Thrombus in Transit: A Case of Extensive Thrombosis Secondary to Coronavirus Disease 2019

Abstract

Introduction: Coronavirus disease 2019 (COVID-19) has spread to more than 200 countries with more than 70 million cases globally caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite a global pandemic, there is a paucity of data on mechanisms of high morbidity and mortality. Studies have shown that patients are at risk of venous thromboembolic (VTE) disease leading to increased mortality. We present a case of new-onset heart failure, who was found to have thrombus in transit with bilateral pulmonary embolism. Case: A 63-year-old woman with a history of hypertension and diabetes presented with bilateral lower extremity swelling for two weeks. She noticed that her legs are getting puffier and during this time, she gained about 15 pounds as well. She also complained of shortness of breath, which was exertional in nature and gradually progressed to dyspnea at rest. She otherwise denied any chest pain, palpitations, cough, runny nose, or loss of sense of taste or smell. She did not travel anywhere prior to the presentation, neither had any sick contacts. She was admitted for heart failure exacerbation and an initial transthoracic echocardiogram (TTE) revealed an ejection fraction (EF) of 20% with global hypokinesis. She was admitted to the Intensive Care Unit for cardiogenic shock with suspected cardio-renal syndrome, and hence diuretics were held. Over the next three days, her kidney function worsened and a repeat TTE was performed which revealed a “cord-like” structure in the right atrium (Figure 1) extending from inferior vena cava (IVC), a dilated right ventricle, and elevated right ventricular systolic pressure at 50mmHg. A venous Doppler ultrasound of the legs revealed acute deep venous thrombosis of the left popliteal vein all the way up to her IVC. Because of the significant clot burden, thrombocytopenia, and hypoxemia she was tested for COVID-19, which resulted positive. She also had a lung perfusion scan which revealed a high probability for acute pulmonary embolism. She was started on full-dose anticoagulation with heparin and with improvement in her kidney function was eventually transitioned to enoxaparin at discharge. Discussion: This case highlights the hypercoagulable states in COVID-19 and its related complications. It not only calls attention to thromboembolic causes of hypoxemia in COVID-19 but also demonstrates the important diagnostic utility of an echocardiogram and the therapeutic role of anticoagulation. Early diagnosis by keeping a high index of suspicion and prompt treatment is vital to avoid adverse outcomes and increased mortality.