Syncope as the initial presentation of pulmonary embolism in a patient with asymptomatic COVID-19: a case report

Syncope is a common clinical presentation, often may remain unexplained. PE is thought to be an uncommon cause of syncope. Hormone therapy (HT) is a known risk factor for thromboembolic disease (TD). The new coronavirus SARS-CoV-2 (COVID-19)pandemic has emerged in China and spread around the world. A higher prevalence of PE has been described in critically ventilated patients with COVID-19 but few data exist on the prevalence of TD in asymptomatic patients. We present a case of insidious development of PE probably promoted by the COVID19 infection. A previously healthy 51 year old female, obese (BMI 34 kg/m2), was admitted to the emergency department for syncope (third generation assays negative for Covid19). She reported HT for 4 months. She was tachypnoic (22 breaths/min), peripheral oxygen (SpO2) was 94% (room air). EKG: sinus tachycardia (137 beats/min) with S1Q3T3 aspect;arterial blood gases: moderate hypoxemia (PaO2 61.2 mmHg). ETT: dilated and hypocontractile right ventricle, D-shape aspect of the IVS, dilated inferior vena cava (23 mm), estimated PAP65 mmHg. We administered parenteral anticoagulant therapy and O2 therapy. We suspected PE, which was confirmed by contrast chest CT;no lung parenchymal involvement was documented.Later, we found RT-PCR assays positive for Covid19. PE should be suspected in all patients with syncope. The prevalence of TD in Covid19 asymptomatic patients is partially studied. Although current guidelines do not recommend the use of thromboprophylaxis in outpatient COVID-19, we believe that each case must be evaluated individually. More studies are needed to evaluate the risk-benefit ratio.

The COVID-19 pandemic: is it really just a flu? Focus on epidemiology

As the main title 'COVID-19 revolution: a new challenge for the internist' states, the global coronavirus infection disease 2019 (COVID-19) pandemic represented a new challenge for the internists. This paper is part of a series of articles written during the difficult period of the ongoing global pandemic and published all together in this fourth issue of the Italian Journal of Medicine, with the aim of sharing the direct experiences of those who were the first to face this severe emergency, expressing each point of view in the management of COVID-19 in relation to other diseases. Each article is therefore the result of many efforts and a joint collaboration between many colleagues from the Departments of Internal Medicine or Emergency Medicine of several Italian hospitals, engaged in the front line during the pandemic. These preliminary studies therefore cover diagnostic tools available to health care personnel, epidemiological reflections, possible new therapeutic approaches, discharge and reintegration procedures to daily life, the involvement of the disease not only in the lung, aspects related to various comorbidities, such as: coagulopathies, vasculitis, vitamin D deficiency, gender differences, etc.. The goal is to offer a perspective, as broad as possible, of everything that has been done to initially face the pandemic in its first phase and provide the tools for an increasingly better approach, in the hope of not arriving unprepared to a possible second wave. This paper in particular deals with the epidemiology of COVID-19.