Thrombosis and Bleeding as Presentation of COVID-19 Infection with Polycythemia Vera. A Case Report

Abstract

Coronavirus disease (COVID-19) has a wide spectrum of clinical manifestations. In this case report, we describe our first case of COVID-19 pneumonia that was complicated by cerebral venous thrombosis and bleeding in a patient with polycythemia vera. Madam A, a 72-year-old lady with polycythemia vera, ischemic stroke, hemorrhoids, diabetes mellitus, hypertension, and dyslipidemia was admitted to the hospital for COVID-19 pneumonia. She was treated with hydroxychloroquine and lopinavir/ ritonavir as per hospital protocol. She continued taking hydroxyurea and aspirin for her treatment of polycythemia vera. Subsequently, she developed rectal bleeding when her platelet count was 1247 × 10 3 /μl, even though she was not on an anticoagulant. Her aspirin was withheld. One week later, she was readmitted to the hospital for cerebral venous thrombosis and her D-dimer was 2.02 μg/ml. She was commenced on a therapeutic dose of low molecular weight heparin. Following that, her D-dimer level showed a decreasing trend and normalized upon her discharge. Patients with polycythemia vera are prone to develop thrombotic and bleeding complications. Management of this group of patients has become more complex with COVID-19 infection. It is crucial for us to decide when to start an anticoagulant especially when there is a history of recent bleeding. We need to balance the risks of further bleeding versus potentially fatal thrombotic events. Studies have shown that D-dimer can be used as a clinical marker to predict thrombotic events in COVID-19 infection. Patients with COVID-19 infection and polycythemia vera will benefit from both pharmacological thromboprophylaxis and close monitoring for bleeding.

Cerebral venous thrombosis and severe acute respiratory syndrome coronavirus‐2 infection: A systematic review and meta‐analysis

“…Overall, 28 reports of CVT in patients with SARS‐CoV‐2 infection were included in the qualitative synthesis (Table 1) [17–38]. Four were retrospective observational studies describing cerebrovascular diseases in a cohort of SARS‐CoV‐2–positive patients [19,22,38,39], two were prospective observational studies with consecutive enrolment [23,36], one was a retrospective multicenter case series [40]; the remaining articles were retrospective case series or case reports.…”

“…Overall, 57 CVT cases were collected from 28 reports (Table 1) [17–44]. Mean age was 53.5 years, with 11 cases presenting CVT at age <50 years and balanced gender distribution (50% female).…”

“…Risk factors for CVT were reported inconsistently. Overall, details of known risk factors for CVT independent of SARS-CoV-2 infection were reported in 11 cases (30.6%): five women [27,28,40] were taking oral contraceptives; one individual had a previous diagnosis of polycythemia vera for which aspirin was taken as primary prevention [17], two individuals had solid tumors (one with breast cancer using hormone therapy and one with B-cell lymphoma [30,31]), one individual was a 3-year old child with concomitant tuberculous meningitis [37] and another individual had concomitant traumatic occipital skull fracture [36]. No patient had preexisting thrombophilia or a history of previous CVT or deep venous thrombosis (Table 1).…”

“…Nine patients were treated with anticonvulsive medication, in one instance as prophylactic treatment (Table 4) [17]. Anticoagulants were administered to 37 patients (95%); one pediatric patient was treated with antiplatelets [37] and one patient received endovascular treatment (mechanical thrombectomy and local thrombolysis) [28].…”

“…Anticoagulants were administered to 37 patients (95%); one pediatric patient was treated with antiplatelets [37] and one patient received endovascular treatment (mechanical thrombectomy and local thrombolysis) [28]. Follow-up imaging was reported in only four cases, at variable time points ranging from 1 to 4 weeks after admission, and showed partial [18,44] or no recanalization [17,26].…”