The incidence of deep vein thrombosis following COVID-19 vaccination in an Australian population

Introduction: After the COVID-19 vaccination roll out in March 2021 patients began presenting to a Victorian Emergency Department with lower limb pain following their vaccination. As a result, requests for ultrasound examinations, to exclude post vaccination deep vein thrombosis (DVT) began appearing. Method(s): A retrospective study of ultrasound examinations and their result over a 1-year period was undertaken. Patients were identified who had a clinical indication of having been referred following COVID-19 vaccination. Bivariate analysis was conducted, using logistic regression, to determine the strength of association between independent variables. Result(s): The study found 1689 patients had a lower limb DVT ultrasound examination. Ultrasound was positive for DVT in 244/1689 patients (14.4%). 104/1689 (6.1%) patients presented for ultrasound following COVID-19 vaccination. Six of these were found to have DVT detected. The association between post vaccination and DVT was an odds ratio (OR) of 0.347 (95% CI 0.150 to 0.799, p = 0.013). All patients had recently received AstraZeneca (AZ) vaccine. Four patients were diagnosed with superficial vein thrombosis (SVT) post vaccination. Nineteen patients were identified as COVID-19 positive. Three of these had DVT detected. Conclusion(s): This study found 6 patients out of 1689 (0.35%) of lower limb ultrasound examinations over a one-year period, were positive for DVT after COVID-19 vaccination. Take home message: The results showed post vaccination patients were less likely to be diagnosed with a DVT than the population referred who had not had recent vaccination.

Macrolide Antibiotics

Macrolide are inhibitors of protein synthesis. Three members of this class are widely used in clinical medicine. These are erythromycin, clarithromycin and azithromycin. Although their spectrum overlaps, each of these is a unique compound in the context of application. They also have differing pharmacological properties. Target site mutation, efflux, and inactivation can lead to macrolide resistance. Macrolides have important drug interactions. The main areas of macrolide therapeutics are respiratory tract infections, certain gastrointestinal infections, skin & skin structure infections, sexually transmitted infections, non-tubercular mycobacterial infections and, of late, azithromycin has been used in coronavirus disease although the evidence base for this is lacking. One compound in this class called spiramycin can prevent transmission of Toxoplasma infection from mother to baby. Macrolides can lead to serious adverse effects which include gastrointestinal side effects, thrombophlebitis, ototoxicity, toxic effects on liver and heart, and neurotoxicity. A related group of compounds are ketolides such as telithromycin. Telithromycin has been associated with a constellation of adverse effects which are together known as ketek effects. © 2022 Elsevier Inc. All rights reserved

Lemierre's Syndrome in the External Jugular Vein Precipitated by COVID-19 Infection.

Lemierre's syndrome is a condition when an oropharyngeal infection, typically from Fusobacterium necrophorum, causes thrombophlebitis of the internal jugular vein. There have been few case reports of Lemierre's syndrome affecting the external jugular vein, but to our knowledge, this is the first case report where COVID-19 infection is the prime suspect for causing this syndrome. SARS-CoV-2 infection, known to cause hypercoagulability and immunosuppression, increases the risk of deep venous thrombosis and secondary infections. We report a case of a young male with no known risk factors who developed Lemierre's syndrome as a complication of COVID infection.

Not all shortness of breath and throat pain is COVID

Case Report: A previously, healthy 18-year-old female presents to a Pediatric Emergency Medicine Department with shortness of breath, fever, and worsening throat and abdominal pain for 3 days. She had a sick contact, a teacher that tested positive for COVID-19 2 weeks prior to presentation. She denies runny/stuffy nose, cough, loss of taste/smell, or rashes/lesions. She denies any significant past medical history including allergies, as well as any history of smoking or any illicit drug use. Upon arrival to the ED, the patient was noted to be tachycardic, hypotensive and febrile. There were no desaturations. Initial physical examination revealed a generally uncomfortable female that was alert and oriented, with noted tenderness over the right anterior neck region, diffuse cervical lymphadenopathy, and painful neck range of motion. Her pharynx was noted to be erythematous without exudates or any unilateral tonsillar swelling. In the ED patient received IV fluid resuscitation and was started on norepinephrine drip, broad spectrum antibiotics. Initial lab workup revealed an anion gap metabolic acidosis, likely secondary to uremia or lactic acidosis from poor perfusion in setting of sepsis and hypovolemia. BUN and creatinine were elevated, likely due to an acute kidney injury (AKI) secondary to hypovolemia. The patient was also found to have an elevated LDH, fibrinogen, and mild elevation of AST. D-Dimer was elevated at 29 000. Covid PCR, Rapid Strep, and respiratory PCR panel were negative. Her chest X-ray (CXR) was negative and ECG showed sinus tachycardia. Given the patient's history of throat and neck pain with shortness of breath, in the setting of a septic picture, a CT scan of neck, chest, abdomen was ordered prior to transferring the patient to the PICU. CT scan of the chest revealed small patches of consolidation with ground glass opacities in the right lung apex, as well as an nearly occlusive, acute thrombosis of the anterior right facial vein. The patient's initial blood cultures grew gram negative bacilli which later were revealed to be Fusobacterium necrophorum. These findings are consistent with Lemierre's syndrome. The patient was treated in the PICU on vasopressors, heparin anticoagulation, and antibiotics for 6 days and discharged with a course of Augmentin. Lemierre's syndrome is an infectious thrombophlebitis of the internal jugular vein. First described by Andre Lemierre in 1936, it begins as a bacterial pharyngitis, generally developing into a peritonsillar abscess or other deep space neck infection with progressive erosion into the internal jugular vein. Diagnostic criteria for Lemierre's syndrome includes radiographically evidence of thrombophlebitis of the internal vein and positive blood cultures. CT and MRI can help make the diagnosis, but are not always required. Treatment is prompt intravenous antibiotics with beta-lactamase penicillins, metronidazole, clindamycin, and third generation cephalosporins. [Figure presented] Copyright © 2023 Southern Society for Clinical Investigation.

Temporary markers of increased risk groups for thrombophlebitis of the saphenous veins of the lower extremities in post-COVID-19 patients

Background: Over the past decades, thrombophlebitis of the saphenous veins (TSV) of the lower extremities has remained one of the most common causes of acute vascular diseases, which requires contact with surgeons. This disease has acquired new risk factors with the advent of a new coronavirus infection. During the time since the onset of infection and up to the present time, many studies have already proven procoagulant effects and endotheliitis, which provoke venous thromboembolic complications. Method(s): We analyzed 379 the outpatient case histories of patients from 2019 to 2021 who applied to a vascular surgeon at polyclinic No. 21 in Ufa and City Clinical Hospital No. 21 with a diagnosis of TSV. Of these, a sample of patients who had a COVID-19 with a polymerase chain reaction confirmed smear, or with signs of viral pneumonia on computed tomography and a COVID-19 was diagnosed. The period from the moment of COVID-19 was limited to 6 months. The number of patients meeting this criterion was: 164 (43.27%). According to the CEAP classification: In 64 (39.02%) C2 stage, in 37 (22.56%)C3, in 8 (4.88%)C4 stage, C6 was in 3 (1.83%) patients, C5 - not a single patient. In 52 (31.71%) patients, there were no signs of previous chronic venous insufficiency. Age of patients: From 48 to 60 years, mean age 56 +/- 4 years. By sex - women - 102 patients (62.19%), men - 62 (37.8%). According to the period from the moment of covid-19 to the onset of thrombophlebitis: In the firstmonth 42 patients, in the period of 2months - 12 patients, in the period of 3 months - 56 patients, in the period of 4 months - 46 patients, in the period of 5 months - 4 patients and after 6 months from COVID-19, TFPV was diagnosed in 2 patients. Result(s): The frequency of episodes of TSV was higher at 1,3,4 months, and the increase prevailed at the end of 3 and the beginning of 4 months. From the anamnesis, in this period of time the intake of anticoagulants prescribed after COVID-19 was completed. In 29 cases, signs of past deep vein thrombosis of the lower extremities were revealed. In 1 case, signs of a past pulmonary embolism, unspecified by prescription, were revealed. Conclusion(s): Episodes of TSV are increased, as after any viral infection, but the role of hypercoagulation syndrome after a COVID-19 is somewhat more important compared to other viral infections. It is worth paying attention to the continuity in relation to the abolition of anticoagulant therapy at the outpatient stage of convalescents of COVID-19..

INCIDENTAL PULMONARY CAVITARY LESIONS AS AN UNCOMMON PRESENTATION OF LEMIERRE SYNDROME

SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Pulmonary cavitary lesions can have varying etiologies. Among these, Lemierre syndrome is an uncommon disease which usually presents with symptoms of upper respiratory tract infection with unilateral neck pain, tenderness or swelling. In recent years, antibiotic stewardship for upper respiratory illnesses has led to its delayed diagnosis resulting in possible increased morbidity and mortality. There have been few reported cases of pulmonary cavitary lesions as the initial presentation of Lemierre syndrome. Our patient presented with incidental bilateral pulmonary cavitary lesions, which led to a diagnosis of Lemierre syndrome. CASE PRESENTATION: A 30-year-old gentleman with no significant past medical history visited urgent care for reproducible chest pain following motor vehicle accident. Chest x ray obtained for suspected rib fracture showed bilateral patchy and rounded opacities, confirmed by CT as bilateral cavitary nodules and consolidation. He was referred to our hospital for further care. Two weeks prior, following administration of COVID booster vaccine, he had developed fever, sore throat, tender lump behind left ear, left jaw and anterior left neck. Most symptoms self resolved in 3-5 days except persistent fever. On arrival, patient was febrile to 102F and hemodynamically stable. Physical examination revealed dry mucous membranes and erythematous pharynx. Labs were significant for leukocytosis of 24.5uL with bandemia and elevated inflammatory markers. Three sets of blood cultures were drawn and empirically started on vancomycin and piperacillin/tazobactam. Echocardiogram ruled out heart valve vegetations. CT angiography of neck showed intraluminal thrombi in left internal jugular vein. Blood cultures finalized to Fusobacterium nucleatum and antibiotics were tapered to metronidazole. Due to persistent fever, anticoagulation was initiated with apixaban 5mg twice daily. Pan CT showed improvement in size of many pulmonary septic emboli. After 48 hours of patient being afebrile, he was discharged on antibiotics and apixaban for at least 4 weeks until surveillance CT angiography showed non progression of thrombus. DISCUSSION: Lemierre syndrome is septic thrombophlebitis of internal jugular vein which presents within 1-3 weeks following upper respiratory tract infections with multi-system complications. Management involves prolonged antibiotic course with use of anticoagulation and vein stripping still being debated. Our patient came to the hospital with an incidental finding of bilateral cavitary pulmonary lesions which went on to be diagnosed as Lemierre syndrome from positive blood cultures and CT angiography findings. CONCLUSIONS: Lemierre syndrome is an uncommon disease with mortality up to 18%. A call out to health care providers to keep a low threshold for its diagnosis in patients with initial presentation of bilateral pulmonary cavitary lesions, warranting prompt management. Reference #1: Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore). 1989 Mar;68(2):85-94. PMID: 2646510. Reference #2: Golpe R, Marín B, Alonso M. Lemierre's syndrome (necrobacillosis). Postgrad Med J. 1999 Mar;75(881):141-4. doi: 10.1136/pgmj.75.881.141. PMID: 10448489;PMCID: PMC1741175. Reference #3: Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre's syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect. 2020 Aug;53(4):513-517. doi: 10.1016/j.jmii.2020.03.027. Epub 2020 Apr 4. PMID: 32303484. DISCLOSURES: No relevant relationships by Sumukh Arun Kumar No relevant relationships by Megna Machado No relevant relationships by Sushmita Prabhu No relevant relationships by PAWINA SUBEDI No relevant relationships by Mithil Gowda Suresh No relevant relationships by Bradley Switzer

CLINICAL PROFILE OF COVID-19 INFECTION AND IMMUNE RESPONSE AFTER 3AND6 MONTH VACCINATION AGAINST SARS-COV-2 IN ADULT PATIENTS WITH TRANSFUSION-DEPENDENT THALASSAEMIATHE EXPERIENCE OF A GREEK CENTER

Background: Patients with transfusion-dependent-thalassaemia (TDT) are considered as increased risk population for severe and/or morbid COVID-19 infection. Timely vaccination is the main preventive method for severe COVID-19. Aims: To provide an overview of the clinical profile and outcome of COVID-19 infection in patients with TDT as well as to study the immune response after 3 and 6 months after vaccination against COVID-19 in adult patients with transfusion-dependent thalassaemia. Methods: This analysis focused on the evaluation in TDT patients on the long-term immune response post vaccination and on the course of COVID-19 infection and its correlation with immunization status. Serum was collected at 4 pre-defined time points, namely, just before 1st dose (TP1), 7 weeks after the 1st dose (TP2), 3 months (TP3) and 6 months (TP4) after 2nd dose. Neutralizing antibodies (NAbs) against SARS-CoV-2 were measured using FDA-approved methods. According to manufacturer, the scale of NAbs titer is 0-100%, with ≥30% considered as positive and ≥50% as clinically relevant viral inhibition. Age-matched healthy volunteers (median age: 46 years, range: 24-64 years, 24 males / 53 females) who received mRNA vaccines served as the control group for NAbs evaluation. Results: 340 (170female/170male) TDT patients older than 18 years (mean 43.6±11.5 years) followed in a single unit were included in the analysis. 270 patients (79%) were vaccinated with 2 or 3 doses. Immune response to vaccination was evaluated in 90 patients (median age: 46 years, range: 19-63 years, 40 males / 50 females). NAbs were at the level of non-immunity in all the patients at baseline (TP1) (mean 16.57% ±11.85) and showed a significant increase after the second dose (TP2) mean 86.96%±12.95 (p<0.0001). At TP3 and TP4 Nabs showed a significant decrease but remained in protective levels for the majority of the patients (mean 88.75% ±9.7 and 74.64% ±17.2 respectively(p<0.0001). The kinetics of NAbs were similar to controls except for levels at TP4 (p=0.02) (Figure 1). Up to 10/FEB/2022, 43 TDT patients (median age 43.52 range 18.6-57.9 years) were diagnosed with COVID-19, with 1 of them being infected twice. Of them, 17 were unvaccinated, 18 had received 2 doses of vaccine, while 8 had received 3 doses of the vaccine. The incidence rate was 9.6% and 24.3% for vaccinated and unvaccinated patients, respectively. The severity of the COVID-19 for vaccinated and unvaccinated patients were as follows, respectively, ;Grade 1 (asymptomatic): 0 and 1, Grade 2 (mild symptoms, symptomatic therapy, no COVID19 specific therapy): 23 and 9, Grade 3 (mild symptoms, symptomatic therapy, with COVID19 specific therapy): 1 and 3, Grade 4 (moderate: pneumonia, thrombophlebitis, Hospitalization): 2 and 3, Grade 5 (Hospitalization requiring ICU, death): 0 and 1. Thrombotic event was documented in 1 patient. All patients except one from unvaccinated group are alive. Summary/Conclusion: Immune response to vaccination may wean faster in TDT patients. in Unvaccinated TDT patients were more likely to be infected and to develop more serious COVID-19 infection compared to vaccinated patients. (Figure Presented).

A Crick in theNeck: Lemierre Syndrome in a 4-year Old Female Presenting as Fever and Torticollis

Introduction: Described by Dr. Andre Lemierre in a 1936 case series of 20 patients, Lemierre Syndrome (LS) is defined as a septic thrombophlebitis of the internal jugular vein (IJV). LS typically begins as an oropharyngeal infection that advances to the IJV through direct extension through the fascial planes of the neck, or indirect lymphatic or hematogenous spread from the peritonsillar vessels. We present a case of LS in a 4-year-old patient who presents much younger than the typical age range of affected individuals, and who recovered well without any longterm sequelae. Case Description: A 4-year-old ex-27 week female presented with a near 3 week history of intermittent fevers and progressive right-facing torticollis. She had multiple interactions with the health care system over her illness course, and was given diagnoses ranging from general viral syndrome to gingivostomatitis and acute otitis media. Around the 2 week mark, her caretaker described her as having developed a “crick” in her neck while consistently favoring a rightward tilt. On illness day 16, she presented to her pediatrician for routine visit, and was noted to have fever, right tonsillar enlargement, and cervical lymphadenopathy, thereby prompting referral to the emergency department. Her physical exam on admission was additionally significant for a 30 degree rightward head rotation, a swollen and tender right sternocleidomastoid, and submandibular lymphadenopathy. She was resistant to active or passive neck rotation due to discomfort, but was able to traverse the midline with coaxing. Laboratory workup was notable for leukocytosis and thrombocytosis with elevated inflammatory markers, as well as mild transaminitis. Infectious serologic workup was negative for: SARS-CoV-2, Bartonella henselae, Bartonella quintana, EBV, and Mycoplasma. Blood culture showed no growth, but was drawn after antibiotics were given. A CT neck with contrast demonstrated intrinsic occlusion vs compression of the right IJV, and ultrasound and MRI confirmed IJV thrombophlebitis. Discussion: LS is typically associated with Fusobacterium necrophorum infection, a gram-negative anaerobe, with incidence estimated to be around 1 to 3.6 per million per year and mortality rate around 5 to 9%. Significant morbidity is often present, due to dissemination of septic thromboemboli, potentially affecting the CNS, bones/joints, and lungs. The typical age range for LS in pediatric patients clusters around adolescence, but infants as young as 6 months of age have been reported. As oropharyngeal infections most often precede LS, it is important to keep this rare but serious infection on any differential. Conclusion: This patient was diagnosed with Lemierre Syndrome. She was treated with an inpatient course of ampicillin/sulbactam before transitioning to oral amoxicillin/clavulanic acid to complete a total of 4 weeks of antibiotic therapy. All elevated laboratory markers normalized prior to hospital discharge, and the patient had complete resolution of symptoms at outpatient follow up.

STANDARDIZED THROMBOPROPHYLAXIS PROTOCOL IN MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN

Background: Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) exhibit laboratory evidence of hypercoagulability and are at risk of experiencing thrombotic complications. We developed and implemented a standardized multidisciplinary treatment approach which encompassed a thromboprophylaxis protocol and a computerized clinical decision support system including a provider order set to guide and unify practice. In high-risk patients defined as critically ill and/or having additional risk factors for thromboembolism, prophylactic-dose enoxaparin (target anti-Factor Xa of 0.1-0.3 U/mL) was added. Objectives: To evaluate impact of implementation of a standardized thromboprophylaxis protocol in hospitalized patients with MIS-C. Design/Method: We conducted a retrospective study of patients who were admitted to our center between March 2020 and December 2021 with confirmed MIS-C based on Centers for Disease Control and Prevention case definition. Relevant data were extracted from prospectively maintained institutional databases and the electronic medical records and were summarized using descriptive statistics. Key outcome measures included frequency of objectively confirmed venous and/or arterial TE during hospitalization and within 30 days after discharge and frequency of major bleeding and/or clinically relevant nonmajor bleeding (CRNMB) defined according to the International Society on Thrombosis and Haemostasis criteria. Results: A total of 136 patients (59 females, median age 8 years) with confirmed MIS-C were included in this study. Forty-five patients (33%) were ≥12 years of age. Of 136 patients, 124 patients (91%) required intensive care unit (ICU) stay and 64 patients (47%) required a central venous catheter for a median duration of 5 days [Interquartile range (IQR) 4-7]. The median total hospital and ICU length of stays were 11 days [IQR 6-14] and 3 days [IQR 2-6], respectively. Prophylactic-dose enoxaparin was initiated in 119 patients (88%) who were deemed high-risk per our protocol at a median of 1 day after admission [IQR 0-3] achieving target levels at a median of 1 day [IQR 1-2]. The median first anti-Factor Xa level was 0.13 u/mL [IQR 0.05-0.19]. Only 1 patient (0.7%) developed symptomatic non-catheter related superficial vein thrombosis requiring therapeutic anticoagulation. There were no other TEs encountered in our cohort. Bleeding events occurred in 5 patients (4.2%). All bleeding events were considered CRNMB (gastrointestinal bleeding in 4 patients and epistaxis in 1 patient). There were no mortalities. Conclusion: Implementation of an institutional standardized thromboprophylaxis protocol in patients with MIS-C was feasible and led to timely initiation of prophylactic anticoagulation and low rates of TEs and bleeding complications.

Venous Thromboembolism in COVID-19 Patients During the First and the Second Waves of the Pandemic: Real-Practice Data

Objective. To analyze the incidence, structure, course and outcomes of venous thromboembolism (VTE) in patients with a novel coronavirus infection (COVID-19) during the first and the second waves of the pandemic, to identify and evaluate the features of laboratory data. Material and methods. We assessed instrumental and laboratory data in COVID-19 patients during the first (1839 patients) and the second (840 patients) waves of the pandemic. Mortality, localization of thrombosis, variants of anticoagulation and laboratory data (leukocytes, C-reactive protein, fibrinogen, ferritin) were analyzed. Results. VTE occurred in 27 (1.5%) and 13 (1.5%) patients with a novel coronavirus infection during the first and the second waves of the pandemic, respectively. In the first wave, thromboembolic events included deep vein thrombosis (DVT) in 16 (59%) cases, pulmonary embolism (PE) in 6 (22%) cases, DVT + PE in 2 (8%) patients, saphenous vein thrombophlebitis in 3 (11%) cases. In the second wave, DVT was detected in 5 (38.5%) patients, DVT+PE in 5 (38.5%) cases, PE without DVT in 2 (15.4%) patients and thrombosis of the right renal vein in 1 (7.6%) patient. In the first wave, mean leukocyte count was 9.2 x 109/L (6.9—14.3), C-reactive protein — 77.5 mg/L (26-159), fibrinogen — 593.5 mg/ml (500—700), ferritin — 1132.6 µ/L (165-1753). The second wave of the pandemic was characterized by moderate leukocytosis (12.2·109 /L (7—19)), increase of serum fibrinogen (544 mg/ ml (405—781)), C-reactive protein (102.75 mg/L (80—163)) and ferritin (510 μg/L (230—566)). Conclusion. VTE in patients with a new coronavirus infection is followed by high mortality. In the second wave of the pandemic, mortality of patients with VTE was higher that may be associated with both thrombotic complications and cardiovascular comorbidities.

Superficial thrombophlebitis in ipsilateral breast after COVID-19 vaccination.

On December 2020, the US Food and Drug Administration issued the first emergency use authorization for a vaccine for the prevention of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We report development of superficial thrombophlebitis in the ipsilateral breast of a 43-year-old female 7 days after receiving the first dose of the Pfizer-BioNTech COVID-19 vaccine. Given that this is the first case of superficial thrombophlebitis in the breast shortly after mRNA vaccination for COVID-19 reported to our knowledge, we suggest that this may be a rare vaccine-related event.

An audit of therapeutic anticoagulation with Anti-Xa monitoring during pregnancy

The risk of venous thromboembolism (VTE) increases by 10% in pregnancy to around 1/1000 and is a leading cause of death in pregnant women. Low molecular weight heparins (LMWHs) are the anticoagulant of choice for treatment of acute VTE during pregnancy. The initial dose of LMWH is weight based but currently there is lack of evidence supporting routine Anti-Xa monitoring during pregnancy and LMWH dose adjustments based on Anti-Xa levels. We conducted a retrospective audit of pregnant patients receiving therapeutic dose LMWH between October 2020 and October 2021 in a tertiary referral centre. The aim of this audit was to review LMWH dosages required in pregnancy to achieve peak Anti-Xa levels relative to weight-based and report maternal thrombotic or bleeding outcomes based on dose adjustments. A total of 21 pregnant patients were included who required therapeutic LMWH (Tinzaparin) during pregnancy. Of these, 10 (48%) had an acute VTE in the index pregnancy;one (4%) had recurrence of DVT despite weight adjusted LMWH. Ten (48%) were on long-term anticoagulation for a prior VTE including two with antithrombin deficiency and one with JAK 2 positive myeloproliferative disorder. They were all changed to LMWH during pregnancy. The site of acute VTE in index pregnancy (11) included: five (45%) deep vein thrombosis (DVT), three (28%) pulmonary emboli (PE), two (18%) had thromboses at an unusual site, and one patient (9%) had a superficial thrombophlebitis with gestational age range 7-40 weeks. Majority of pregnant patients (18/21;86%) had at least one peak Anti-Xa measured, and 12 (67%) patients had dose of LMWH increased at least once to achieve a target peak Anti-Xa level of 0.5-0.7 IU/ml. Five required two dose adjustments, and one required three dose adjustments. Nineteen patients have delivered and two have ongoing pregnancy. Twelve patients had spontaneous vaginal delivery, three assisted vaginal delivery and four had caesarean section for obstetric reasons. No patients had a recurrent thrombosis while on therapeutic dose LMWH and with dose adjustments as per peak anti-Xa level. One patient who presented with an acute DVT at 40 weeks of gestational age (GA) was managed with twice daily therapeutic dose Tinzaparin and insertion of an inferior vena cava (IVC) filter for anticoagulation interruption around delivery. The last dose Tinzaparin was 12 h prior to emergency Caesarean Section. She had postpartum haemorrhage with an estimated blood loss of 1800 ml but did not require blood product support and there was no evidence of progression of her symptoms of VTE or bleeding postoperatively when anticoagulation was resumed. Of note, six patients (29%) had a BMI >30 with five (83%) needing at least one adjustment of LMWH dose based on Anti-Xa levels and two (33%) needing > 2 dose increments with LMWH based on Anti-Xa monitoring. One patient had recurrence of PE on weight based LMWH dose with no recurrence of symptoms when the LMWH dose was adjusted to peak Anti-Xa level. None of the patients developed SARS-CoV-2 infection in the reported cohort. Fourteen (67%) pf pregnant had received their COVID-19 vaccination during this period . None of the thrombotic episodes were associated with COVID-19 vaccination. Although this audit study has limitations due to small patient numbers there was no evidence of increase in bleeding or thrombotic risk with ongoing anticoagulation with Anti-Xa monitoring during pregnancy..

COVID-19 infection as a new risk factor for penile Mondor disease.

BACKGROUND: Penile Mondor disease is a superficial dorsal vein thrombophlebitis of the penis, which mainly affects young and middle-aged men. It generally manifests as a visible painful cord located along the dorsal surface of the penis with signs of skin inflammation. The condition is usually self-limiting, but in severe cases a surgical procedure may be necessary in addition to pharmacological treatment. Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 is associated with a frequent incidence of thrombophilia; therefore, such a prothrombotic state during infection may be a significant risk factor for penile Mondor disease. CASE PRESENTATION: The 34-year-old patient reported moderate pain felt on the surface of the penis. During the medical interview, the patient did not admit significant risk factors for Mondor Disease, apart from the previous, a month earlier COVID-19 disease. Examination revealed swelling erythema and a thick indurated cord on the surface of the penis. Color Doppler ultrasound was performed to confirm assumptions and exclude thrombosis of other penile vessels. Based on visible clots in the course of the superficial penile vein and after exclusion of vasculitis due to autoimmune disease the diagnosis of penile Mondor disease was made. Pharmacological therapy was implemented to further break down the clot and prevent rethrombosis in the penile vessels. The patient did not report any treatment complications and returned for a control visit, which revealed complete clot dissolution on ultrasound; therefore, complete recovery was stated. CONCLUSIONS: This case report presents the correlation between SARS-Cov-2 infection and penile Mondor disease, based on the confirmed influence of COVID-19 on the pathophysiology of thrombosis. It can be concluded that COVID- 19 is a risk factor for Mondor disease, as in the presented case the virus was the only prothrombotic risk factor for the patient. Consequently, the possibility of developing thrombosis in the form of penile Mondor disease should be taken into account among patients with post-COVID-19 and active SARS-Cov-2 infection.

Superficial Thrombophlebitis of the Penis following AstraZeneca ChAdOx1-S Vaccination: A Rare Venous Thromboembolic Complication.

Penile Mondor's disease is a rare condition characterised by superficial thrombophlebitis of the penis which is usually self-limiting. The cause is often unknown. The AstraZeneca ChAdOx1-S vaccine has been found to cause a hypercoagulable state, which is well documented. This case report describes a man who presented with Mondor's disease following ChAdOx1-S vaccination with no other risk factors. LEARNING POINTS: This is the first documented case of penile thrombophlebitis following ChAdOx1-S vaccination.We highlight a rare presentation of an uncommon condition.Clinicians should be aware of the clotting risks associated with ChAdOx1-S vaccination.

Treatment of acute promyelocytic leukemia (APL) in a symptomatic patient with Coronavirus disease 19 (COVID-19) pneumonia

Introduction: In December 2019, a new variant of a coronavirus led to a pandemic outbreak. Patients with haematological malignancies are at high risk for a severe progression of COVID-19 with high mortality rates. Case report: 54-year-old patient was tested positive for COVID-19 upon admission. The CT scan showed bilateral ground-glass pulmonary opacities. He received dexamethasone and remdesivir. Due to severe thrombocytopenia and detection of blasts in peripheral blood a bone marrow biopsy was done. Cytological and molecular results confirmed the diagnosis intermediate risk APL. We started a therapy with arsenic trioxide and all-trans retinoic acid (ATO/ATRA). The white blood cells (WBC) increased and the respiratory situation worsened. The patient developed a thrombophlebitis. Bleeding complications appeared as an epistaxis, which required an intervention. 28 days after starting the induction, the bone marrow biopsy showed < 5% blasts. A complete peripheral remission was documented on day 50. Discussion: A major concern in treating APL is the differentiation syndrome, which can ultimately result in pulmonary failure. This patient presented with severely impaired lung function due to simultaneous COVID-19 pneumonitis. Therapy of APL had to consider both clinical conditions. Key decisions were (beyond antiviral therapy and supportive measures) a consequent dosing of glucocorticoids and early cytoreductive therapy using hydroxyurea (HU). The pulmonary function was critical during days 7-15 after start of APL therapy, consistent with differentiation syndrome being the main cause of worsening, and clinically met by stop of ATO/ATRA. Another concern was coagulation dysfunction, given the high risk of thromboembolic complications associated with COVID-19, the severe thrombocytopenia and plasmatic coagulation disorder caused by APL. In this case - besides supportive platelet transfusions - we treated by low dose heparin only when a thrombophlebitis occurred. Overall in this patient presenting with COVID-19 and simultaneously APL, the most challenging problem was overcoming pulmonary worsening in the initial phase of APL therapy.

Cerebral thrombophlebitis revealing SARS-CoV-2 infection: About one case.

INTRODUCTION: SARS-CoV-2 infection is a pandemic that continues to ravage the world, the list of its complications continues to grow longer every day. CASE PRESENTATION: We report the case of a patient admitted to intensive care for cerebral thrombophlebitis revealing a SARS-CoV-2 infection. DISCUSSION: The inflammatory nature of SARS-CoV-2 infection exposes an increased risk of thrombosis.In this article, we will discuss its mechanism and the anticoagulant treatment modalities. CONCLUSION: Besides the typical clinical signs, SARS-CoV-2 infection can manifest as thromboembolic complications such as pulmonary embolism, deep vein thrombosis, and less frequently cerebral thrombophlebitis.

A case of COVID-19 with superficial thrombophlebitis caused by an indwelling peripheral venous catheter.

A local hypercoagulable state caused by SARS-CoV-2 and an indwelling peripheral venous catheter can lead to superficial thrombophlebitis. If the venous catheter is no longer needed during treatment for COVID-19 it should be removed promptly.

Ovarian Vein Thrombosis after Pelvic Surgery in Patient with Recent Coronavirus Disease.

An abundance of literature has demonstrated that coronavirus disease (COVID-19) contributes to a hypercoagulable state that is associated with venous thromboembolic events. Data on postoperative complications after a mild COVID-19 infection are limited. We report a case of ovarian vein thrombosis after pelvic surgery in a patient with a recent mild COVID-19 infection. The patient presented with complaints of fever and worsening right-sided abdominal pain postoperatively and was found to have a right ovarian vein thrombosis. Thrombophilia workup was negative. The hypercoagulable state of patients with COVID-19 may have implications on postoperative complications after gynecologic surgery even in cases of mild infection. Further research is needed to determine the optimal thromboembolic prophylaxis for patients undergoing pelvic surgery after a COVID-19 infection.

The Anticoagulant Therapy for Otogenic Sigmoid Sinus Thrombophlebitis: A Case Report and Literature Review.

Sigmoid sinus thrombophlebitis is a severe and potentially fatal intracranial complication of acute otitis media and middle ear cholesteatoma. Early administration of broad-spectrum antibiotics and immediate radical mastoidectomy are the recommended standard treatments; however anticoagulant therapy is always an option worthy of clinical consideration. Here, we report a case of middle ear cholesteatoma complicated with sigmoid sinus thrombophlebitis in a patient who received anticoagulant therapy for 1 year before the operation because of the coronavirus disease 2019 pandemic.