ABSTRACT
Purpose of study COVID-19 primarily affects the respiratory system from flu-like syndrome to acute hypoxic respiratory failure. Neurological manifestations are uncommon and can result in serious complications. We report a unique case of sudden onset of rapidly progressive encephalopathy in the setting of COVID-19. Methods used Reviewed the manifestations, clinical course, and outcome for a patient presenting with altered mental status secondary to COVID-19. Summary of results A 48-year-old with no significant past medical history presented to the emergency department complaining of severe headache for four days. His vital signs on presentation showed a blood pressure of 154/90, pulse of 114 bpm, temperature of 99.6 degreeF, and oxygen saturation of 97% on room air. Physical exam was unremarkable. Lab work showed elevated D-dimer 8,500 ng/L, Elevated ESR:42, LDH:340 and Ferritin:692. White blood count: 7.59 uL, Platelets 50 x 103 uL. Computer tomography angiography (CTA) of the chest showed bilateral multifocal pneumonia. CT Head was performed and was negative for an acute hemorrhage, hydrocephalus or territorial infarcts. Patient spiked a fever shortly after admission 103degreeF. Patient was started on Ceftriaxone and Azithromycin. Blood and urine cultures were positive for Klebsiella pneumonia. Patient was re-evaluated in the morning and was found altered with associated neck stiffness. Antibiotics were switched to cover for suspected meningitis. Neurology was consulted and recommended lumbar puncture. Within a few hours, the patient's mental status deteriorated and was found to be hypertensive with a blood pressure of 220/110. Repeat CT Head was negative. The patient was tested and found to be positive for COVID-19. Patient further decompensated within a few hours and became unresponsive, pulseless. ACLS was performed and the patient was transferred to the intensive care unit. Conclusions This case report highlights the heterogenous presentation in patients with COVID-19 and the importance of recognizing a new onset, severe headache as the only initial presentation. Headaches in some cases may precede the respiratory symptoms or may be the only manifestations in COVID-19 patients and it is crucial to be aware of the neurological complications and the rapid decompensation these patients may undergo if not recognized early.
ABSTRACT
INTRODUCTION: Right heart thrombi (RVT) are uncommon, usually found concurrent with pulmonary embolism and associated with significantly increased mortality. We describe a rare etiology of RVT formation ?in situ? complicating acute pulmonary embolism of a patient with COVID-19 infection already on anticoagulation with direct oral anticoagulants (DOACs). METHODS: A 43 yo obese male was diagnosed with presumptive COVID-19 infection based on clinical, inflammatory markers, and radiographic evidence. PCR was negative, which is encountered in 38% of tests. D-dimer was elevated 12499 ng/L however, CT angiogram (CTA), lower extremity duplex, and transthoracic echocardiogram (TTE) were unremarkable for thrombus. He received therapeutic enoxaparin for 3 days and was discharged on apixaban 5 mg twice daily. 5 days later, he developed worsening shortness of breath and hypoxemic respiratory failure. Repeat CTA revealed bilateral pulmonary emboli and TTE showed a 1.4 x 1.2 cm mobile thrombus in the right ventricle. Hypercoagulable workup was negative. Catheterdirected thrombolysis and salvage extracorporeal membrane oxygenation (ECMO) were considered however, the patient was unstable for transfer and ultimately expired after a sudden cardiac arrest. RESULTS: The existing consensus favors enoxaparin as the preferred anticoagulation for COVID-19 patients. It promotes anti-inflammatory properties by reducing IL-6 and lung edema. Other benefits include reducing the exposure of personnel by the absence of activated partial thromboplastin monitoring. There is a lack of anti-inflammatory properties with the use of DOACs as well as an understanding of the appropriate dose requirements. Therefore, the decision to discharge patients on prophylactic anticoagulation with enoxaparin as compared to DOACs is essential given the increased propensity of thromboembolic disease. We highlight the unique challenges in the evaluation and treatment of patients with COVID-19 and an elevated D-dimer. The increased risk of microthrombi warrants the initiation of therapeutic anticoagulation. We recommend the use of enoxaparin upon discharge of patients with elevated D-dimer. Further studies are required to understand the best choice, role, dosage, and duration of anticoagulation therapy in patients with COVID-19 infection.