ABSTRACT
Arterial thrombotic events in younger patients without a readily apparent etiology present significant diagnostic and management challenges. We present a structured approach to diagnosis with consideration of common causes, including atherosclerosis and embolism, as well as uncommon causes, including medications and substances, vascular and anatomic abnormalities, systemic disorders, and thrombophilias. We highlight areas of management that have evolved within the past 5 years, including the use of dual-pathway inhibition in atherosclerotic disease, antithrombotic therapy selection in embolic stroke of undetermined source and left ventricular thrombus, the role of closure of patent foramen ovale for secondary stroke prevention, and the thrombotic potential of coronavirus disease 2019 infection and vaccination. We conclude with a representative case to illustrate the application of the diagnostic framework and discuss the importance of consideration of bleeding risk and patient preference in determining the appropriate management plan.
Subject(s)
Thrombosis/diagnosis , Thrombosis/therapy , Adult , Atherosclerosis/complications , Atherosclerosis/diagnosis , Atherosclerosis/therapy , COVID-19/complications , Disease Management , Embolism/complications , Embolism/diagnosis , Embolism/therapy , Female , Foramen Ovale, Patent/complications , Foramen Ovale, Patent/diagnosis , Foramen Ovale, Patent/therapy , Humans , Secondary Prevention , Stroke/prevention & control , Thrombosis/etiologyABSTRACT
BACKGROUND: Platypnea-orthodeoxia syndrome (POS) is a rare condition characterized by dyspnoea (platypnea) and arterial desaturation in the upright position resolved in the supine position (orthodeoxia). Intracardiac shunt, pulmonary ventilation-perfusion mismatch and others intrapulmonary abnormalities are involved. CASE PRESENTATION: We report a case of POS associated with two pathophysiological issues: one, cardiac POS caused by a patent foramen ovale (PFO) and second, pulmonary POS due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) interstitial pneumonia. POS has resolved after recovery of coronavirus disease 2019 (COVID-19) pneumonia. CONCLUSIONS: Right-to-left interatrial shunt and intrapulmonary shunt caused by SARS-CoV-2 pneumonia contributed to refractory hypoxemia and POS. Therefore, in case of COVID-19 patient with unexplained POS, the existence of PFO must be investigated.
Subject(s)
COVID-19 , Dyspnea , Foramen Ovale, Patent , Hypoxia , Lung/diagnostic imaging , Pneumonia, Viral , COVID-19/diagnosis , COVID-19/physiopathology , Dyspnea/diagnosis , Dyspnea/etiology , Dyspnea/physiopathology , Echocardiography/methods , Foramen Ovale, Patent/complications , Foramen Ovale, Patent/diagnosis , Foramen Ovale, Patent/physiopathology , Hemodynamics , Humans , Hypoxia/diagnosis , Hypoxia/etiology , Hypoxia/physiopathology , Lung Diseases, Interstitial/complications , Lung Diseases, Interstitial/physiopathology , Lung Diseases, Interstitial/virology , Male , Middle Aged , Oxygen/analysis , Pneumonia, Viral/complications , Pneumonia, Viral/diagnosis , Pneumonia, Viral/physiopathology , Posture/physiology , SARS-CoV-2/isolation & purification , Syndrome , Treatment OutcomeABSTRACT
Sickle cell disease (SCD) is an inherited monogenic hemoglobinopathy characterized by formation of sickle erythrocytes under conditions of deoxygenation. Sickle erythrocytes can lead to thrombus formation and vaso-occlusive episodes that may result in hemolytic anemia, pain crisis and multiple organ damage. Moreover, SCD is characterized by endothelial damage, increased inflammatory response, platelet activation and aggravation, and activation of both the intrinsic and the extrinsic coagulation pathways. Cerebrovascular events constitute an important clinical complication of SCD. Children with SCD have a 300-fold higher risk of acute stroke and by the age of 45 about 25% of patients have suffered an overt stoke. Management and prevention of stroke in patients with SCD is not well defined. Moreover, the presence of patent foramen ovale (PFO) increases the risk of the occurrence of an embolic cerebrovascular event. The role of PFO closure and antiplatelet or anticoagulation therapy has not been well investigated. Moreover, during COVID-19 pandemic and taking into account the increased rates of thrombotic events and the difficulties in blood transfusion, management of SCD patients is even more challenging and difficult, since data are scarce regarding stroke occurrence and management in this specific population in the COVID-19 era. This review focuses on pathophysiology of stroke in patients with SCD and possible treatment strategies in the presence of PFO.