SARS-CoV-2 Associated Submassive Pulmonary Embolism Even with the Use of Dabigatran

Abstract

Introduction: The SARS-CoV-2 infection has been associated with a hypercoagulable state with a higher incidence of venous thromboembolic complications including deep venous thrombosis (DVT) and pulmonary embolisms (PE). The use of anticoagulation therapy has been suggested to prevent these complications with SARS-CoV-2 Infection. We present a case of submassive PE in the setting of SARS-CoV-2 infection while using, a direct thrombin inhibitor, dabigatran. Case Presentation: 69 y/o male with a history of DVT, on lifelong dabigatran (PRADAXA), presented with a worsening dry cough, dyspnea, chest pain, headache, nausea, and diarrhea for the past 3 days. The patient denied fever or known sick contact. He endorsed medication compliance with dabigatran 150 mg twice-daily dose. The social history was negative for smoking or illicit drug use. Initial blood work noted for high D-dimer, inflammatory markers like CRP and ferritin as well as high troponin, and pro-BNP with positive SARS-CoV-2 RT-PCR. CTA Chest showed right lower lobe patchy ground-glass opacities as well as large filling defects within the bilateral main pulmonary arteries representing acute bilateral PEs with CT evidence of right-sided cardiac strain (Figure-1). Lower extremities doppler ultrasound also showed acute DVT involving the right popliteal vein as well as partially occlusive DVT in the left superficial femoral vein and left popliteal vein. He was started on UF-heparin infusion for submissive PE. Given increased clot burden and evidence of right heart strain, he underwent successful catheter-directed thrombolysis by IR without complications. He also completed a course of Remdesivir and steroids (Decadron) for COVID-19 pneumonia. His respiratory status remained stable with minimal oxygen requirement and subsequently had negative SARS-CoV-2 RT-PCR. The patient was discharged home on long-term Apixaban anticoagulation therapy. Discussion: Dabigatran, a direct inhibitor of free and fibrin-bound thrombin, has been frequently used as an anticoagulation therapy for its good tolerance, predictable pharmacokinetics, and lack of necessity for coagulation monitoring. Dabigatran has been associated with a 92% reduction in the incidence of VTE in the general population. The SARS-CoV-2 infection has been reported for a higher incidence of 23% of VTE compared to non-SARS-CoV-2 critically ill patients. Our patient presented with submassive PE and DVT even with the use of a therapeutic dose of dabigatran in the setting of SARS-CoV-2 infection. This raises the concern about the anticoagulation effect of direct thrombin inhibitors like dabigatran with SARS-CoV-2 infection.