ABSTRACT
Background: Patients with CoViD-19 pneumonia have hyperactive coagulation status and one of the main causes of death is pulmonary embolism. They also suffer from hypoxia, so they need respiratory support and prone positioning. Description of the case: A 59-year old woman (weight 100 Kg, BMI 32) came to our hospital reporting fever and dyspnea. Chest X-ray: extensive parenchymal thickenings in the subpleural regions of both lungs. Analysis: hemoglobin 14.7 g/dl, creatinine 1.18 mg/dl, D-Dimer >10000 ng/dl, pO2/FiO2 124. Treatment: antibiotics, hydroxychloroquine, tocilizumab, high flow oxygen alternating with NIV, dexamethasone, enoxaparin 8000 U bid and alternating supine and prone position. Eighteen days after admission we noticed a swelling in her breast. A thoracic CT scan showed a leveled hematoma (16x10cm) below the left pectoralis major muscle, an arterial spread from the lateral thoracic artery, a thromboembolic image in a subsegmentary branch of the pulmonary artery and extended bilateral ground glass. The patient underwent blood transfusions for acute anemia (hemoglobin 6.9 g/dl) and multiple arterial embolizations. Conclusions:We hypothesized that the pro-inflammatory endovascular condition, in a severe CoViD-19, and the anticoagulant treatment have determined fragility of the vascular wall. In addition, the continuous changes of posture have probably led to a repeated traumatism and rupture of blood vessels. Therefore in obese women, whose lateral thoracic artery is large and emits mammary branches, pronosupination should be personalized taking into account enoxaparin dosage.