INTRODUCTION: 14-53% of coronavirus disease 2019 (COVID-19) patients have elevated alanine aminotransferase(ALT) and aspartate aminotransferase (AST).[1] We present a case of COVID-19 who developed severe metabolic acidosis from acute liver failure.
The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in more than 300,000 deaths worldwide as of June 1, 2020. Risk factors associated with mortality have been described in prior studies, however, data is still limited in many clinical settings. The purpose of this study is to identify clinical predictors of mortality in hospitalized adult patients with COVID-19 in an urban hospital in Baltimore. METHODS: Retrospective, single-center analysis of hospitalized adult patients (age >18) with confirmed COVID-19 on Nucleic Acid Amplification testing who had been discharged or had died by May 15, 2020. Demographics, comorbidities, travel history, Rothman Index (RI), admission vital signs, laboratory, and imaging were compared between survivors and non-survivors. Unpaired t-tests and chi-square tests were utilized to determine unadjusted associations between clinical indicators and mortality. Multivariate logistic regression models were used to determine associations simultaneously adjusting for multiple clinical indicators.
According to the 2016 CHEST guidelines, thrombolytic therapy is only approved for patients with pulmonary embolism (PE) who deteriorate or become hypotensive on anticoagulation alone [1]. Although the use of thrombolysis with tissue plasminogen activator (tPA) has been shown in several studies to have good outcome, there is no formal recommendation on its use outside of these indications. The BOVA scoring system has been used to determine adverse outcomes in normotensive patients with submassive PE where the optimal management is unclear [2]. We present 2 cases of submassive PE where the BOVA score helped guide management. CASE PRESENTATION: Case 1:70-year-old female. Initial blood pressure (BP): 104/76 mmHg, heart rate (HR):140/min, O2 saturation: 97% on room air. Systolic BP briefly dropped to the 90s but stabilized after fluid resuscitation. Labs: troponin:11, Pro-BNP:4000. EKG: sinus tachycardia with right bundle branch block. Chest computed tomography (CT): bilateral PE. Point of care ultrasound (POCUS): massive right ventricular (RV) dilatation with McConnell's sign. BOVA score: 7, stage 3 (high risk). Treated with heparin drip and half dose tPA (50 mg IV). A formal echocardiogram later showed improvement in RV size from initial POCUS. She remained hemodynamically stable. Discharged after 48 hours. Case 2: 77-year-old-female. Initial BP:140/92 mmHg, HR:108/min, O2 Saturation: 99% on room air. Labs: troponin:1.16 and Pro-BNP:1051. EKG: sinus tachycardia. Chest CT : bilateral distal PE. POCUS: enlarged RV with septal flattening. BOVA score: 4, stage 2 (intermediate risk). Treated with heparin drip without IV tPA. She remained hemodynamically stable. Discharged after 48 hours.
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