Fatal Pulmonary Hemorrhage: Cirrhosis and COVID19

Abstract

Background: The clinical impact and therapeutic implications of COVID-19 infection in a patient with pre-existing liver disease is unknown. We present a case of a middle-aged female with underlying non-alcoholic steatohepatitis associated cirrhosis who suffered a fatal pulmonary hemorrhage associated with COVID-19 infection. While the management of COVID-19 is evolving with regards to therapeutic anticoagulation requirements in critically ill patients, the impact of a pre-existing liver disease and its therapeutic implications when associated with COVID-19 is yet to be thoroughly elucidated. Case Report: Our patient is a 47 year old female with a past medical history of hypertension, hypothyroidism, fibromyalgia, non-decompensated NASH cirrhosis Child-Pugh Class C, gastric bypass surgery who developed progressive shortness of breath secondary to a COVID-19 pneumonia requiring hospitalization. She then developed acute hypoxic respiratory failure that required mechanical ventilation for over two weeks. Dexamethasone and Convalescent plasma were given for treatment of COVID-19. Unfortunately, her respiratory status during her ICU stay, declined requiring interventions including neuromuscular blockers and proning for refractory hypoxemia. She concurrently developed acute kidney injury requiring continuous renal replacement therapy. Her hospital course was also complicated by septic shock requiring vasopressors secondary to candidemia, and she was initiated on antifungal therapy with fluconazole. During ongoing CRRT therapy, we encountered recurrent clotting events and with the presumed COVID related hypercoagulability, patient was initiated on anticoagulation with systemic unfractionated heparin protocol. On day 17, her respiratory status and shock had resolved. However, her clinical status deteriorated quickly with recurrent shock of presumed sepsis, requiring initiation of broad spectrum antibiotics including vancomycin and piperacillin-tazobactam. Over the course of these 24 hours, patient suffered a fatal pulmonary hemorrhage despite massive transfusion protocol and reversal with protamine sulfate. Conclusion: We presented a cirrhotic patient who died of massive pulmonary hemorrhage associated with COVID-19 infection. There is overall paucity in the literature and in our understanding of management of COVID-19 associated with liver disease. While the literature reports a higher incidence of venous thromboembolic disease in COVID-19 patients, there are several challenges encountered with initiation of anticoagulation in a cirrhotic patient with concurrent coagulopathy. There are however anecdotal reports of favorable outcomes reported in these patients with use of anticoagulation possibly secondary to their antifibrotic properties. Future studies are required to clarify the role of safe and effective anticoagulation, criteria to make this decision, and perhaps even the choice of anticoagulation in patients with underlying liver disease.