Occurrence of pulmonary embolism in a patient with mild clinical expression of COVID-19

Novel inflammatory markers in patients with severe COVID-19 and a pulmonary thrombotic event

Venous thromboembolism (VTE), clinically manifested as deep vein thrombosis (DVT) or acute pulmonary embolism (PE), is the third most common acute cardiovascular syndrome following myocardial infarction and stroke. The annual incidence of PE is between 39 and 115 per 100,000 inhabitants. The incidence of VTE is almost eight times higher in people aged 80 and older than in the fifth decade of life. We performed a retrospective study of 226 COVID-19 patients and selected group of patients who experienced a pulmonary thrombotic event. The incidence of PE in hospitalized COVID-19 patients was approximately 1.9-8.9%. The retrospective nature of the analyzed cohorts and relatively short observation periods could have led to underestimation of the actual incidence of PE. This study underlines the role of novel inflammatory biomarkers such as neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in patients with a pulmonary thrombotic event in COVID-19. We suggest that these biomarkers may have high assessment value and complement routinely used biomarkers.

The analysis of Fe-dependent serum enzymes in severe COVID-19 with a pulmonary thrombotic event

Introduction

COVID-19 patients in critical condition requiring ICU admission are more likely to experience thromboembolic complications, especially pulmonary embolism. Since the outbreak of coronavirus disease 2019 (COVID-19), clinicians have struggled with the attempt to diagnose and manage the severe and fatal complications of COVID-19 appropriately. Several reports have described significant procoagulatory events, including life-threatening pulmonary embolism, in these patients. The aim of the study was to analyze the results of selected serum enzymes in patients with a radiologically confirmed pulmonary thrombotic event based on the pulmonary tissue involvement assessed in a computed tomography (CT) scan.

Material and methods

The retrospective study covered a group of 226 COVID-19 patients. Groups were divided based on the degree of lung tissue involvement in CT examinations, including patients with confirmed pulmonary embolism. The analyzed group consisted of 136 men and 90 women with mean age of 70 years.

Results

The group consisted of patients with < 50% of lung volume changes who had higher parameter values in each analyzed parameter, except red blood cells (RBC) (p < 0.05). Especially, the level of ferritin was much higher in the first group (p = 0.000008). Elevated ferritin levels were observed in all patients with lung tissue involvement.

Discussion

This line of research is critical in order to assess the predisposing conditions for pulmonary embolism occurrence in COVID-19, which can be used as a predictive factor for course of the disease. The conducted research will resolve whether there is a relationship between the selected laboratory parameters and the occurrence of pulmonary embolism in patients with COVID-19.

Conclusions

The study demonstrated that elevated levels of several inflammatory and thrombotic parameters such as ferritin, D-dimer, C-reactive protein (CRP) as well as hemoglobin do not correlate with the degree of lung tissue involvement in the computed tomography image.

Lung perfusion findings on perfusion SPECT/CT imaging in non-hospitalized de-isolated patients diagnosed with mild COVID-19 infection

Background

The aim of this retrospective study is to assess the incidence and type of lung perfusion abnormalities in non-hospitalized patients diagnosed with mild COVID-19 infection after de-isolation. Data from 56 non-hospitalized patients diagnosed with COVID-19 infection referred to our nuclear medicine department from July–December 2020 for a perfusion only SPECT/CT study or a ventilation perfusion SPECT/CT study were collected. Images were assessed for the presence and type of perfusion defects. The CT component of the study was also assessed for the presence of mosaic attenuation and COVID pneumonia changes.

Results

Thirty-two (57.1%) cases had perfusion defects. There were 20 (35.7%) cases with defects in keeping with pulmonary embolism, 17 (30.4%) cases with defects associated with mosaic attenuation but not due to pulmonary embolism, and 6 (10.7%) of cases with defects due to pulmonary infiltrates from COVID pneumonia. A total of 24 (42.9%) cases had mosaic attenuation on CT, with 10 (17.9%) of them showing a pattern likely consistent with shunting on the perfusion images.

Conclusion

Lung perfusion abnormalities are a common finding in non-hospitalized COVID-19 patients with mild disease. They are usually either due to pulmonary embolism, parenchymal infiltrates, or other causes of mosaic attenuation related to, but not specific to the pathophysiology of COVID-19 infection. The value of VQ SPECT/CT imaging is also shown in this study, in detecting and differentiating the various types of perfusion abnormalities.

Thromboembolische Erkrankung bei COVID-19-Patienten: Eine kurze narrative Übersichtsarbeit

Die Infektion mit dem Coronavirus 2 (SARS-CoV2, severe acute respiratory syndrome corona virus 2) hat sich zu einer globalen Gesundheitskrise entwickelt. Berichten zufolge ist die Inzidenz von thromboembolischen Erkrankungen bei der SARS-CoV2-Krankheit hoch und betrifft ein breites Spektrum an Organsystemen, von Hautthrombosen bis zu Lungenembolien, Schlaganfall oder Koronarthrombose, bisweilen mit katastrophalen Folgen. Es liegen Hinweise vor, nach denen Thromboembolien, Hyperkoagulabilität und eine Überproduktion proinflammatorischer Zytokine, die einen Zytokinsturm nachahmen, der zu Multiorganversagen führt, eine Schlüsselrolle dabei spielen. Die vorliegende kurze narrative Übersichtsarbeit beleuchtet die Pathophysiologie und die Risikofaktoren der thromboembolischen Erkrankung und liefert einen Rahmen für das Antikoagulationsmanagement auf Grundlage der aktuellen Evidenzlage.

Pulmonary Embolism After Acute Spinal Cord Injury and COVID-19

The coronavirus virus disease 2019 (COVID-19) is best known for its pulmonary sequelae. Understanding of the disease process is rapidly growing and the medical community already appreciates a hypercoagulable state associated with COVID-19. Acute spinal cord injury (SCI) has an inherent increased risk for venous thromboembolism (VTE). In this case report the patient presented with bilateral lower extremity weakness and sensory loss secondary to thoracic disc herniation. Incidentally, at the same time as the initial presentation, the patient was also found to have COVID-19 without significant respiratory symptoms. During hospitalization, the patient developed extensive bilateral lower extremity deep vein thrombosis (DVT) despite chemoprophylaxis. Therapeutic anticoagulation was initiated, yet several days later he developed pleuritic chest pain. Computed tomography (CT) angiography revealed bilateral pulmonary emboli. This case highlights the need for clinicians to have elevated vigilance in regards to screening and treatment for VTE in high-risk patients, such as SCI with a concurrent diagnosis of COVID-19.

Pulmonary embolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: a narrative review

BACKGROUND

Preliminary reports have described significant procoagulant events in patients with coronavirus disease-2019 (COVID-19), including life-threatening pulmonary embolism (PE).

MAIN TEXT

We review the current data on the epidemiology, the possible underlying pathophysiologic mechanisms, and the therapeutic implications of PE in relation to COVID-19. The incidence of PE is reported to be around 2.6-8.9% of COVID-19 in hospitalized patients and up to one-third of those requiring intensive care unit (ICU) admission, despite standard prophylactic anticoagulation. This may be explained by direct and indirect pathologic consequences of COVID-19, complement activation, cytokine release, endothelial dysfunction, and interactions between different types of blood cells.

CONCLUSION

Thromboprophylaxis should be started in all patients with suspected or confirmed COVID-19 admitted to the hospital. The use of an intermediate therapeutic dose of low molecular weight (LMWH) or unfractionated heparin can be considered on an individual basis in patients with multiple risk factors for venous thromboembolism, including critically ill patients admitted to the ICU. Decisions about extending prophylaxis with LMWH after hospital discharge should be made after balancing the reduced risk of venous thromboembolism (VTE) with the risk of increased bleeding events and should be continued for 7-14 days after hospital discharge or in the pre-hospital phase in case of pre-existing or persisting VTE risk factors. Therapeutic anticoagulation is the cornerstone in the management of patients with PE. Selection of an appropriate agent and correct dosing requires consideration of underlying comorbidities.

Thromboembolic disease in COVID-19 patients: A brief narrative review

Corona virus 2 (SARS-CoV2/ Severe Acute Respiratory Syndrome Corona Virus 2) infection has emerged as a global health crisis. Incidence of thromboembolic disease is reported to be high in SARS-CoV2 disease and is seen in a multitude of organ systems ranging from cutaneous thrombosis to pulmonary embolism, stroke or coronary thrombosis sometimes with catastrophic outcomes. Evidence points towards a key role of thromboembolism, hypercoagulability and over production of proinflammatory cytokines mimicking a "cytokine storm" which leads to multiorgan failure. This brief narrative review highlights the pathophysiology and risk factors of thromboembolic disease and provides a framework for management of anticoagulation based on the current evidence.

Large Vessel Occlusion Secondary to COVID-19 Hypercoagulability in a Young Patient: A Case Report and Literature Review

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) initially most appreciated for its pulmonary symptoms, is now increasingly recognized for causing multi-organ disease and stroke in the setting of a hypercoagulable state. We report a case of 33-year-old African American woman with COVID-19 who developed acute malignant middle cerebral artery infarction due to thromboembolic occlusion of the left terminal internal carotid artery and middle cerebral artery stem. Mechanical thrombectomy was challenging and ultimately unsuccessful resulting in limited reperfusion of <67% of the affected vascular territory, and thrombectomized clot was over 50 mm in length, at least three times the average clot length. The final stroke size was estimated at 224 cubic centimeters. On admission her D-dimer level was 94,589 ng/mL (normal 0-500 ng/ml). Throughout the hospitalization D-dimer decreased but never reached normal values while fibrinogen trended upward. Hypercoagulability panel was remarkable for mildly elevated anticardiolipin IgM of 16.3 MPL/mL (normal: 0-11.0 MPL/mL). With respect to remaining stroke workup, there was no evidence of clinically significant stenosis or dissection in the proximal internal carotid artery or significant cardioembolic source including cardiomyopathy, atrial fibrillation, cardiac thrombus, cardiac tumor, valvular abnormality, aortic arch atheroma, or patent foramen ovale. She developed malignant cytotoxic cerebral edema and succumbed to complications. This case underscores the importance of recognizing hypercoagulability as a cause of severe stroke and poor outcome in young patients with COVID-19 and highlights the need for further studies to define correlation between markers of coagulopathy in patients with COVID-19 infection and outcome post stroke.

Late acute pulmonary embolism after mild Coronavirus Disease 2019 (COVID-19): a case series

In late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged as the cause of a cluster of pneumonia cases in China, and the corresponding disease was designated as Coronavirus Disease 2019 (COVID-19), spreading quickly around the world resulting in a pandemic. COVID-19 is associated with a set of coagulation abnormalities that increase the risk of thromboembolic events, especially in patients with severe/critical disease. We describe a series of five cases of mild COVID-19, treated in an outpatient clinic, which, after an apparent clinical improvement, developed acute pulmonary embolism (APE) between the third and the fourth week after the onset of symptoms, when they are mostly related to acute illness disappearance. Thromboembolic events are also a potential complication of mild COVID-19 and can manifest later in the disease course. This finding raises discussion about the prevention of thromboembolic events in selected group of patients with mild COVID-19.

Awareness and Prophylaxis of Venous Thromboembolism in Patients with COVID-19: A National Cross-Sectional Survey in Epidemic Era

Aim: Patients with acute infectious diseases are at an increased risk of venous thromboembolism (VTE). Clinicians should be aware of the VTE risk in patients with COVID-19, many of whom present with severe coagulation disorders.

Method: We used an online platform to conduct a cross-sectional questionnaire survey among doctors in mainland China in March 2020. The questionnaire was designed to figure out the clinician's current awareness of VTE prevention and detection rates, as well as the current status of VTE prophylaxis in patients with COVID-19.

Results: We collected 1,636 replies, of which 1,579 were valid. Among these, 991 (63%) clinicians were involved directly in frontline treatment. Most of the clinicians (1,492, or 94%) thought it was necessary to assess the VTE risk in patients with COVID-19. However, only 234 (24%) clinicians performed appropriate assessment during the COVID-19 outbreak. For patients with mild/moderate COVID-19, 752 (76%) clinicians would prescribe exercise and water to prevent VTE. For patients with severe COVID-19, 448 (45%) clinicians would prescribe mechanical devices if the patient had a high bleeding risk, and 648 (65%) clinicians would choose LMWH as prophylaxis if the patient had a low bleeding risk. The VTE detection rate was not that high in both mild/moderate and severe patients.

Conclusion: Although most clinicians recommended prescribing VTE prophylaxis to patients with COVID-19, the practice still needs to be improved. A real-world registry to investigate the true incidence of VTE, and the effect of prescribing appropriate prophylaxis for patients with COVID-19, is necessary in the future.

Catheter-directed thrombolysis to treat acute pulmonary thrombosis in a patient with COVID-19 pneumonia

We describe a case of a patient who presented to the emergency department with severe shortness of breath and was diagnosed with mild COVID-19 pneumonia and concomitant intermediate-high risk saddle pulmonary thromboembolism. Additionally, the patient had sustained a significant head injury 2 days prior due to a syncopal episode. The patient was treated successfully with catheter-directed thrombolysis (CDT). The case highlights the importance of considering thromboembolic complications in COVID-19 infection, independent of the severity of the associated pneumonia. The case also demonstrates the potential benefit of CDT in treating COVID-19-related thromboembolism.

COVID-19 versus HIT hypercoagulability

A striking feature of COVID-19 is the high frequency of thrombosis, particularly in patients who require admission to intensive care unit because of respiratory complications (pneumonia/adult respiratory distress syndrome). The spectrum of thrombotic events is wide, including in situ pulmonary thrombosis, deep-vein thrombosis and associated pulmonary embolism, as well as arterial thrombotic events (stroke, myocardial infarction, limb artery thrombosis). Unusual thrombotic events have also been reported, e.g., cerebral venous sinus thrombosis, mesenteric artery and vein thrombosis. Several hematology abnormalities have been observed in COVID-19 patients, including lymphopenia, neutrophilia, thrombocytopenia (usually mild), thrombocytosis, elevated prothrombin time and partial thromboplastin times (the latter abnormality often indicating lupus anticoagulant phenomenon), hyperfibrinogenemia, elevated von Willebrand factor levels, and elevated fibrin d-dimer. Many of these abnormal hematologic parameters—even as early as the time of initial hospital admission—indicate adverse prognosis, including greater frequency of progression to severe respiratory illness and death. Progression to overt disseminated intravascular coagulation in fatal COVID-19 has been reported in some studies, but not observed in others. We compare and contrast COVID-19 hypercoagulability, and associated increased risk of venous and arterial thrombosis, from the perspective of heparin-induced thrombocytopenia (HIT), including the dilemma of providing thromboprophylaxis and treatment recommendations when available data are limited to observational studies. The frequent use of heparin—both low-molecular-weight and unfractionated—in preventing and treating COVID-19 thrombosis, means that vigilance for HIT occurrence is required in this patient population.

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HIT and COVID-19 are associated with a high risk of thrombosis (venous > arterial).

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HIT and COVID-19 both feature coagulation and “pancellular” activation.

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Therapeutic anticoagulation is indicated for HIT, but dosing unknown for COVID-19.