Hypercoagulability due to COVID-19 Leads to Sub-massive Bilateral Pulmonary Embolism and Impending Phlegmasia Cerulea Dolens

Hypercoagulability due to COVID-19 Leads to Sub-massive Bilateral Pulmonary Embolism and Impending Phlegmasia Cerulea Dolens. Mancheno, Kevin, MS-II, College of Allopathic Medicine, Obando, Manuel, MD, Emergency Medicine, Aventura Hospital and Medical Center, Hashemi, Amir, MD, Emergency Medicine, Aventura Hospital and Medical Center, Marra, Erin, MD, Assistant Professor, Residency Research Director, Aventura Hospital and Medical Center Introduction: COVID-19 can lead to significant morbidity and mortality due to hypercoagulability. Patients with comorbidities have higher risks for extensive thrombosis. Complications include stroke, myocardial infarction, deep venous thrombosis (DVT) or pulmonary embolism1. Phlegmasia cerulea dolens is a severe form of DVT with high risk for limb loss. We will present the case of a healthy adult male with COVID-19 with subsequent bilateral sub-massive pulmonary emboli and impending phlegmasia cerulea dolens. Case Description: A 47-year-old male, recently diagnosed with COVID-19, otherwise healthy, presented to the emergency department for dyspnea and painful left lower extremity swelling. Physical exam was significant for tachypnea, hypoxia, and left lower extremity edema with non-palpable pedal pulses. Ultrasound showed extensive DVT of the left leg along with acute right heart strain. There was high probability for PE per ventilation and perfusion scan. The patient required ICU monitoring and treatment with continuous infusions of alteplase and heparin. The patient’s hospital stay was uncomplicated and was able to be safely discharged. Discussion: This case demonstrates how COVID-19 can manifest beyond a mild upper respiratory infection. This patient had extensive thrombus burden that required emergent intervention and administration of anti-coagulation and antithrombotic medication1. The Wells’ criteria and Geneva scores are not reliable in predicting and assessing the need for CT angiogram studies along with anti-thrombotic therapy in COVID-19 patients 8. Treatment with low-molecular weight heparin was associated with lower mortality in severe cases 11. Future research is necessary to create an algorithm for the management and treatment of coagulopathic COVID-19 patients. References 1. Zhang, L., Feng, X., Zhang, D., Jiang, C., Xie, M. (2020). Correction to: Deep Vein Thrombosis in Hospitalized Patients With COVID-19 in Wuhan, China: Prevalence, Risk Factors, and Outcome. Circulation, 142(2), 114-128. doi:10.1161/cir.0000000000000887 2. Middeldorp S, Coppens M, van Haaps TF, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. Preprints.org. 2020:0. doi:10.20944/preprints202004.0345.v1 3. Helms, J., Tacquard, C., Severac, F. et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med46, 1089–1098 (2020). https://doi.org/10.1007/s00134-020-06062-x 4. Perkins JM, Magee TR, Galland RB. Phlegmasia caerulea dolens and venous gangrene. Br J Surg. 2005;83(1):19-23. 5. Levi M, Thachil J, Iba T, Levy JH. Coagulation abnormalities and thrombosis in patients with COVID-19. Lancet Haematol. 2020;7(6):e438-e440. doi:10.1016/S2352-3026(20)30145-9. 6. Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens [published online ahead of print, 2020 May 15]. Am J Emerg Med. 2020;10.1016/j.ajem.2020.05.022. doi:10.1016/j.ajem.2020.05.022 7. Price LC, McCabe C, Garfield B, Wort SJ. Thrombosis and COVID-19 pneumonia: the clot thickens!. Eur Respir J. 2020;56(1):2001608. Published 2020 Jul 30. doi:10.1183/13993003.01608-2020. 8. Girardi AM, Bettiol RS, Garcia TS, et al. Wells and Geneva Scores Are Not Reliable Predictors of Pulmonary Embolism in Critically Ill Patients: A Retrospective Study [published online ahead of print, 2018 Dec 16]. J Intensive Care Med. 2018;885066618816280. doi:10.1177/0885066618816280. 9. Yao, Y., Cao, J., Wang, Q. et al. D-dimer as a biomarker for disease severity and mortality in COVID-19 patients: a case control study. j intensive care 8, 49 (2020). https://doi.org/10.1186/s40560-020-00466-z 10. Fletcher-Sandersjöö A, Bellander BM. Is COVID-19 associated thrombosis caused by overactivation of the complement cascade? A literature review [published online ahead of print, 2020 Jun 18]. Thromb Res. 2020;194:36-41. doi:10.1016/j.thromres.2020.06.027 11. Tang N, Bai H, Chen X, Gong J, Li D, Sun Z, et al. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020. https://doi.org/ 10.1111/jth.14817.