ABSTRACT
TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: In the COVID-19 pandemic, pathogenesis and complications of COVID-19 were studied intently. Due to the associated cytokine storm, it is theorized that this triggers a hypercoagulable state for venous and arterial thromboembolism. Elevated D-dimer, fibrinogen, c-reactive protein (CRP), ferritin, and procalcitonin were seen in thrombotic complications. CASE PRESENTATION: A 66 year old male with dyslipidemia presented 11 days after diagnosis of COVID-19. He had worsening shortness of breath, myalgias, and loss of taste. He denied any diarrhea, nausea, or vomiting. On physical exam, he had crackles with diminished lung sounds using his accessory muscles. He was hypoxic with oxygen saturation of 81% on room air. Labs showed normal WBC count, d-dimer of 1.42 mg/L, ferritin of 961 ng/mL, lactate dehydrogenase of 621 U/L, and CRP of 2.1 mg/dL. Chest x-ray showed atypical pneumonitis with patchy abnormalities. He was started on vapotherm 40 L with FiO2 of 100% proning as tolerated. He received dexamethasone, prophylactic enoxaparin, 1 unit of plasma therapy, remdesevir, ceftriaxone, and azithromycin. On day 2, dexamethasone was increased to twice daily due to hypoxemia. Due to elevated d-dimer of 2.64 mg/L, enoxaparin was changed to twice daily. On day 5, he required continuous positive airway pressure (CPAP) with pressure support of 10 and FiO2 of 85% with dexamethasone every eight hours. His d-dimer increased from 1.65 to 3.51 mg/L. Computed tomography angiogram (CTA) of chest showed extensive ground glass opacities and 2.4 x 1.9 x 1.3 cm distal thoracic aortic intraluminal thrombus. He was started on a heparin drip, and enoxaparin was discontinued. CTA of aorta showed thrombus or hypoattenuation within splenic artery and areas of wedge-shaped extending from the hilum and possible infarction with a six mm thrombus in the infrarenal abdominal aorta. Vascular surgeon recommended no surgical intervention since he was asymptomatic. His d-dimer peaked to 6.92 mg/L but trended down. After two days of heparin drip, he was transition to enoxaparin 1 mg/kg twice daily. He remained asymptomatic with no flank pain. DISCUSSION: At least 17 cases thus far found splenic infarction as a rare thrombotic complication of COVID-19. Presentation is usually with left flank pain, which our patient did not have. Elevation of d-dimer were predictive of thrombosis complications in those hospitalized. Management includes therapeutic dose anticoagulation like subcutaneous low molecular weight heparin before being discharge home with oral anticoagulant. CONCLUSIONS: Although pulmonary embolism is the most common thromboembolism complication of COVID-19, arterial thrombosis are common especially in critically ill patients. Physicians need to consider arterial and venous thrombosis and investigate appropriately based on symptoms in order to manage. Prophylactic anticoagulation is recommended for hospitalized COVID-19. REFERENCE #1: Santos Leite Pessoa M, Franco Costa Lima C, Farias Pimentel AC, et. al. Multisystemic Infarctions in COVID-19: Focus on the Spleen. Eur J Case Rep Intern Med. 2020 Jun 3;7(7):001747. doi: 10.12890/2020_001747. REFERENCE #2: 2. Klok FA, Kruip MJHA, van der Meer NJM, et. al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020 Jul;191:145-147. doi: 10.1016/j.thromres.2020.04.013. REFERENCE #3: 3. Besutti G, Bonacini R, Iotti V, et. al. Abdominal Visceral Infarction in 3 Patients with COVID-19. Emerg Infect Dis. 2020 Aug;26(8):1926-1928. doi: 10.3201/eid2608.201161. DISCLOSURES: No relevant relationships by Jayaramakrishna Depa, source=Web Response No relevant relationships by Cassandra Do, source=Web Response No relevant relationships by shyam Ganti, source=Web Response No relevant relationships by Mythili Kanthi Gudipati, source=Web Response