Extensive DVT and Pulmonary Embolism Leading to the Diagnosis of Coronavirus Disease 2019 in the Absence of Severe Acute Respiratory Syndrome Coronavirus 2 Pneumonia

Venous thromboembolism in COVID-19: A meta-summary of cases

OBJECTIVES

To summarize cases of venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT) among coronavirus disease (COVID-19) patients and discuss their symptoms, diagnostic method, clinical features, and prognosis.

METHODS

All major databases were searched for relevant studies published between December 1, 2019 and May 5, 2021.

RESULTS

A total of 233 articles were identified, 22 describing 48 patients were included. A total of 79.1% had PE and 20.9% had DVT. Most patients were men, with a mean age of 56 years. Comorbidities were present in 70.8%, and 85.4% had at least one risk factor of VTE. 56.3% had received anticoagulation therapy. Most patients were treated in the general ward. Complications occurred in 27.1% of the patients, and recovery was achieved in 80.4%.

CONCLUSION

Venous thromboembolism must be suspected even in patients who had received prior anticoagulant regimens or in stable cases, especially in males, the elderly, and patients with comorbidities and high D-dimer levels.

Early-stage COVID-19 pandemic observations on pulmonary embolism using nationwide multi-institutional data harvesting

We introduce a multi-institutional data harvesting (MIDH) method for longitudinal observation of medical imaging utilization and reporting. By tracking both large-scale utilization and clinical imaging results data, the MIDH approach is targeted at measuring surrogates for important disease-related observational quantities over time. To quantitatively investigate its clinical applicability, we performed a retrospective multi-institutional study encompassing 13 healthcare systems throughout the United States before and after the 2020 COVID-19 pandemic. Using repurposed software infrastructure of a commercial AI-based image analysis service, we harvested data on medical imaging service requests and radiology reports for 40,037 computed tomography pulmonary angiograms (CTPA) to evaluate for pulmonary embolism (PE). Specifically, we compared two 70-day observational periods, namely (i) a pre-pandemic control period from 11/25/2019 through 2/2/2020, and (ii) a period during the early COVID-19 pandemic from 3/8/2020 through 5/16/2020. Natural language processing (NLP) on final radiology reports served as the ground truth for identifying positive PE cases, where we found an NLP accuracy of 98% for classifying radiology reports as positive or negative for PE based on a manual review of 2,400 radiology reports. Fewer CTPA exams were performed during the early COVID-19 pandemic than during the pre-pandemic period (9806 vs. 12,106). However, the PE positivity rate was significantly higher (11.6 vs. 9.9%, p < 10^-4) with an excess of 92 PE cases during the early COVID-19 outbreak, i.e., ~1.3 daily PE cases more than statistically expected. Our results suggest that MIDH can contribute value as an exploratory tool, aiming at a better understanding of pandemic-related effects on healthcare.

Pulmonary Thromboembolism in Patients After COVID-19: Predictive Indicators for Correct Diagnosis

Background: Infection caused by SARS-CoV-2 can lead to significant procoagulant events, sometimes involving life-threatening pulmonary thromboembolism (PE). Additional conditions complicating the diagnosis are the presence of risk factors for PE in almost all patients with COVID-19 and the overlap of clinical presentation between PE and COVID-19. Objectives: We conducted a single-center study at the Heart and Brain Hospital, Pleven, from December 2020 to February 2021. It included 27 consecutively hospitalized patients with recent pneumonia caused by COVID-19 and clinical presentations corresponding to PE. Methods: The cohort was divided into two groups with and without a definitive diagnosis of PE, proven by CT pulmoangiography. The aim was to find the indicators predicting the presence of PE in patients with acute or post-acute COVID-19 conditions. Results: Our results showed that some ECG criteria, including S-wave over 1.5 mm in leads I and aVL (P = 0.007), Q-wave in leads III and aVF (P = 0.020), and D-dimer as a quantitative variable (P = 0.025), were independent predictors of PE. The RV/LV diameter ratios ≥ 1.0 and right ventricular dysfunction showed a sensitivity (Se) of 62.5%, specificity (Sp) of 100%, positive predictive value (PPV) of 100%, and negative predictive value (NPV) of 86.4% to verify the PE diagnosis. Besides, the D-dimer cutoff value of 1,032 ng/mL had an optimal Se of 87.5%, Sp of 57.9%, PPV of 46.7%, and NPV of 91.7% for PE diagnosis (P = 0.021). Conclusions: Against the background of acute and post-acute COVID-19 conditions, ECG and EchoCG criteria remain the PE predictors. We suggest that a higher D-dimer cutoff value be applied in COVID-19 and post-COVID-19 patients to confirm/dismiss PE diagnosis.

Extensive deep vein thrombosis and pulmonary embolism as a unique clinical manifestation of COVID-19 in a young healthy patient

Background/Objective

Deep vein thrombosis and pulmonary embolism have been described as complications in previously diagnosed COVID-19 patients, especially in those admitted in critical ill units, but, to our knowledge, there is no report of venous thromboembolism in an otherwise asymptomatic COVID-19 patient.

Methods

We report the case of a 22-year-old female, healthy patient with pulmonary embolism (Pulmonary Embolism Severity Index Score 22 points, low risk) and extensive proximal deep vein thrombosis as a unique clinical manifestation of the new coronavirus disease.

Results

The patient had no risk factors and no familial history of venous thromboembolism. All thrombophilia markers were negative. The patient was treated as first by an independent vascular team, performing vena cava filter placement and open thrombectomy. Her symptoms worsened, and after 3 weeks, she underwent US-enhanced thrombolysis and mechanical thrombectomy. She was isolated for 10 days and did not develop any other clinical manifestation of COVID-19 disease. During follow-up, she remained asymptomatic and complete patency of the venous system was achieved. Full oral anticoagulation was conducted for 6 months.

Conclusion

COVID-19 appears to be a multi-symptomatic disease, and venous thromboembolism without any other previous described COVID-19 symptom could be considered one of its diverse clinical presentations and RT-PCR for SARS-CoV-2 tests emerge to be mandatory in patients with otherwise unexpected venous thrombosis.