SARS-COV-2-INDUCED COAGULOPATHY DEMONSTRATING HEMORRHAGIC CARDIAC TAMPONADE: A TIGHT SQUEEZE

ABSTRACT

SESSION TITLE COVID-19 Case Report Posters 3 SESSION TYPE Case Report Posters PRESENTED ON 10/19/2022 1245 pm - 0145 pm INTRODUCTION: There is a growing volume of evidence of extrapulmonary manifestations of Coronavirus disease 2019 (COVID-19), particularly within the cardiovascular and hematological systems. In this case, we describe a unique manifestation of a COVID-19 presenting with a hemorrhagic pericardial effusion and cardiac tamponade physiology with a supratherapeutic international normalized ratio (INR). CASE PRESENTATION A 68-year-old male with coronary artery disease and atrial fibrillation on warfarin presented to the emergency department with acutely worsening shortness of breath. Upon arrival, he was hypotensive, tachypneic, and hypoxic. Physical exam findings included jugular venous distention and muffled heart sounds. A transthoracic echocardiogram demonstrated a large concentric pericardial effusion with tamponade physiology (Figure 1). Pertinent initial laboratory values included an elevated INR of 6.1, a prolonged prothrombin time of 61.2 seconds, and an elevated D-dimer level of 5.34 mg/L (Table 1). The prolonged INR was reversed with prothrombin complex concentrate (PCC). Emergent pericardiocentesis yielded 1.7L of dark-bloody appearing fluid. Pericardial fluid analysis (Table 1) demonstrated over 2.4 million red blood cells and 3,650 total nucleated cells with 94% lymphocytes. Cultures and cytology were unrevealing. Given the profound lymphocytic component, a COVID-19 nasal swab was obtained and resulted positive. Prior to contracting COVID-19, the patient's weekly INR levels were consistently at goal. DISCUSSION: The global pandemic of the COVID-19 continues to identify extrapulmonary manifestations of the disease. A rising number of publications have implicated COVID-19 with causing myocarditis, pericardial effusions, and hemorrhagic cardiac tamponade(1). Hemorrhagic cardiac effusions are typically seen with malignancy, tuberculosis, trauma, recent cardiac procedures, post-myocardial infarction, and are also seen in Coxsackie viral infections. Multiple studies implicate COVID-19 interactions with oral-vitamin K antagonists as the cause of unpredictable INR's which can lead to spontaneous bleeding2. There are fewer than 10 reported instances of hemorrhagic pericardial effusions with tamponade physiology in COVID-19 patients;however, none of the other cases presented with a super-therapeutic INR. We are also the first to demonstrate a primary lymphocytic component of the pericardial fluid suggesting viral etiology. Profound coagulopathies in COVID-19 result in an increased mortality(3). CONCLUSIONS: We propose that based on the increase in publications of case-reports describing COVID-19 viral infections and hemorrhagic pericardial effusions, that SARS-CoV-2 should be added to the list of known viral etiologies. Further, COVID-19 patients who are systemic anticoagulation with vitamin K antagonists should be monitored closely for abrupt changes in their INR. Reference #1 1. Gupta A, Madhavan MV, Sehgal K, et al. Extrapulmonary manifestations of COVID-19. Nature Medicine. 2020;26(7)1017-1032. Reference #2 2. Camilleri E, Van Rein N, Van Der Meer FJM, Nierman MC, Lijfering WM, Cannegieter SC. Stability of vitamin K antagonist anticoagulation after COVID-19 diagnosis. Research and Practice in Thrombosis and Haemostasis. 2021;5(7) Reference #3 3. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. Journal of Thrombosis and Haemostasis. 2020;18(4)844-847. DISCLOSURES No relevant relationships by Gregory Hicks No relevant relationships by Daniel Kissau No relevant relationships by Andrew Labelle No relevant relationships by Scott Mayer No relevant relationships by Dmitriy Scherbak