Saddle Up! A Case of Covid-19-Associated Saddle Pulmonary Embolism

Abstract

The novel COVID-19 virus has been found to be associated in a wide variety of complications most commonly involving the lungs namely by pneumonia with resultant ARDS. We present a case of COVID19 related extensive pulmonary emboli. CASE PRESENTATION: A previously well 47-year-old male presented with an 8 day history of fever, cough & dyspnea. He tested positive for COVID-19 as an outpatient. Four days later, he developed left sided pleuritic chest pain & presented to hospital. On examination, blood pressure was 119/89mmHg, HR 124beats/min & RR 44breaths/min. Despite this, he was saturating 93% on room air. On examination, he had diminished breath sounds and faint crackles bilaterally. Significant laboratory investigations revealed, leucocytosis of 18 (4.00-11.00 K/ul), troponin of 3.13 (0.00-0.03ng/ml), C-reactive protein was 236 (<10mg/l) , Ddimer was >20 UG/ml FEU (0.00-0.04 ug/ml) and BNP of < 5 (0-100pg/ml). Electrocardiogram revealed sinus tachycardia with no ST segment changes. Plain chest radiograph had subsegmental airspace disease in the left lower lobe. CT pulmonary angiography revealed a saddle pulmonary embolus with filling defects throughout right upper middle and lower lobe and left upper and lower lobe pulmonary arteries, and evidence of right heart strain. There were airspace opacities in the left and right lungs. A transthoracic echocardiogram study confirmed right heart strain. He underwent emergent catheter directed thrombolysis and was placed on heparin infusion. Two days later, an IVC filter was placed. He was discharged on day 7 with a six month course apixaban. He received five days of hydroxychloroquine, thiamine, vitamin C and zinc. He was also given 5 days of ceftriaxone. At 2 month follow up, he continues to do well and no longer has any respiratory symptoms or further hypoxia