Virginia Research Day 2022

Medical Resident Research Case Reports

11 Increased Risk For Pulmonary Embolism In Patient’s With COVID-19

Alexa Krebs, MD; Kimberly Bird, MD Corresponding author: Alexa.krebs@lpnt.net

SOVAH Health Internal Medicine Residency Program

Context: COVID-19 infection is associated with an increased risk for pulmonary embolism (PE). Case Report: 54 y/o AA female with PMH of hypertension and prediabetes who presented to the ED with worsening SOB and syncope. Pt tested positive for COVID-19 two weeks prior. She was quarantining at home with her daughter. After 14 days at home, patient was on her way to her PCP’s office when she passed out at the bus stop. Bystanders called EMS. Medical History: Hypertension, prediabetes, morbid obesity, mood disorder. No surgical Social History: Pt lives at home with her daughter. She ambulates without assistance and does not use oxygen at baseline. She denies tobacco, alcohol, and illicit drug use. Pertinent ROS: SOB and cough. Physical Examination: Mucous membranes dry with positive skin tenting. Lungs bilaterally clear in all lobes with equal chest rise. No wheezes, rales, or rhonchi. history. Family History: Mother had hypertension and type 2 diabetes.

Pertinent Labs: Potassium 3.4, COVID-19 test positive, Lactic acid 2.5 EKG/Imaging: EKG -- NSR, rate 136, normal axis, inverted T waves in leads II, III, aVF, V2-V6. CXR – bilateral pulmonary infiltrates consistent with COVID-19 pneumonia. CT chest – multifocal pneumonia suspicious for COVID-19, pulmonary embolism involving the left upper lobe, left lower lobe, right middle lobe, and right lower lobe. LE doppler – B/L LE negative for DVT. Diagnosis: Acute hypoxic respiratory failure secondary to COVID-19 pneumonia and multifocal pulmonary emboli. Treatment: IV ceftriaxone 1 g daily for 5 days, IV azithromycin 500 mg daily for 3 days, dexamethasone 6 mg daily for 10 days, supplemental oxygen, Acapella and incentive spirometry, Eliquis 10 mg BID for 7 days and 5 mg BID thereafter. Comment: Studies have shown that patients hospitalized with COVID-19 have an increased incidence of PE compared to those without COVID-19. The risk of PE is even higher in ICU patients with COVID-19. Several

case studies have revealed thromboembolic events in the mild-to-moderate outpatient COVID-19 patients, but minimal research has been performed in the outpatient COVID-19 patients and risk of PE. D-dimer is useful for identifying patients likely to have PE in the hospitalized patient and subsequent imaging and DVT prophylaxis are ordered as the standard of care. In contrast, the outpatient COVID-19 patients do not undergo extensive workup for VTE risk. One study researched the benefit of using QT-SPECT/CT to detect PE in the relatively low risk mild-to moderate COVID-19 patients treated in the outpatient setting. The results showed that QT-SPECT/ CT could detect perfusion defects without CT abnormality in patients with mild-to-moderate COVID-19 at a rate of 36.6% in patients who had elevated D-dimer or dyspnea and a rate of 56.5% in those that had both. Based on the above findings, screening with D-dimer and imaging in the outpatient setting may be reasonable to help guide the decision to treat with anticoagulant prophylaxis for prevention of DVT. Further research is warranted in this area of treatment of outpatient COVID-19 patients.

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