Acute Aortic Injury and Bilateral Pulmonary Emboli in the Setting of COVID-19.

In this report, we present the case of a 72-year-old female diagnosed with an aortic dissection variant and bilateral pulmonary emboli (PE) in the setting of Coronavirus Disease of 2019 (COVID-19) infection. The patient was transported from home to the emergency department (ED) via emergency medical services (EMS) with acute chest pain and dyspnea. After arriving at the ED, she was hypoxic on her baseline supplemental O2 requirement and tachycardic and tachypneic. Computed tomography (CT) angiogram of the chest showed evidence of possible thoracic aortic dissection and bilateral PE. The patient was ultimately transported to a tertiary center for operative aortic repair and bilateral embolectomy and, fortunately, survived the procedures. Interestingly, during operative repair of the aorta, no obvious dissection flap was noted, but rather evidence of a limited tear in the intimal layer of the aorta. This is an interesting case as acute aortic injuries in the setting of COVID-19 infection have not been as widely documented as PE in the setting of COVID and highlight the need for further research on the possible association between them.

Anaplastic Lymphoma Kinase-Positive Primary Lung Adenocarcinoma Presenting With Pericardial Effusion and Tamponade in a COVID-19 Patient: A Case Report.

Primary lung cancer usually presents in older adults with a smoking history. However, there is an estimated incidence of 15-20% among men who have never smoked. The diagnosis of lung malignancy can often be incidental. Moreover, cardiac tamponade can be an initial presentation of malignancy, especially lung cancer, as these are the most common tumors that involve the pericardium. Here, we present a 54-year-old male with no known medical history presented with dyspnea on exertion. He was found to have a large pericardial effusion with tamponade physiology on a bedside echocardiogram. He was also found to have bilateral deep vein thrombosis and pulmonary embolism on admission. The patient underwent an emergent pericardiocentesis due to hemodynamic compromise, and pericardial fluid cytology suggested adenocarcinoma with lung primary. Subsequently, gene testing revealed anaplastic lymphoma kinase-positive adenocarcinoma of the lung. The patient was discharged home with close oncology follow-up. It is imperative to recognize malignant pericardial effusion as one of the causes of dyspnea. Emergent pericardiocentesis may be needed in case of hemodynamic compromise and tenuous clinical status.

Multiple simultaneous embolic cerebral infarctions 11 months after COVID-19.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has led to an unprecedented worldwide burden of disease. However, little is known of the longer-term implications and consequences of COVID-19. One of these may be a COVID-19 associated coagulopathy that can present as a venous thromboembolism (VTE) and further, as multiple paradoxical cerebral emboli. CASE PRESENTATION: A 51 year old man presented to the emergency department with multiple simultaneous embolic cerebral infarctions 11 months after mild COVID-19. In the subacute phase of the COVID-19 illness the patient developed increasing shortness of breath and was found to have an elevated D-dimer and multiple bilateral segmental pulmonary emboli. He was subsequently treated with 3 months of anticoagulation for a provoked VTE. The patient then presented 11 months after the initial COVID-19 diagnosis with multiple simultaneous cerebral infarctions where no traditional underlying stroke etiology was determined. A patent foramen ovale (PFO) and an elevated D-dimer were found suggesting a paradoxical thromboembolic event due to an underlying coagulopathy. CONCLUSIONS: This case report highlights the one of the potentially more serious complications of long-term COVID-19 where VTE due to a persistent coagulopathy is seen almost a year after the initial illness. Due to the highly prevalent nature of PFO in the general population, VTE due to COVID-19 associated coagulopathy could lead to ischemic stroke. This case report highlights the possibility for an underlying COVID-19 associated coagulopathy which may persist for many months and beyond the initial illness.

A Case of Acute Pulmonary Embolus after mRNA SARS-CoV-2 Immunization.

Vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), is a critical strategy to overcome the COVID-19 pandemic. Multiple SARS-CoV-2 vaccines have been developed in a rapid timeframe to combat the pandemic. While generally safe and effective, rare cases of venous thromboembolism (VTE) have been reported after two adenovirus-based vaccines, the AstraZeneca ChAdOx1 nCoV-19 vaccine and the Janssen Ad.26.COV2.S vaccine, as well as after the Pfizer-BioNTech BNT162b2 mRNA vaccine. Here, we present the case of a patient who developed acute pulmonary emboli (PE) shortly after his second dose of the Moderna mRNA-1273 SARS-CoV-2 vaccine. We report the results of an extensive thrombophilia workup that was normal except for the identification of positive lupus anticoagulant (LA) signals. It is our goal to contribute to the body of knowledge regarding SARS-CoV-2 vaccines and encourage vaccine adverse event reporting so that clinicians can have a full appreciation and awareness of the possible adverse events related to these critical vaccines.

Fever, pancytopenia, and elevated D-dimer in a 95-year-old woman with ehrlichiosis: a case report.

BACKGROUND: Pancytopenia, fever, and elevated D-dimer are significant clinical findings. The differential diagnosis includes hematological malignancies, severe coronavirus disease 2019 (COVID-19), tick-borne illnesses, and other etiologies. CASE PRESENTATION: We report the case of a 95-year-old woman who presented with high fever (103.6 °F), pancytopenia, and markedly elevated D-dimer (32.21 mg/L; reference range ≤ 0.95 mg/L) in late-autumn during the COVID-19 pandemic at a large academic institution. After remaining persistently febrile, a peripheral blood smear was ordered and revealed parasites consistent with Ehrlichia spp. Doxycycline monotherapy led to symptomatic improvement and resolution of her pancytopenia. During her hospital stay, a computed tomography angiogram of the chest revealed pulmonary emboli, and esophagogastroduodenoscopy uncovered arteriovenous malformations. After appropriate treatment, she was discharged on hospital day 7 and has since done well. CONCLUSIONS: Overall, our case offers a dramatic, unexpected presentation of ehrlichiosis in a nonagenarian. To our knowledge, this is the first report of concurrent ehrlichiosis and pulmonary embolus.

Chronic therapeutic anticoagulation is associated with decreased thrombotic complications in SARS-CoV-2 infection.

BACKGROUND: Thrombotic disease complicates severe SARS-CoV-2 infection and is associated with increased morbidity and mortality. Various anticoagulation strategies have been evaluated in hospitalized patients to prevent complications. The impact of chronic anticoagulation before SARS-CoV-2 infection on the risk for subsequent thrombosis has not been systematically studied. METHODS: This was a retrospective single-center study. All patients with positive SARS-CoV-2 PCR testing from March 13, 2020, through May 6, 2020, at the University of Rochester Medical Center were identified. We included all patients receiving therapeutic anticoagulation for at least 1 month before COVID diagnosis. We documented the rate of thrombotic complications, type of anticoagulation, bleeding complications, and mortality. RESULTS: A total of 107 SARS-CoV2-infected patients were chronically anticoagulated before SARS-CoV-2 testing with a median age of 78. Of those, 42 required hospital admission, with 17 requiring intensive care. No patients, inpatient or outpatient, were diagnosed with a new symptomatic thrombotic complication. Three patients had minor bleeding in the hospital. Thirteen (12%) patients died (69% male). CONCLUSION: Our uncontrolled findings suggest that chronic anticoagulation at the time of infection may protect against thrombotic complications and decrease disease severity.

Opportunistic Diagnosis of Extensive Pulmonary Embolus Following "COVID-19 Blood Battery" in Very Frail Older Patients.

D-dimer is routinely measured to exclude the diagnosis of venous thromboembolism and is its main biomarker. Appropriate age-adjusted D-dimer testing improves D-dimer specificity, could decrease inappropriate CT pulmonary angiograms in the older person, and prevent unnecessary radiation exposure. A "COVID-19 blood battery", designed to increase the efficiency of evaluation of COVID-19 suspected patients is used in our institution. It includes D-dimers which are elevated in COVID-19 infections and potentially an index of severe infection. These 3 very frail patients presented late to the emergency department, all acutely and non-specifically unwell, with high prevalence of comorbidities and were transferred in by ambulance. They were triaged to the COVID-19 pathway of our hospital, and subsequently had negative COVID-19 swabs. All had an incidental finding of markedly elevated D-dimers, with potential causes of their symptoms other than pulmonary embolus. They were transferred to an acute geriatric ward specifically designated to manage older patients (>75years) who had negative nasopharyngeal swab results. They were all ultimately diagnosed with extensive pulmonary emboli with evidence of raised pulmonary pressures on CTPA and/or echocardiogram. It is possible that these patients had false negative COVID-19 swabs. Allowing for the novel nature of COVID-19, prospective evaluation for new symptoms and complications such as thromboembolic disease in those affected by milder symptoms should be considered. In the absence of clinical improvement following treatment of other conditions in frail older patients, D-dimer testing could be indicated with pursuit of specific diagnostic evaluation for venous thromboembolism when significantly elevated.