labs revealed elevated inflammatory markers, including D-dimer of 2.2. She was started on hydroxychloroquine, azithromycin, dexamethasone, tocilizumab, and prophylactic-dose enoxaparin. Inflammatory markers continued to rise, so she was switched to therapeutic-dose enoxaparin and high-flow nasal cannula. Two days later, she developed heavy bleeding due to menses and was switched back to prophylactic enoxaparin. She subsequently developed worsening hypoxia requiring BiPAP. Repeat CTA now demonstrated central emboli in the left pulmonary artery. She was given alteplase and started on therapeutic unfractionated heparin with transition to coumadin. CTA three weeks after admission demonstrated resolution of pulmonary emboli, but the patient’s diffuse ground-glass opacities and hypoxia persisted. DISCUSSION: These patients raise concerns about the thrombotic nature of COVID-19 and suggest that prophylactic doses of anticoagulation may not be enough to prevent thrombotic events. Trending D-dimers in combination with monitoring changes in oxygen requirements may be useful tools when suspecting new PEs and deciding when to start therapeutic anticoagulation. CONCLUSIONS: While more data is needed on the thrombotic nature of COVID-19, therapeutic doses of anticoagulation may be necessary to prevent major thrombotic events in COVID-19 patients at low risk of bleeding. Reference #1: Levi M, Thachil J, Iba T, Levy JH. Coagulation abnormalities and thrombosis in patients with COVID-19. Lancet Haematol. 2020;7(6) DISCLOSURES: No relevant relationships by Tiffany Chen, source=Web Response No relevant relationships by Justin Gasper, source=Web Response No relevant relationships by Adam Rothman, source=Web Response No relevant relationships by Frederick Rozenshteyn, source=Web Response