Wednesday, May 13, 2020

EID Journal: Two Reports On Thrombotic Events In COVID-19 Patients

Acute Pulmonary Embolism in Postpartum Patient


Although we don't yet know the full range of illness, potential sequelae, or ultimate impact of this COVID-19 pandemic, it has become increasingly apparent that the SARS-CoV-2 is more than just a respiratory pathogen.
Over the past couple of weeks we've seen reports (see here, here, and here) of a Pediatric Multi-System Inflammatory Syndrome, which has hospitalized more than 100 children across the country, killing at least 3.
In addition to anecdotal reports of 400%  increase in heart attacks in New York City during their COVID-19 outbreak, we've seen reports suggesting COVID-19 is linked to cardiac injury   -  particularly in those with underlying cardiovascular disease - but sometimes in previously healthy individuals.

A month ago, in  JAMA: Neurologic Manifestations Of Patients With Severe Coronavirus Disease,  we saw a JAMA Neurology report that found more than 1/3rd of a study group of 214 patients hospitalized in Wuhan, China showed signs of neurological involvement.
Neurological manifestations ranged from relatively mild (headaches, dizziness, anosmia, mild confusion, etc.) to more profound (seizures, stupor, loss of consciousness, etc.) to potentially fatal (ischemic stroke, cerebral hemorrhage, muscle injury (rhabdomyolysis), etc.).
And three weeks ago, in EID Journal: Pulmonary Embolism and Increased Levels of d-Dimer in COVID-19 Patientswe looked at the cases histories of three COVID-19 patients who developed pulmonary embolisms in the second week of their hospitalization (roughly 18 days into their illness).
Although COVID-19 is having its greatest impact on the elderly, this disease is more than just a severe pneumonia that takes out people in their 70s & 80s. 
We've two new reports published yesterday in the EID Journal on thrombotic events (blood clots) occurring in COVID-19 patients, including several under the age of 60. I've only posted the abstract and some selected excerpts, so follow the links to read these reports in their entirety.

Volume 26, Number 8—August 2020
Research Letter
Abdominal Visceral Infarction in 3 Patients with COVID-19
Giulia Besutti , Riccardo Bonacini, Valentina Iotti, Giulia Marini, Nicoletta Riva, Giovanni Dolci, Mariarosa Maiorana, Lucia Spaggiari, Filippo Monelli, Guido Ligabue, Giovanni Guaraldi, Paolo Giorgi Rossi, Pierpaolo Pattacini, and Marco Massari

A high incidence of thrombotic events has been reported in patients with coronavirus disease (COVID-19), which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. We report 3 clinical cases of patients in Italy with COVID-19 who developed abdominal viscera infarction, demonstrated by computed tomography.

Frequent thrombotic events, mostly pulmonary embolisms, have been reported in patients with coronavirus disease (COVID-19) (14). We describe 3 cases of COVID-19 complicated by abdominal visceral infarction that occurred in inhabitants of the Emilia Romagna region in northern Italy.

Between the start of the SARS-CoV-2 outbreak in Reggio Emilia at the end of February and March 24, the province has had 460 hospitalizations in all hospitals. Among these, 2 (0.4%) patients (1,2) had acute ischemic events involving abdominal viscera; therefore, these events should not be considered too rare. Visceral infarction is probably a clinical manifestation of the prothrombotic state that has been described in patients with COVID-19 (16). Consistently, reports about pathological changes in organs other than the lungs describe parenchymal cells necrosis and small-vessel thrombosis (7).
The possibility of abdominal visceral infarction during COVID-19 has major implications in clinical practice. First, when patients with COVID-19 report severe abdominal pain, visceral infarction should be considered in differential diagnosis and taken into account in laboratory and imaging diagnostic workups. Second, this finding should further prompt the scientific community to stress the need to routinely use LMWH in patients with COVID-19 and to open the debate on the appropriate dosage. Finally, the prothrombotic state in patients with COVID-19 may justify therapeutic rather than prophylactic LMWH.

Dr. Besutti is a radiologist in Azienda USL–IRCCS of Reggio Emilia, Italy, and a PhD student in the clinical and experimental medicine PhD program, University of Modena and Reggio Emilia, Modena, Italy. Her primary research interest is about comorbidities in HIV-infected patients, especially involving the lungs, liver, and cardiovascular system.

Research Letter
COVID-19 and Acute Pulmonary Embolism in Postpartum Patient

Zohre Khodamoradi, Shahrokh Sadeghi Boogar , Farnaz Kamali Haghighi Shirazi, and Pariya Kouhi 
We report a 36-year-old woman in Iran who sought care for left shoulder pain and cough 5 days after a scheduled cesarean section. Acute pulmonary embolism and coronavirus disease were diagnosed. Physicians should be aware of the potential for these concurrent conditions in postpartum women.

Venous embolism has been associated with severe infection. Acute pulmonary embolism has been associated with severe acute respiratory syndrome coronavirus infections, but no cases have been reported with Middle East respiratory syndrome (2,3).
A study reported a 75-year-old hospitalized woman with COVID-19 and pulmonary embolism (4). In addition, in 2 COVID-19–positive patients, 57 and 70 years of age, from Wuhan, China, computed tomography angiography (CTA) confirmed pulmonary embolism (5). 
Three cases of deep vein thrombosis with COVID-19 also have been reported (6).
Pregnancy increases the risk for venous embolism (7). Although approximately half of venous embolism occurs during pregnancy and half occurs during the postpartum period, the risk per day is greatest in the weeks immediately after delivery (8). We report a patient in Iran who sought care for cough and shoulder pain 5 days after an uncomplicated cesarean delivery in whom an acute pulmonary embolism and COVID-19 infection were subsequently diagnosed. The ethics committee of Shiraz University of Medical Sciences (Shiraz, Iran) approved the study.
The patient we report was young, was not critically ill or septic, and had no evidence of disseminated intravascular coagulation. Alteration in coagulation pathways during pregnancy increases the risk for embolic events. The risk in the immediate postpartum period is particularly high. Venous embolism is an important cause of maternal illness and death (7).
CTA or ultrasonography for deep vein thrombosis may be important for COVID-19–positive pregnant or postpartum patients who have signs or symptoms of possible venous embolism, given their potentially heightened risk. In this patient population, with an already elevated risk for venous embolism, physicians should be aware of the potential for concurrent mild COVID-19 and acute pulmonary embolism.

Dr. Khodamoradi is an internal medicine resident in Shiraz University of Medical Sciences, Shiraz, Iran. Her primary research interests focus on internal medicine, gastroenterology, rheumatology, and cardiology.
While COVID-19 remains a mostly mild illness in healthy people under the age of 60, we have seen enough exceptions to make this a non-trivial disease in the younger individuals as well.