A Case of COVID-19 Infection With Delayed Thromboembolic Complication on Warfarin

Abstract

Novel coronavirus disease 2019 (COVID-19) pandemic has posed an unprecedented threat to humanity with more than eight million infections and 450,000 deaths reported worldwide so far. The spectrum of the disease varies from mild asymptomatic infection to severe disease with rapid progression to acute respiratory distress syndrome and multiorgan failure. It is associated with a prothrombotic state and hence there is a risk of thromboembolic complications in critically ill patients, even after recovery. However, the duration of prothrombotic risk after recovery is yet to be determined. We present the case of a 78-year-old man with a history of atrial fibrillation on warfarin who had been recently discharged to a nursing home after recovering from COVID-19 pneumonia and presented to the emergency department a month later with worsening shortness of breath and cough. He was found to have worsening respiratory failure with multiple segmental pulmonary emboli, despite being on warfarin, and supratherapeutic international normalized ratio (INR). He required mechanical ventilation and was started on steroids and therapeutic enoxaparin anticoagulation. This case highlights the risk of delayed thromboembolic complications in patients with COVID-19 infection and the need to identify the subgroup of patients with a higher risk of thromboembolism, such as discharges to nursing homes and those in need of oxygen requirement; and those with underlying comorbid conditions that may require anticoagulation for a longer duration. The role of heparin is being increasingly investigated in patients with COVID-19 infection; however, the role of other anticoagulants such as warfarin is yet to be defined.

Systemic inflammation in COVID‐19 patients may induce various types of venous and arterial thrombosis: A systematic review

“…9 [27, 28, 31, 32, 35, 45, 48, 13, 60] PE 21[15,17,23,24,25,27,28,30,32,33,35,36,37,40,45,46,48,50,13,53, 56] Strokes 10 [19, 20, 27, 29, 35, 46, 51, 55, 57, 58] Abbreviations: CRAO, Central Retinal Artery Occlusion;DVT, Deep Vein Thrombosis; PE, Pulmonary Embolism; PVT, Portal Vein Thrombosis. T A B L E 2 Types of COVID-19associated thrombosis reported in the 48 included case reports/series…”

Delayed manifestation of extensive COVID-19-associated coagulopathy in high-risk patient

“…Development of coagulopathy while on anticoagulation secondary to COVID-19 has been previously described as well. 18 Most importantly in respect to her malignancy, PET/CT scan showed complete response with no active hypermetabolic disease. These factors suggest that there was a secondary mechanism at play with hyperinflammatory state leading to extensive coagulopathy due to COVID-19 infection itself.…”

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review

“…Considering the topics addressed by the research question, 61% of papers (1 cross-sectional 25 , 1 case-control study 26 , 2 historical cohort studies 30,31 , and 18 case reports/series [35][36][37][38][39][40][41][42][43][44]46,48,[50][51][52][53][54]56 ) reported epidemiological data on the clinical presentation of COVID-19 infection, 1 cohort study 23 ,…”

“…One case control study reports that COVID-19 patients who are still dyspnoic one month after remission from fever may exhibit extended hypoperfused areas of lung parenchyma, despite the absence of residual pulmonary fibrous stripes 28 , whereas one case report describes a patient developing delayed lung thromboembolic complications 41 .…”