Bilateral Pulmonary Embolism Research Articles

Moringa Oleifera leaf extract induced pulmonary embolism-a case report

BackgroundM. oleifera leaf extract supplement is famous for its anti-inflammatory, antioxidant, antimicrobial, antifertility, anticancer, antihepatotoxic, and antiulcer properties. However, limited data exist on the coagulation effect of M. oleifera leaf extract in human plasma, which maybe a predisposing factor to venous thromboembolism (DVT and PE); a disorder that is well known to be induced by risk factors such as surgery, trauma, cancer, or prolonged immobility.Case presentationWe report a case of a 63-year-old Hispanic female with past medical history of obesity and type 2 diabetes mellitus who presented to the emergency room with a three-day history of worsening shortness of breath and chest pain. Computerized tomography-pulmonary angiogram (CT-PA) revealed bilateral pulmonary embolism (PE) and right ventricle strain. Based on CT imaging findings, the absence of a major transient risk factor for venous thromboembolism (VTE), no history suggestive of an underlying hypercoagulable disorder, and a medication history that was significant for a recent 5-month use of M. oleifera leaf extract that has been reported to induce clot formation, she was diagnosed as a rare case of sub-massive pulmonary embolism provoked by M. oleifera leaf extract supplement. She received initial anticoagulation (AC) during her hospitalization and was discharged on maintenance AC for 3 months.Discussion and conclusionWe report the first case of PE likely triggered by using Moringa oleifera leaf extract herbal supplement. Cohort studies on the coagulation effect of Moringa oleifera leaf extract in humans are necessary to determine the relationship between Moringa Oleifera leaf extract and VTEs.

Treatment resistant M-type phospholipase A2 receptor associated membranous nephropathy responds to obinutuzumab: a report of two cases

BackgroundMembranous Nephropathy (MN) is a common cause of nephrotic syndrome (NS) in adults. Recognition of MN as an antibody mediated autoimmune disease has enabled the introduction of anti-B-cell therapy. Rituximab, a type I anti-CD20 antibody has been used in the management of MN, but has a 35-45% failure rate. Obinutuzumab, a fully humanised type II anti-CD20 monoclonal antibody produces greater CD20 depletion and is superior to rituximab in the treatment of certain B-cell malignancies. In the two reports published to date involving nine patients with M-type phospholipase A2 receptor (PLA2R) associated MN (six of whom were rituximab resistant), treatment with obinutuzumab lead to immunological remission (IR) in 75% of patients, with improvement of proteinuria, normalisation of serum albumin and stable renal function in all patients.Case presentationWe report on two cases of PLA2R-associated MN, two males aged 33 and 36-years, who presented with NS and bilateral sub massive pulmonary emboli requiring anticoagulation. Both were diagnosed serologically as PLA2R-associated MN where a renal biopsy was initially deferred due to bleeding risk on anticoagulation, but later confirmed. Both patients were refractory to multiple lines of therapy including rituximab, but achieved IR, normalistation of serum albumin, improved proteinuria and stable renal function with obinutuzumab.ConclusionsOur cases add to the current limited literature on the successful use of obinutuzumab in PLA2R associated MN refractory to standard therapy including rituximab.

The Mystery of Inappropriate Hypoxia After Single Lung Transplant

<h3>Introduction</h3> Single lung transplantation (SLT) is a treatment option for end stage lung disease in select patients, increasing utilization of a scarce resource. Increase in relative perfusion to the allograft from hypoxic vasoconstriction typically ameliorates hypoxia despite native lung disease. We present a SLT recipient with idiopathic pulmonary fibrosis (IPF) who developed hypoxia due to inappropriate shunting to the native lung after an IPF exacerbation. <h3>Case Report</h3> A 66 year old female with IPF had a left SLT eight months prior to presentation. Four months post transplant, she developed submassive bilateral extensive pulmonary embolism (PE) requiring suction thrombectomy, catheter-directed thrombolysis and anticoagulation without subsequent oxygen requirement. Three months later, she presented with two weeks of productive cough and hypoxia requiring high flow nasal cannula. CT chest showed worsening native lung fibrosis with ground glass opacities without PE or allograft infiltrate. Bronchoalveolar lavage was negative for infection, recent transbronchial biopsies were negative for rejection, and no donor specific antibodies were identified. Despite empiric antibiotics and pulse dose steroids for native lung exacerbation, she developed worsening hypoxia with progressive native lung infiltrates. A perfusion scan revealed 68% and 32% perfusion to the left and right lung, respectively. A right heart catheterization was performed, showing no intracardiac or pulmonary shunt, a mildly increased gradient across the left pulmonary artery (PA) anastomosis, and a marked improvement in left PA PaO2 during right PA balloon occlusion. On hospital day 16, repeat perfusion scan demonstrated an increase in relative perfusion to the allograft (83%). The patient was discharged on 3L oxygen and remains stable as an outpatient. <h3>Summary</h3> Severe hypoxia in the setting of a functioning SLT during a native lung exacerbation is rare. Literature on normal perfusion after SLT remains limited, with small studies suggesting ∼75% of fractional perfusion to the allograft without native lung exacerbation. Similar cases of inappropriate shunting after SLT had improvement in oxygenation after contralateral PA banding with other options including intravascular interventions or contralateral SLT. Further studies characterizing optimal perfusion after SLT and interventions for inappropriate shunting are needed.

Pulmonary Embolism Developing Despite the Use of Anticoagulants in Covid-19 Pneumonia: A case report

COVID-19 pneumonia is one of the diseases that can cause hypercoagulability. It is not uncommon to encounter arterial or venous thromboembolic events during COVID-19 infection. In this case, we wanted to discuss a case of a pulmonary embolism due to COVID-19 infection, which developed despite the usage of therapeutic dosage of anticoagulants. A 41-year-old male patient with a known diabetes mellitus was admitted to our clinic with complaints of cough and headache. The patient was found to be COVID-19 positive. Along with steroid treatment, 2x6,000 IU enoxaparin treatment was initiated for the patient. He developed sudden respiratory distress and showed an increase in oxygen demand. D-dimer value increased abruptly to 35.2 mg/L. Pulmonary CT angiography showed multiple bilateral subsegmental pulmonary embolisms. Since COVID-19 infection can cause arterial and venous thromboembolic events in patients following up with COVID-19 pneumonia, prophylactic anticoagulation should be initiated in hospitalized patients. Attention should be paid to signs of bleeding, and dose adjustment should be made by monitoring coagulation parameters.

Analysis of the Occurrence of Acute Pulmonary Embolism in the ICU Ward and Related Risk Factors Predicting Its Severity.

To investigate the occurrence of acute pulmonary embolism in the intensive care unit (ICU) and analyze the related risk factors for predicting its severity. From January 2016 to December 2020, 83 patients with acute pulmonary embolism in the intensive care unit of Peking University People's Hospital were selected as the research subjects, including 34 males (40.96%) and 49 females (59.04%), with an average age of 62.06±16.83 years. The patients were divided into a high-risk group (N = 31), medium-risk group (N = 32), and low-risk group (N = 20), according to the guidelines for diagnosis and treatment of acute pulmonary embolism issued by ASH in 2020. The clinical characteristics, treatment, and prognosis of the three groups were summarized, and the severity of the patients could be predicted and the related risk factors affecting prognosis were analyzed. There were significant statistical differences in respiratory rate, syncope as the first symptom, bilateral pulmonary embolism, and APACHE-II score among the three groups (P < 0.05). There were significant statistical differences in the laboratory indexes, such as BNP, cTnI and D-dimer before and immediately after APE among the three groups (P < 0.05). There were significant statistical differences in cTnI and D-dimer among the three groups (P < 0.05). By pairwise comparison, it was found that there were significant statistical differences between the high-risk and low-risk groups in the immediate test indexes of APE, such as BNP, D-dimer, lower extremity vascular ultrasound abnormalities, and ECG abnormalities (P < 0.05), while there was no significant statistical difference between the medium-risk and low-risk groups in the immediate test indexes of APE (P > 0.05). However, in the medium-risk group, the laboratory indexes tended to increase, in terms of treatment and outcome, thrombolysis rate, and inferior vena cava filter implantation rate. ICU stay (> 2 weeks) of the high-risk group was significantly higher than those of the other two groups, with significant statistical difference (P < 0.05). Logistic regression analysis showed that respiratory rate (or = 1.778,95% CI 1.043-3.032, P = 0.034), D-Dimer (or = 1,95% CI 1.0-1.0, P = 0.006), and APACHE-II score (or = 1.879,95% CI 1.398-2.527, P = 0.000) were independent risk factors for predicting the severity of APE patients in the ICU ward. Acute pulmonary embolism (APE) is a critical disease in ICU. By monitoring BNP, cTnI and D-dimer, we can identify critical patients with APE early. In addition, we found that respiratory rate, D-dimer, and APACHE-II score were independent risk factors for predicting the severity of APE patients in the ICU. Clinically, APE can be identified early. The diagnosis, treatment rate, and prognosis can be improved by monitoring these indicators.

PULMONARY EMBOLISM OF BUTYL-CYANOACRYLATE AFTER ENDOSCOPIC SCLEROSIS OF GASTRIC VARICES

Pulmonary embolic complications may occur during endoscopic treatment of gastric varices using butyl-cyanoacrylate glue. Combined with a contrast agent, in particular Lipiodol, these vascular embols can only be diagnosed by computed tomography without injection of iodinated contrast. We report the case of a 21-year-old patient who presented with bilateral pulmonary embolism due to the injection of this glue into gastric varices.

Intravascular Ultrasonography and Endovascular Balloon Assisted Repair of Saccular Popliteal Vein Aneurysm

Popliteal venous aneurysm (PVA) is rare, and the most frequently reported surgical repair is tangential aneurysmectomy and lateral venorrhaphy. A 60 year old man presented with bilateral pulmonary embolism and a left 4.6 × 4.4 × 7.9 cm partially thrombosed saccular PVA with a1 cm neck. Anticoagulation was initiated and a vena cava filter was inserted two weeks prior to surgery.

HIV Infection Diagnosis in a Late Presenter Patient during a Severe Imported Falciparum Malaria: A Challenging

BACKGROUND: Malaria and HIV share the same epidemiological spreading and coinfection may be clinically challenging. In 2019, nearly all malaria cases reported by EU/EEA countries were imported. Severe falciparum malaria is a medical emergency often associated with poor outcome, even when treated with appropriate therapy. CASE PRESENTATION: Here, we described an unusual case of a late presenter HIV diagnosis made during the management of a severe falciparum malaria in an Italian traveler returning from Nigeria, who did not take antimalaria prophylaxis. Clinical course was complicated by the occurrence of several superinfections caused by deep immunosuppression, and bilateral subsegmental pulmonary embolism. CONCLUSION: Although critical conditions, malaria prompt diagnosis and treatment, along with HIV diagnosis and the successful treatment of occurred superinfection, resulted in a positive outcome.

Concurrent pulmonary arteriovenous malformation and pulmonary embolism causing stroke: a therapeutic dilemma

BackgroundAs pulmonary arteriovenous malformation (PAVM) include a right-to-left shunt, it can be accompanied by fatal complications such as stroke and brain abscess due to paradoxical embolism. A concurrent PAVM and pulmonary embolism (PE) is a rare condition. Therefore, the sequence of management has not been established.Case presentationA 62-year-old female patient was transferred to our hospital with a sporadic simple PAVM and concurrent bilateral PE. On chest computed tomography (CT), the acute PE was extended to the segmental pulmonary artery where the feeding artery of PAVM originated. Despite the anticoagulation, the patient complained of left sided weakness on the fifth day of admission, and magnetic resonance imaging revealed an acute infarction in the right lateral thalamus, which was thought to be caused by paradoxical embolism. This situation could lead to a dilemma between the risk of thrombus migration during PAVM embolization and another embolic event due to delayed shunt occlusion during anticoagulation. After a multidisciplinary discussion, a delayed endovascular embolization was performed for PAVM after confirming the complete resolution of PE with 4 months of anticoagulation. The cause of PE in this patient was eventually diagnosed as antiphospholipid syndrome.ConclusionThe authors reported a rare case of concurrent PAVM and PE that led to an embolic stroke during hospitalization. This patient was managed with delayed endovascular embolization for PAVM after an anticoagulation for PE and stroke. It is thought to be valuable in deciding for a treatment plan for this rare condition.

A Troika of Tricuspid Valve Thrombus, Bilateral Upper Extremity Deep Venous Thrombosis and Pulmonary Embolism

Background: Tricuspid valve thrombus with concomitant bilateral pulmonary embolism (PE) and right heart strain poses a significant risk of hemodynamic instability and increased mortality. Case Report: We report the unique case of a female who presented with dyspnea and tachycardia, and was subsequently found to have a structure attached to the tricuspid valve. Concomitantly, she also had bilateral upper extremity deep venous thrombosis (UEDVT) and bilateral sub-massive PE. Thorough clinical assessment, and diagnostic and risk stratification tools were applied to guide the management and disposition. Tricuspid valve thrombus resolved after unfractionated heparin therapy followed by oral anticoagulation as seen on repeat transthoracic echocardiography. We think the readership will benefit from our experience of managing an uncommon and critical clinical presentation of tricuspid valve thrombus in the setting of extensive venous thromboembolism. Conclusion: Careful clinical assessment, risk stratification tools, and close monitoring are needed to guide the management of tricuspid valve thrombus with concomitant bilateral PE and UEDVT.

Isolated tricuspid valve disease in antiphospholipid syndrome

We report the case of a 27-year-old male, presenting with dyspnea and chest pain. Radiographic and echocardiographic evaluations revealed bilateral segmental pulmonary embolism, left lower extremity deep vein thrombosis, and isolated tricuspid valve endocarditis. Microbiologic and serologic tests ruled out an infectious etiology and supported a diagnosis of nonbacterial thrombotic endocarditis as a manifestation of a newly diagnosed antiphospholipid syndrome. We discuss the clinical presentation, diagnostic evaluations, treatment, and clinical outcome.

Paradoxical pulmonary embolism in a patient with bilateral renal infarction: The role of contrast-enhanced ultrasound imaging

We present the case of a 52-year-old male who was admitted to the hospital for a bilateral pulmonary embolism. On the 5th day of hospitalization, an acute kidney injury (AKI) occurred. A transesophageal echocardiogram was performed and it demonstrated a large patent foramen ovale with a consistent right-to-left shunt. Contrast-enhanced ultrasound (CEUS) was performed and it demonstrated multiple bilateral renal ischemic areas. CEUS represents a valid alternative to computed tomography or magnetic resonance to confirm the diagnosis of bilateral kidney infarction, especially in patients who experience an AKI.

Острый тромбоз бедренно-подколенного сегмента, осложнившийся ТЭЛА. Описание клинического случая

Deep vein thrombosis (DVT) and PE are classified as venous thromboembolic complications (VTEO), they remain an important problem in clinical medicine and affect the professional sphere of doctors of all specialties, since their pathogenesis is based on hypercoagulation caused by various causes, in particular, genetic defects of blood clotting factors, diseases of the cardiovascular system, severe injuries and subsequent immobilization, iatrogenic lesions, etc. The article describes a clinical case of treatment, observation and treatment of a patient diagnosed with Subacute phlebothrombosis of the left lower limb. Popliteal-femoral segment. VN II. Non-massive bilateral pulmonary embolism. DN 0-1. Arterial hypertension 2 stages, 2 degrees, risk 3.CHF 1. The study was conducted on the basis of the Regional Clinical Hospital No. 2 in Tyumen. Aim. Description of the identified case, subcute thrombosis of the femoral-popliteal segment, complicated by PE, for a more complete understanding of the problem due to the high prevalence of this pathology in the structure of vascular diseases; analysis of the possibility of early diagnosis and treatment on the example of a specific case. Material and methods. A retrospective analysis of the patient’s medical history was carried out and an example from the practice of the admission department of the Regional Clinical Hospital No. 2 in Tyumen of clinical observation of a patient diagnosed with subacute thrombosis of the femoral-popliteal segment, complicated by PE. Anamnesis of life and disease, clinical, laboratory and instrumental data were evaluated. Conclusion. The most realistic prevention of threatening PE is the effective treatment of acute venous thrombosis. It is very important to timely and adequately assess the risk of thrombosis in each individual case. The consequences of the lack of prevention of thrombosis lead to an increased risk of repeated episodes of venous thromboembolism, the development of post-thrombotic disease, and can also lead to death from PE. It should be noted that it is necessary to monitor CT scans – angiopulmonography – to control the development of pulmonary embolism as a complication against the background of newly formed thrombosis of the femoral-popliteal segment. Sanitary and educational work, active tactics, timely treatment and hospitalization of patients with acute deep vein thrombosis BPS will contribute to improving the quality of life of this category of patients, reducing the percentage of PE and deaths.

Submassive pulmonary thromboembolism, post-COVID sequelae; with mechanical thrombus aspiration and accelerated thrombolysis by Ekos ultrasound with successful resolution

IntroductionAcute pulmonary thromboembolism is a pulmonary pathology that is becoming more frequent nowadays, the use of new mechanical and thrombolytic therapies has a significant impact on the cardiopulmonary prognosis.CaseA 41-year-old male, a retired military man, smoking, overweight, dyslipidemia, alcoholic liver disease, who attended the emergency department due to abrupt dyspnea, with tachycardia, chest pain, and syncope; the patient had tachycardia of 120 bpm, BP 90/60 mmHg and SO2 of 82%, with a history of COVID-19 infection, suspected of massive pulmonary embolism, it was decided to carry out computed tomography where a bilateral submassive pulmonary embolism was documented (Fig. 1A), it was proposed to perform systemic thrombolysis, however due to the risk of bleeding, it was decided to perform EKOS ultrasound directed thrombolysis. Baseline pulmonary angiography was performed with a large number of thrombi (Fig. 1B), distributed in both main right and left branches and deficient pulmonary filling of distal vessels, due to the large amount of thrombus, it was decided to perform manual thrombus aspiration, obtaining a large amount of thrombus (Fig. 1C), as well as thrombolysis in situ with Alteplase a dose of 1 mg/catheter/hour for 12 hours, with a total dose of 24 mg; Ultrasound probe was placed in both pulmonary arteries with the EKOS system (Fig. 1D).ResultsPulmonary angiography was performed 24 hours after the procedure, where no bleeding occurred and almost complete resolution of the thrombus was observed. The patient later with 92% SO2, without oxygen requirements, with HR 90 bpm, with no evidence of ventricular dysfunction, was discharged home with anticoagulation.ConclusionLow dose fibrinolysis and thromboaspiration are considered, as well as the use of EKOS endovascular ultrasound, a safe and effective procedure, in the context of a patient with high-risk of bleeding, with favorable results that condition clinical and prognostic improvement.

Unexpected Pulmonary Embolism Late After Recovery from Mild COVID-19?

SARS-CoV-2 infection is associated with an increased risk of venous thromboembolism (VTE), which is common during active illness but unusual in milder cases and after healing. We describe a case of bilateral acute pulmonary embolism occurring 3 months after recovery from a paucisymptomatic SARS-CoV-2 infection. The only VTE risk factor demonstrable was a history of previous SARS-CoV-2 infection, with laboratory signs of residual low-grade inflammation. Clinicians should be aware of VTE as a potential cause of sudden dyspnoea after COVID-19 resolution, especially in the presence of persistent systemic inflammation.LEARNING POINTSVenous thromboembolism may occur after COVID-19, even in milder SARS-CoV-2 infections and late after coronavirus clearance.Laboratory signs of systemic inflammation are clues for suspecting venous thromboembolism as a cause of sudden dyspnoea in patients with low risk scores for pulmonary embolism but with previous COVID-19 infection.

216 The ‘inflammatory perfect storm’: a case of COVID-19 pneumonia complicated by pulmonary embolism

AimsThe inflammatory ‘cytokine storm’ that distinguishes COVID-19 pneumonia is associated with a state of systemic hypercoagulability, which leads to thrombotic complications on the venous, arterial, and microvascular side. Indeed, in patients with COVID-19, systemic inflammation, coagulation activation, hypoxemia, and immobilization expose a high risk of pulmonary embolism, which significantly worsens the prognosis of these patients.Methods and resultsIn this report, we discuss the case of a 71-year-old female, with no prior medical history, admitted to the emergency department for syncope, dyspnoea, and fever started 48 h earlier. At presentation, ear temperature was 37 °C, oxygen saturation was 96% on oxygen therapy (6 l/min), the patient appeared hypertensive (160/80 mmHg) and tachycardic (114 b.p.m.). Laboratory tests revealed normal white blood cells count (10 000/μl) and increased C reactive protein (5.60 mg/dl), troponin I (0.417 ng/ml), and d-dimer levels (15743 ng/ml). Electrocardiogram showed sinus tachycardia at HR of 120/min, normal atrioventricular conduction time, new onset right bundle branch block, and inverted T waves on DIII. Considering the symptoms, CTPA was performed, revealing massive acute bilateral pulmonary embolism with peripheral ground glass opacities. Those findings were suggestive of COVID-19 pneumonia. Indeed, the patient was positive for SARS-CoV-2 infection, and a diagnosis of COVID-19 pneumonia complicated by pulmonary embolism was made. Treatments included oxygen, subcutaneous low molecular weight heparin (LWMH), and corticosteroids have been administrated according to current international guidelines. Since no haemodynamic instability was observed during hospitalization the patient was discharged on Warfarin therapy for 6 months.ConclusionsIn COVID-19 patients treated in a hospital the incidence of pulmonary embolism (PE) is very high. Patients with COVID-19 infection have respiratory symptoms, which often may not be distinguishable from pulmonary embolism symptoms. So, unexpected respiratory worsening, signs of right ventricular dysfunction on transthoracic echocardiogram, and ECG changes should lead to suspicion of the co-presence of pulmonary embolism. This case report shows how COVID-19 infection can be strongly associated with thrombotic complications. For this reason, the guidelines recommend anticoagulation at standard prophylactic doses in all patients admitted with COVID-19 infection.

Compliance Issues in Managing 21 Hydroxylase Deficiency and their Short/Long-Term Consequences.

ObjectiveTo report a case of untreated classic 21 hydroxylase (OH) deficiency congenital adrenal hyperplasia (CAH) in a transgender patient resulting in pulmonary embolisms (PEs) and bilateral adrenal masses.MethodsA 36-year-old male (birth sex: female) presenting with bilateral PEs in the setting of long-standing, untreated classic 21OH CAH was also found to have bilateral adrenal masses (unconfirmed myelolipomas).ResultsFurther history revealed a known diagnosis of CAH. The patient had been treated with glucocorticoid and mineralocorticoid replacement in childhood but stopped taking these medications against medical advice. During his hospital admission, he was noted to have elevated 17-hydroxyprogesterone, low cortisol with elevated ACTH levels, and male-level testosterone measurements. CT of the abdomen/pelvis revealed a 23 cm mass in the left renal fossa and a 2.5 cm mass in the right renal fossa consistent with bilateral adrenal myelolipomas. The patient attended follow-up in clinic, but declined any further hormonal treatment as he identified as male and felt further treatment was unnecessary.ConclusionThis case demonstrated the unique long-term effects of untreated classic CAH due to 21OH deficiency, including bilateral adrenal myelolipoma, adrenal compensation to the point of producing male-level androgens, and possibly PEs. Treatment with hydrocortisone was recommended to suppress ACTH and it was planned that the patient would eventually start on testosterone (although this would have been complicated by his bilateral PEs). Potential aetiologies for the PEs included vascular compression of the renal artery (which could explain the elevated EPO/erythrocytosis contributing to hypercoagulability) or the renal vein by the adrenal mass.LEARNING POINTSGender dysphoria in patients with congenital adrenal hyperplasia (CAH) is not uncommon.Adrenal enlargement can allow untreated CAH patients to compensate.Pulmonary embolisms can be a consequence of treating as well as untreated CAH.

Spontaneous Heparin-Induced Thrombocytopenia and COVID-19 Infection

Background and Objective: Heparin-induced thrombocytopenia (HIT) can develop if immune responses to infections become pathologic in the presence of heparins. Low molecular weight heparin or unfractionated heparin are recommended for prophylaxis and treatment of venous thromboembolic disease in hospitalized patients with Covid-19 infection but may trigger HIT. Our aim is to alert clinicians that HIT occurs in association with Covid-19 infections even in the absence of prior exposure and may not be easily recognized without a high index of suspicion. Case Summary: A 33-year-old previously healthy male was initially evaluated for low grade fever, dyspnea without hypoxia and cough. A Covid-19 PCR swab was negative despite a recent exposure. He was treated with azithromycin. However, his symptoms did not improve, he then developed right leg swelling and hypoxia, so he was re-evaluated. CTA of the chest showed bilateral pulmonary emboli and ground-glass opacities at the lung bases. Venous Duplex Ultrasound showed non-occlusive thrombus in the deep veins of right lower extremity. He was hospitalized and placed on oxygen and heparin. Covid-19 swab was negative again. Laboratory tests before heparin showed a decreased platelet count of 64,000 k/ul, elevated prothrombin time of 16.4 seconds, normal aPTT at 30.8 seconds, decreased serum fibrinogen at 120 mg/dl and markedly elevated D-dimer at 59,966 ng/ml. Lupus anticoagulant and anti-phospholipid antibody tests were negative. On heparin at the desired therapeutic aPTT target range, the right leg became significantly swollen and painful by day five. Platelet count had decreased further to 39,000 k/ul. Repeat doppler examination of the right leg now showed more severe and extensive deep venous thrombosis. D-dimer had increased to 125,133 ng/ml. The HIT 4T score was 4, suggesting intermediate probability. Rapid HIT immunoassays on 2 separate samples were positive. Heparin was discontinued and he was placed on argatroban. Serotonin release assays on 2 separate samples came back positive. Suspicion for Covid-19 infection remained high and so a Covid-19 serology sample was obtained which was positive for IgG. A repeat nasopharyngeal swab at this time turned positive. He did not receive any COVID specific treatments. As viability of his leg appeared threatened, he underwent right iliofemoral vein thrombectomy with arteriovenous fistula creation. He improved on argatroban and was transitioned to apixaban with gradual normalization of hemostasis laboratory parameters, improvement in hypoxemia and fading clinical symptoms, he was discharged home on day 15. Conclusion: Current consensus guidelines for thromboprophylaxis and treatment of thromboembolism in hospitalized patients with Covid-19 infection recommend heparins as primary therapy to reduce morbidity and mortality. However, our report in addition to the two previous reports of HIT in Covid-19 patients illustrate that HIT can be a complication in the setting of Covid-19 infection. Further, our report also highlights that HIT with thrombosis can occur in a spontaneous manner in the absence of prior heparin exposure, which has been so far studied only in bacterial infection with the hypothesis that Platelet factor 4 (PF4) can bind to negatively charged polysaccharides on the surface of bacteria, triggering an immune response. DisclosuresNo relevant conflicts of interest to declare.

P1‐88: Persistent bilateral unprovoked pulmonary embolism ‐ A case of chronic thromboembolic pulmonary hypertension in a young lady with seronegative antiphospholipid syndrome

P1‐88: Persistent bilateral unprovoked pulmonary embolism ‐ A case of chronic thromboembolic pulmonary hypertension in a young lady with seronegative antiphospholipid syndrome

TCT-457 Contralateral Effects of Unilateral Catheter-Directed Thrombolysis for Bilateral Acute Pulmonary Embolism

TCT-457 Contralateral Effects of Unilateral Catheter-Directed Thrombolysis for Bilateral Acute Pulmonary Embolism