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SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Corona Virus Disease (COVID-19) main presenting feature is hypoxia which coincidentally is a feature of Pulmonary Embolism (PE) that can be life-threatening if not diagnosed early COVID-19 causes excessive inflammation that can induce expression tissue factors, which is a major coagulation activator1,2 Therefore, PE should also be a consideration for those presenting with COVID-19 with worsening hypoxia CASE PRESENTATION: 79-year-old a man with non-ischemic cardiomyopathy with Ejection Fraction (EF) 45- 50% presented with worsening shortness of breath, dry cough, and bilateral lower limb edema for 2 weeks On presentation, he was afebrile normotensive with tachypnea, tachycardia, and hypoxia On physical examination, he was in respiratory distress with faint bilateral crackles and bilateral lower limb edema Lab Investigations showed elevated Brain Natriuretic Peptide to 1830 pg/ml (normal range 0-100 PG/ml), troponin level to 6 89 ng/ml (normal range 0 00-0 03 ng/ml) and the D-dimer level was >20 00 UG/ml FEU (normal range 0 00-0 40 UG/ml FEU) Viral PCR confirmed COVID-19 No ischemic changes noted in EKG Echocardiography (Echo) revealed EF (Ejection Fraction) at 10-15%, dilated right ventricle with reduced function, and left ventricular thrombus In CT chest with contrast noted to have acute segmental right middle lobe pulmonary arterial embolus He was therapeutically anti-coagulated with enoxaparin He received antibiotics, systemic steroids, and diuresis On day 3 of admission, he had worsening hypoxia and dyspnea while on 100% oxygen therapy The patient opted for no escalation in care with ventilation or resuscitation As he had no clinical improvement, the family agreed on comfort care He died on day 5 of admission DISCUSSION: We described a case of COVID-19 complicated by PE, which is found among 13% of COVID-19 patients in a study done in Netherland1 Studies showed that elevated D-dimer levels can correlate with risk for pulmonary embolism In this case, D-dimer found to be elevated which is consistent with prior cases 3 The patient found to have cardiomyopathy with ejection fraction at 15% during presentation despite prior Echo done about 6 months earlier revealed an EF 45% Evidence of myocardial injury was found in previous articles from China as found in 19 7% of patients (total 416) with evidence of cardiac injury including elevated troponin and reduced ejection fraction It was noted to be independently associated with a higher risk of mortality 4 CONCLUSIONS: Diagnosis of pulmonary embolism in COVID19 patients may represent a diagnostic challenge as hypoxia is arguably the feature of COVID19 that could be explained by a viral lung infection Thus, it is necessary to have a lower index of suspicion and CT chest to be considered in patients with worsening hypoxia so as to evaluate for pulmonary embolism especially among patients with an elevated D- dimer level Reference #1: Klok, F A , Kruip, M J H A , van der Meer, N J M , Arbous, M S , Gommers, D A M P J , Kant, K M , … Endeman, H (2020) Incidence of thrombotic complications in critically ill ICU patients with COVID-19 Thrombosis Research https://doi org/10 1016/j thromres 2020 04 013 Reference #2: Goeijenbier, M , van Wissen, M , van de Weg, C , Jong, E , Gerdes, V E A , Meijers, J C M , … van Gorp, E C M (2012) Review: Viral infections and mechanisms of thrombosis and bleeding Journal of Medical Virology, 84(10), 1680–1696 https://doi org/10 1002/jmv 23354 Reference #3: J Chen, X Wang, S Zhang, et al , Findings of acute pulmonary embolism in COVID-19 patients, The Lancet Infectious Diseases (3/1/2020), https://doi org/10 2139/ ssrn 3548771 (preprint Available at SSRN), https://ssrn com/abstract=3548771 DISCLOSURES: No relevant relationships by Musaab Alfaki, source=Web Response No relevant relationships by Nia Flemming, source=Web Resp nse No relevant relationships by Janeen Grant, source=Web Response No relevant relationships by Fausto Lisung, source=Web Response No relevant relationships by Rani Sittol, source=Web Response
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