INTRODUCTION: Coagulopathy in COVID-19 has been associated with increased mortality and can result in deep venous thrombosis/pulmonary embolism, ischemic stroke and disseminated intravascular coagulation (DIC). Herein we present a case of a patient with severe COVID-19 complicated by ischemic stroke despite therapeutic enoxaparin. CASE PRESENTATION: Our patient was a 48 year-old-male with past medical history of morbid obesity, hypertension and hyperlipidemia who presented with one week history of progressive cough and dyspnea. He was hypoxemic requiring nonrebreather oxygen at 15 liters/minute to maintain saturation's >92%. Blood work was remarkable for an elevated c-reactive protein to 9.86 mg/dL and and high sensitivity d-dimer to 732 ng/dL. Chest x-ray revealed extensive bilateral airspace opacities (Image 1). The patient was admitted to our intensive care unit and transitioned to high-flow nasal cannula oxygen. Initial arterial blood gas revealed PaO2/FiO2 of 71. He was started on deep venous thrombosis prophylaxis with enoxaparin 40mg every 12 hours and continued on his home aspirin, 81mg daily. On hospital day (HD) 1 patients COVID-19 PCR returned positive. He received 400mg of intravenous tocilizumab and a unit of convalescent plasma. Early HD 3 the patients d-dimer trended up to >1000 ng/mg and he was transitioned to therapeutic enoxaparin at a dose of 1mg/kg twice daily. His platelet count remained stable and within normal limits. Late HD 4 he was found to have paralysis of his left upper and lower extremity. STAT imaging revealed large right middle cerebral artery infarction with mid-line shift (Image 2). He was not a candidate for systemic thrombolytic therapy or mechanical thrombectomy. HD 6 patient required right hemicraniectomy for worsening cerebral vasogenic edema. Brain biopsy revealed acute cerebritis characterized by marked perivascular and parenchymal neutrophilic infiltrates and associated acute hypoxic neurons, marked edema and small vessel thrombi (Image 3). Unfortunately the patient's condition ultimately deteriorated and he expired on HD 13.
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