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SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: COVID-19 is associated with a hypercoagulable state and has been linked with Disseminated Intravascular Coagulation (DIC) [1]. DIC causes systemic thrombosis in micro- and macro- vasculature and in rare instances can involve coronary arteries [2]. In this case report, we present a patient who presented as an ST-segment elevation myocardial infarction (STEMI) and DIC in the setting of severe COVID-19 disease. CASE PRESENTATION: A 46-year-old lady with a history of hypertension presented with acute onset of typical chest pain. She tested positive for COVID-19 infection. Emergency room EKG showed anterior STEMI, and the patient underwent cardiac catheterization via a femoral approach which revealed a 99% stenosis in the proximal LAD, with filling defects consistent with a thrombus. Thrombectomy was performed and three drug-eluting stents were placed in the left anterior descending artery. Following stent placement, the patient went into ventricular fibrillation cardiac arrest followed by PEA. ROSC was attained after 3 rounds of CPR. Labs showed an acute drop in hemoglobin from 14 gm/dL to 5 gm/dL with CT evidence of extensive retroperitoneal bleed, extraperitoneal bleed, and large abdominal aorta thrombus proximal to the bifurcation. Labs were significant for prolonged INR (2.1), PT (23.4 seconds), PTT (106.7 seconds), elevated D-dimer (>4.0), decreased platelets (101K/μl), and increased fibrin split products (80uG/mL) consistent with DIC. The acute aortoiliac occlusive thrombus resulted in acute limb ischemia, rhabdomyolysis causing renal failure, and compartment syndrome requiring bedside fasciotomy. She was treated with triple therapy and demonstrated gradual clinical improvement. DISCUSSION: DIC was a possible precipitant of STEMI in this patient with evidence of thrombotic occlusion of LAD. DIC is a life-threatening coagulopathy characterized by mixed hypo- and hypercoagulation. This often leads to a systemic distribution of clots, evidenced by thrombi present in the coronary and aortoiliac arteries. Historically, bacterial sepsis was more strongly linked with DIC than viral causes;however, there has been an increasing amount of evidence linking COVID-19 with DIC, likely due to the severity of the illness. In this patient with recent stent placement, large aortic thrombus, and extensive retroperitoneal bleed, management was complicated by need for dual antiplatelet therapy for drug-eluting stents as well as anticoagulation for acute limb ischemia. Another diagnosis to keep in the differential includes heparin-induced thrombocytopenia, characterized by similar findings to DIC, but is associated with antibodies against platelet factor 4, which was not found in our patient. CONCLUSIONS: In this case, a young female patient without traditional cardiac risk factors was found to have an anterior STEMI, likely precipitated by DIC as a complication of COVID-19 infection. Reference #1: Asakura, Hidesaku, and Haruhiko Ogawa. "COVID-19-associated coagulopathy and disseminated intravascular coagulation.” International journal of hematology vol. 113,1 (2021): 45-57. doi:10.1007/s12185-020-03029-y Reference #2: M. Sugiura, K. Hiraoka, and S. Ohkawa, "A clinicopathological study on cardiac lesions in 64 cases of disseminated intravascular coagulation,” Japanese Heart Journal, vol. 18, no. 1, pp. 57–69, 1977. DISCLOSURES: No relevant relationships by radhika deshpande No relevant relationships by Shruti Hegde No relevant relationships by Robert Kropp No relevant relationships by Prashanth Singanallur
ABSTRACT
Background: Cytomegalovirus (CMV) is known to cause symptomatic disease in immunocompromised individuals. We present a rare case of CMV myopericarditis with findings of acute pulmonary embolism (PE) thought to be from the procoagulant effect of CMV in an immunocompetent middle-aged female. Case: 55-year-old female who presented to the ED for chest pain. Found to have non-specific EKG changes in V4-V6, troponin and COVID negative. TTE with EF 68% and pericardial effusion. ESR and CRP were elevated. Started on treatment for viral myopericarditis with colchicine, unfortunately developed diarrhea and was switched to high dose aspirin. CT coronary angiogram was performed to rule out ischemia. Calcium score of 0 and non-obstructive CAD in the LAD. CT also showed a new acute PE with no RV strain and she was started on Xarelto for anticoagulation. Infectious work up was performed, serum CMV IgM positive and CMV DNA of 18,205 copies. Oral valganciclovir was started for a total 21-day course for CMV myopericarditis. Patient was discharged with improvement of symptoms and plan for follow up with infectious diseases and cardiology for follow-up cardiac MRI. Decision-making: Symptomatic CMV infection is common in immunocompromised individuals. Immunocompetent patients that present with pulmonary embolism are far fewer. Cardiovascular complications have only been mentioned a handful of times in literature. In addition, and to the best of our knowledge, this is only the second known description of a patient to experience both myo-pericarditis and pulmonary embolism simultaneously from a symptomatic CMV infection. Conclusion: It is important for clinicians to be aware of this rare presentation of CMV, adding this to the differential diagnosis when an immunocompetent patient presents with symptoms concerning for viral pericarditis and/or evidence of pulmonary embolus.