Covid-19 Vaccine-Induced Myositis

Background/Aims Through the COVID pandemic there have emerged reports of autoimmunity or new rheumatic diseases presenting in patients after they had COVID-19. This is thought to be caused by cross-reactivity of the COVID-19 spike protein to human antigens. Given the use of mRNA COVID-19 vaccinations which express the spike protein we might expect to see presentation of new rheumatic diseases following their use. We discuss a case where this appears to have occurred. Methods Our patient is a 24-year-old male with mixed phenotype acute leukaemia who had been treated with allogenic stem cell transplant and was currently in remission. He presented with fevers, palpitations, myalgia and bilateral arm and leg swelling. Symptoms began the day after receiving the first dose of an mRNA COVID-19 vaccination (Pfizer/BioNTech.) There were no other symptoms or recent change in medications. Physical examination revealed tender oedema in his forearms, biceps and thighs bilaterally with sparring of the hands. He had reduced power with shoulder (MRC 3/5), elbow (4), wrist (4+) and hip (4) movements. Observations revealed tachycardia and fevers up to 40C. Results Laboratory studies showed markedly elevated C-reactive protein (202), creatinine kinase (6697) and troponin (593) whilst investigations for infection were negative. An autoimmune panel was positive for anti- PM-SCL-75-Ab. An electrocardiogram showed sinus tachycardia. Echocardiogram was normal. Bilateral upper limb dopplers revealed no deep vein thrombus. An MRI of his thighs showed diffuse symmetrical oedema within the muscles, in keeping with an inflammatory myositis. A quadricep muscle biopsy showed evidence of MHC class 1 up-regulation, suggesting an inflammatory process. In addition, there were numerous macrophages evident in the endomysium. While this can be seen in graft-versus-host disease (GVHD), they would usually be found in the perimysium. After discussion between haematology, rheumatology and neurology, this was felt to be a case of vaccine induced myositis and myocarditis. Autoimmune myositis was thought to be less likely due to the relative sparing of the hands and the absence of Raynaud's phenomenon. 1 gram of intravenous methylprednisolone was then given for 3 days. The patient had a marked response with defervescence, improving laboratory markers, improved myalgia and decreased limb swelling. The patient was stepped down to a reducing regime of prednisolone and discharged. Due to relapse whilst weaning he has started on mycophenalate mofetil and rituximab and now continues to improve. Conclusion There are case reports of myositis following COVID-19 vaccination but our patient's case is complicated by the differential diagnosis of GVHD and concurrent myocarditis. Ongoing work is needed to clarify the exact link between vaccination and the presentation of a new inflammatory myositis, but it is important to recognise and start treatment early in order to preserve muscle bulk and ensure recovery.

A novel approach to low-energy calcaneal tuberosity avulsion fractures in patients with fragile bone quality: A report of two cases

Maintaining reduction of a calcaneal tuberosity avulsion fracture is challenged by the powerful force exerted upon the bone fragment by the Achilles tendon. Low-demand, elderly patients with osteoporotic bone usually undergo a low-energy mechanism when this fracture pattern occurs. Likely attributable to poor bone quality, the rate of early fixation failure has been documented to be as high as 40%. We present the cases of two 65-year-old female patients who each sustained a calcaneal tuberosity avulsion fracture. Both patients underwent a low-energy mechanism of injury and had a medical history of many comorbidities. The first patient underwent a partial calcaneal ostectomy and tenotomy after failing open reduction internal fixation (ORIF). The second patient primarily underwent a partial calcaneal ostectomy and tenotomy. Postoperatively, after the incision site was fairly healed, both patients could bear weight as tolerated. This method of excision and release may allow for decreased risk of skin compromise and return trips to the operating room for failed ORIF. In low-demand patients with low-energy calcaneal avulsion type fractures and osteoporotic bone, this technique may be the preferred surgical option.Copyright © 2022 The Author(s)

A Controversy: Warfarin Failure in Covid-19 with Supratherapeutic Inr

Background COVID-19 has been previously associated with thromboembolism. We present a unique case of a patient who was compliant with warfarin and yet developed breakthrough Deep Venous Thrombosis after recently being diagnosed with COVID-19. Case A 49-year-old female with past medical history of rheumatic fever complicated with mitral stenosis and treated with mechanical mitral valve replacement in 2003, presented with right-sided leg swelling, warmth, and pain for the past 1 week. She tested positive for COVID-19 almost 2 weeks ago but was not hospitalized or treated due to minimal symptoms. She had been on warfarin for the last 19 years due to underlying mechanical valve with an INR (international normalized ratio) goal of 2.5-3.5. On examination, the right calf was swollen and tender to palpation. Homan sign was positive. INR was elevated to 9.88 (a month ago it was within the therapeutic range of 2.5-3.5). The rest of the lab work up including fibrinogen levels, PT, aPTT, CBC, and CMP was unremarkable. A lower extremity venous duplex was performed that came back remarkable for acute right popliteal DVT. Decision-making Warfarin was held considering elevated risk of bleeding. INR was repeated daily and once it was below 2.5, therapeutic dose of enoxaparin 1mg/kg twice daily was started for 3 months. Due to limited anticoagulation options, a shared decision was made to place the patient back on warfarin, since she was out of the window of COVID-19 infection. She was not a candidate for DOAC's considering her mechanical valvular heart disease history and patient did not want to consider invasive interventions as well. Conclusion Our case study is the first ever reporting warfarin failure with supratherapeutic INR due to COVID-19 infection. It also raises concerns if warfarin is safe to use in COVID-19 patients, which might need further research studies to have clear answers. In patients with mechanical heart valves and supratherapeutic INR who present with concerns of warfarin failure, treatment options are limited. Recommended management is holding warfarin to achieve therapeutic INR levels, switch to enoxaparin temporarily, and eventually placement of IVC filter.Copyright © 2023 American College of Cardiology Foundation

A Rare COVID-19 Presentation, Relapse of Nephrotic Syndrome in a Pediatric Patient

Background: In early 2020, severe acute respiratory syndrome-corona virus 2 (SARS-CoV-2) pandemics caused previously unheard of health, social, and economic problems worldwide. The disease can affect different organs such as the lungs, heart, pancreas, kidney, and unusual symptoms can be seen. Information on the clinical impact of SARS-CoV-2 infection on renal function among pediatric age groups is scarce. Case Report: In this report, we presented a 13-year-old boy who was admitted to our hospital with the relapse of nephrotic syndrome caused by COVID-19. The patient had mild upper respiratory tract symptoms, eyelid edema and progressive swelling of the lower extremities. Clinical remission was achieved with oral prednisolone therapy without the use of any antiviral drugs. Conclusion(s): Patients with nephrotic syndrome presenting with relapse should be evaluated for potential COVID-19 infection during the pandemic. The use of routine doses of prednisolone appears to be safe in mild disease. Copyright © 2023 by Erciyes University Faculty of Medicine.

THE CLOT THICKENS: THE CASE OF A YOUNG MALE WITH RECURRENT PULMONARY EMBOLISMS

SESSION TITLE: Rare Cases with Masquerading Pulmonary Symptoms SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Paget-Schroetter (PS) syndrome, also known as venous thoracic outlet syndrome, is a primary thromboembolic sequela of compression of the subclavian vein. CASE PRESENTATION: A previously healthy 24 year old male presented with shortness of breath and cough. He had recently been exposed to COVID. He denied fever, diarrhea, vomiting, leg swelling, and rashes. On physical exam he was tachycardic, had no murmurs or JVD, and was CTAB with no wheezing or rales. Labs were significant for a WBC of 17k, and troponin of 0.033. CTA of the chest showed multiple filling defects in the pulmonary arteries consistent with Pulmonary Embolism (PE). He was started on a heparin drip. All COVID testing was negative. Lower extremity venous doppler ultrasounds (US) were negative for DVT. His respiratory status improved, and he was discharged on apixaban with the diagnosis of PE provoked by possible COVID infection. He returned approximately 2 months later with exertional dyspnea and upper extremity swelling and was found to have recurrent PE despite having been compliant with his apixaban. Upper extremity venous doppler US was significant for DVT in his right subclavian vein. He was placed on warfarin. At this time his hypercoagulable workup was also negative. Symptoms persisted despite being on warfarin with outpatient monitored INR. A venogram was ordered to evaluate upper torso blood flow. The venogram was remarkable for high-grade stenosis of the right subclavian vein. This finding led to the consideration of thoracic outlet syndrome aka Paget-Schroetter (PS). DISCUSSION: PS is a rare clinical entity that results from stress placed on the endothelium of the subclavian vein as it passes between the junction of the first rib and the clavicle. It can predispose otherwise healthy patients to recurrent venous thromboembolisms that are refractory to anticoagulation. The clinical features usually include upper extremity swelling and pain which is exacerbated by repetitive or strenuous exercise. Venous collaterals can also be seen in some patients. Evaluation should include some form of upper extremity Doppler and a CT/MR venogram or venography to make the final diagnosis. Treatment may involve anticoagulation, thrombolysis, and/or surgical decompression. Best results are seen with early thrombolysis and surgical decompression. If caught early and treated appropriately, PS has a good outcome with few long-term sequela. CONCLUSIONS: Our goal was to describe a patient with an uncommon cause for recurrent venous thromboembolisms that were refractory to anticoagulation. Our patient's presentation of PS serves to describe many aspects of the disease process, evaluation, diagnosis, and management as seen in the case presentation. The patient's demographic fit the epidemiological profile age of 20s-30s with typical imaging findings and pertinent negative workup which would lead providers to this rarer diagnosis. Reference #1: Saleem T, Baril DT. Paget Schroetter Syndrome. [Updated 2022 Jan 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK482416/ Reference #2: Alla VM, Natarajan N, Kaushik M, Warrier R, Nair CK. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010;11(4):358-362. Reference #3: Karl A. Illig, Adam J. Doyle, A comprehensive review of Paget-Schroetter syndrome, Journal of Vascular Surgery, Volume 51, Issue 6, 2010,Pages 1538-1547,ISSN 0741-5214, https://doi.org/10.1016/j.jvs.2009.12.022. DISCLOSURES: No relevant relationships by Jonathan Marks No relevant relationships by Zachary Stachura

UNUSUAL CASE OF ANTI-SYNTHETASE SYNDROME CORRELATED WITH EXPOSURE TO COVID-19 INFECTION OR VACCINE

SESSION TITLE: Systemic Disease with Diffuse Lung Symptoms Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Since its first detection at Wuhan, China, SARS-CoV-2 (novel coronavirus 2019) has engulfed the world with more than 100 million cases and manifestations of COVID19 have been evolving over time. Various post COVID19 syndromes are being recognized. Reactive arthritis, connective tissue disorders such as myositis and pulmonary complications have been correlated with exposure to COVID infection. We describe the case of antisynthetase syndrome in a patient correlated with exposure to COVID infection or vaccine. CASE PRESENTATION: A 68 year old female with history of hypertension and exposure to COVID infection in the family member, presented with 2-3 months worsening generalized body ache/pain started 2 weeks after receiving second dose of mRNA vaccine. Patient also reported dyspnea and leg swelling for 1 month. Upon presentation, she was placed on 4 liter oxygen via nasal cannula. Chest x-ray concerning for infiltrates, possibly COVID. CT chest no pulmonary embolism but evidence of pneumonia superimposed on chronic appearing bronchiectasis. Flu and Covid testing were negative. Patient was started on IV antibiotics for community acquired pneumonia. Labs showed elevated ESR, CRP and CK level. No fever, weakness, mechanics hands, rash or Raynaud's phenomenon. Infectious work up remained negative. No lymphadenopathy on CT chest to suggest sarcoid. ACE level normal. ANA and anti aminoacyl-tRNA synthetase antibody positive but other ENA were negative. HMG-COA ab negative. MPO/PR3 neg. Echocardiogram was unremarkable. Work up was suggestive of Anti synthetase syndrome with interstitial lung disease(ILD), a form of dermatomyositis. Patient was started on intravenous steroid with good improvement in symptoms and later transitioned to oral prednisone. Patient was discharged on minimal home oxygen with plan to start immunosuppressive medications. DISCUSSION: We are unsure if our patient had COVID19 infection since COVID testings were negative (antigen, antibody and nucleic acid detection ). The likelihood of autoimmune and rheumatic diseases in COVID19 survivors is a big issue. COVID19 infection may unmask previously undiagnosed rheumatic conditions and precipitate de novo disease, both of which may persist after resolution of the initial infection. Corticosteroids remain the cornerstone of early treatment with initial doses at 1mg/kg of the ideal body weight. In an effort to reduce steroid related side effects, other immunosuppressive agents should be considered at the outset of therapy, particularly when treating anti-synthetase syndrome with manifestations of ILD. CONCLUSIONS: Patients with anti-synthetase syndrome with ILD could have correlation with exposure to COVID infection or vaccination, and are steroid responsive. It is likely that clinical improvement may result from prompt suppression of inflammatory systemic response by corticosteroid. Reference #1: 1. Ahmed S, Zimba O, Gasparyan AY. COVID-19 and the clinical course of rheumatic manifestations. Clin Rheumatol. 2021;40(7):2611-2619. doi:10.1007/s10067-021-05691-x Reference #2: 2. Witt LJ, Curran JJ, Strek ME. The Diagnosis and Treatment of Antisynthetase Syndrome. Clin Pulm Med. 2016;23(5):218-226. doi:10.1097/CPM.0000000000000171 DISCLOSURES: No relevant relationships by ELINA MOMIN No relevant relationships by Mohammedumer Nagori

A RARE CASE OF ASYMPTOMATIC COVID-19 INFECTION MASQUERADING AS PHLEGMASIA CERULEA DOLENS

SESSION TITLE: Look again: Infections and Mimics SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Phlegmasia Cerulea Dolens (PCD) is a rare and critical condition caused by venous thrombosis requiring emergent treatment to prevent limb ischemia. COVID 19 has been widely reported to cause venous thromboembolism and compromise of tissue perfusion. We report a case of PCD in a patient with asymptomatic COVID-19 infection. CASE PRESENTATION: A 60 year-old female with no known medical history, unvaccinated for COVID-19 presented with sudden onset left lower extremity pain and swelling associated with numbness. Physical examination was remarkable for left lower extremity swelling with bluish discoloration, poikilothermia, and paraesthesia. Computed tomography angiogram (CTA) chest, abdomen and pelvis revealed left lower extremity deep vein thrombosis with compromised blood flow with focal thrombosis of the IVC extending inferiorly to the great saphenous and popliteal vein, along with small bilateral segmental and subsegmental pulmonary emboli. Diffuse Ground glass opacities suspicious for COVID-19 pneumonia. COVID-19 PCR was positive. Anticoagulation with heparin drip was initiated, and the patient underwent successful left iliocaval to popliteal vein thrombectomy and venoplasty by interventional radiology with successful restoration of circulation to the affected extremity. She was eventually transitioned to apixaban. She experienced marked improvement in her symptoms post procedure. DISCUSSION: Patients with COVID 19 develop venous thromboembolisms at an alarming rate despite thromboprophylaxis. The mechanism is likely explained by the virchow's triad (venous stasis, hypercoagulable state, vessel wall injury) in the setting of increased pro-inflammatory markers. We report the first case at our institution of PCD in the setting of COVID-19.We noted that our patient had a similar presentation as those reported in literature, which include acute leg swelling associated with pain and cyanosis. Complications include venous outflow obstruction, which can result in compartment syndrome with arterial ischemia, eventually progressing to gangrene of the affected limb. PCD is a very rare but life-threatening complication caused by extensive clot burden associated with acute limb ischemia and increased mortality rates. This condition requires emergent initiation of intravenous anticoagulation and thrombectomy with or without tissue plasminogen activator (tPA). If this condition is not treated in a timely fashion, it can result in acute limb ischemia and gangrene requiring amputation. CONCLUSIONS: Physicians should recognize PCD in patients who have been exposed to COVID-19 as it is a life-threatening condition which requires emergent initiation of anticoagulation and treatment. Diagnosis is usually made with clinical examination and ultrasonography or CT imaging. Management options include open thrombectomy with leg fasciotomy or catheter directed thrombolysis or percutaneous transluminal angioplasty. Reference #1: Chun TT, Jimenez JC, Pantoja JL, Moriarty JM, Freeman S. Phlegmasia cerulea dolens associated with acute coronavirus disease 2019 pneumonia despite supratherapeutic warfarin anticoagulation. J Vasc Surg Cases Innov Tech. 2020;6(4):653-656. doi:10.1016/j.jvscit.2020.10.002 Reference #2: Gutierrez JR, Volteas P, Skripochnik E, Tassiopoulos AK, Bannazadeh M. A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy. Ann Vasc Surg. 2022 Feb;79:122-126. doi: 10.1016/j.avsg.2021.07.034. Epub 2021 Oct 10. PMID: 34644637;PMCID: PMC8502248 Reference #3: : Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med. 2020;38(9):1978.e1-1978.e3. doi:10.1016/j.ajem.2020.05.022 DISCLOSURES: No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Steven Miller N relevant relationships by jasparit minhas No relevant relationships by houman mirtorabi No relevant relationships by Kunal Nangrani No relevant relationships by Gaurav Parhar No relevant relationships by Kiran Zaman

COVID MYOCARDITIS, A POST-COVID SYNDROME

Case Report Learning Objective Recognizing Covid Myocarditis in Post covid syndrome Case Presentation A 56-year-old female with a medical history of hypertension and unvaccinated to COVID presented with sudden onset of chest pain radiating to the arm, 7/10 intensity aggravated with excretion, associated with palpitation and worsening bilateral leg swelling for last two weeks. She was recently tested positive for COVID infection four weeks ago. However, she did not seek medical treatment as she was asymptomatic at the time of infection. In the ER, she was diagnosed with A.Fib with RVR in hypotension needing two liters of oxygen and volume overload state with mildly elevated Troponin and EKG showing LBBB, grossly elevated BNP, all her inflammatory markers, and white cell counts within the reference range. She was admitted to ICU with cardiogenic shock needing two pressors and IV amiodarone. Urgent LHC was performed, showing normal coronary arteries with severely reduced EF of less than 20% with global hypokinesia on LV gram. Impella device was placed, and gradual diuresis with pressor support was administered. Overall hemodynamics improved, and pressors were weaned with continued aggressive diuresis. She improved well and was discharged with lifevest and an outpatient cardiology follow-up plan. Discussion The clinical features of myocarditis are usually non-specific, such as myalgias with a history of recent upper respiratory infection and typical age at onset varying between 20 to 50 years. New-onset HF over two weeks to three months with classical symptoms and non-specific changes EKG showing bundle branch block, atrioventricular (AV) block, or ventricular arrhythmias. Myocarditis should be suspected with or without cardiac signs and symptoms with elevated cardiac biomarkers, ECG changes suggestive of acute myocardial injury, arrhythmia, or global or regional abnormalities of LV systolic function, mainly if the clinical findings are new and unexplained. The clinical presentation of myocarditis is highly variable and can mimic other noninflammatory cardiac disorders;a high level of clinical suspicion is required. Conclusion We conclude that this new-onset HF with no evidence of acute coronary disease or any cardiac and familial risk factors with recent COVID infection makes us think that viral myocarditis is a possible cause of this acute presentation. Cardiovascular magnetic resonance (CMR) imaging is indicated in patients with suspected myocarditis if T2-based and T1- based imaging meet Lake Louise Criteria. Viral myocarditis should be an important consideration in patients with Covid- 19 and those who have recovered from even minor infections.

Gaisbock in 2021

Case Report The purpose of the study is to explore the possible diagnosis of Gaisbock in a patient with long-standing erythrocytosis and hypertension. Methods Used Case Study Summary of Results A 40-year-old Caucasian man with obesity was admitted with recurrent leg swelling and increasing oxygen requirements two weeks after hospitalization with COVID-19 pneumonia. Upon review of the patient's history, he was found to have untreated hypertension over several medical encounters and an erythrocytosis spanning ten years. Recent medical history included a diagnosis of deep vein thrombosis (DVT) in the same leg two and a half months prior and was treated with Xarelto. The patient reported a history of low testosterone for 12 years. However, he had not used any testosterone supplementation for the last nine months. He reported daytime fatigue, frequent bouts of nighttime awakenings, and frequent snoring. The patient never had a sleep study or used a CPAP. The patient used half a can of chewing tobacco daily for thirteen years, and he smoked one pack per day for ten years but quit 12 years ago. He worked strenuous jobs in the construction industry most of his life. On this admission, the patient's lab work was notable for hemoglobin of 18.7 gm/dL (13.7-17.5) and a normal erythropoietin level of 5.7 MIU/mL (2.6-18.5) without thrombocytosis or leukocytosis and a positive factor V Leiden mutation. His blood pressure was 132/91 mmHg. On review of previous records, the patient was found to have consistently elevated hemoglobin The patient had a stocky, ruddy appearance without hepatosplenomegaly. Conclusion Erythrocytosis can be categorized as primary, secondary, or relative. Patients with relative erythrocytosis have a decreased plasma volume with a relative increase in hemoglobin. Additionally, elevated hemoglobin levels have been associated with hypertension. Gaisbock's syndrome, first described in 1905, is characterized by hypertension and erythrocytosis without splenomegaly, leukocytosis, or thrombocytosis. It is associated with mild obesity, elevated blood pressure, and increased blood viscosity, which may explain why these patients often develop cardiovascular complications. Patients with relative erythrocytosis are at a higher risk for thromboembolic complications. In this case, Gaisbock's syndrome was suspected because the patient had had a stocky, plethoric appearance with persistently elevated hemoglobin and blood pressure with a normal erythropoietin level. Gaisbock's syndrome establishes a relationship between benign erythrocytosis, hypertension, and an increased risk for cardiovascular events. (Table Presented).

Spontaneous Heparin-Induced Thrombocytopenia and COVID-19 Infection

Background and Objective: Heparin-induced thrombocytopenia (HIT) can develop if immune responses to infections become pathologic in the presence of heparins. Low molecular weight heparin or unfractionated heparin are recommended for prophylaxis and treatment of venous thromboembolic disease in hospitalized patients with Covid-19 infection but may trigger HIT. Our aim is to alert clinicians that HIT occurs in association with Covid-19 infections even in the absence of prior exposure and may not be easily recognized without a high index of suspicion. Case Summary: A 33-year-old previously healthy male was initially evaluated for low grade fever, dyspnea without hypoxia and cough. A Covid-19 PCR swab was negative despite a recent exposure. He was treated with azithromycin. However, his symptoms did not improve, he then developed right leg swelling and hypoxia, so he was re-evaluated. CTA of the chest showed bilateral pulmonary emboli and ground-glass opacities at the lung bases. Venous Duplex Ultrasound showed non-occlusive thrombus in the deep veins of right lower extremity. He was hospitalized and placed on oxygen and heparin. Covid-19 swab was negative again. Laboratory tests before heparin showed a decreased platelet count of 64,000 k/ul, elevated prothrombin time of 16.4 seconds, normal aPTT at 30.8 seconds, decreased serum fibrinogen at 120 mg/dl and markedly elevated D-dimer at 59,966 ng/ml. Lupus anticoagulant and anti-phospholipid antibody tests were negative. On heparin at the desired therapeutic aPTT target range, the right leg became significantly swollen and painful by day five. Platelet count had decreased further to 39,000 k/ul. Repeat doppler examination of the right leg now showed more severe and extensive deep venous thrombosis. D-dimer had increased to 125,133 ng/ml. The HIT 4T score was 4, suggesting intermediate probability. Rapid HIT immunoassays on 2 separate samples were positive. Heparin was discontinued and he was placed on argatroban. Serotonin release assays on 2 separate samples came back positive. Suspicion for Covid-19 infection remained high and so a Covid-19 serology sample was obtained which was positive for IgG. A repeat nasopharyngeal swab at this time turned positive. He did not receive any COVID specific treatments. As viability of his leg appeared threatened, he underwent right iliofemoral vein thrombectomy with arteriovenous fistula creation. He improved on argatroban and was transitioned to apixaban with gradual normalization of hemostasis laboratory parameters, improvement in hypoxemia and fading clinical symptoms, he was discharged home on day 15. Conclusion: Current consensus guidelines for thromboprophylaxis and treatment of thromboembolism in hospitalized patients with Covid-19 infection recommend heparins as primary therapy to reduce morbidity and mortality. However, our report in addition to the two previous reports of HIT in Covid-19 patients illustrate that HIT can be a complication in the setting of Covid-19 infection. Further, our report also highlights that HIT with thrombosis can occur in a spontaneous manner in the absence of prior heparin exposure, which has been so far studied only in bacterial infection with the hypothesis that Platelet factor 4 (PF4) can bind to negatively charged polysaccharides on the surface of bacteria, triggering an immune response. Disclosures: No relevant conflicts of interest to declare.