Thrombus in Transit and Impending Pulmonary Embolism Detected on POCUS in a Patient with COVID-19 Pneumonia

Abstract

Coronavirus disease 2019 (COVID-19) is a pandemic that started in China in December 2019 and carries a high risk of morbidity and mortality. To-date (4-22-2020) it affected over 2.6 million people and resulted in nearly 200,000 death worldwide mainly due to severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). Among the major underlying pathophysiologic mechanisms in COVID 19 is hypercoagulability, leading to increased risk for deep vein thrombosis and pulmonary embolism that contribute to increased morbidity and mortality. In this report, we present the case of a 55-year-old man who presented with COVID-19 pneumonia, and was found to have a thrombus in transit by routine point of care ultrasound (POCUS). While computer tomography (CT) angiography is the test of choice, the utilization of point of care ultrasound (POCUS) has gained traction as an adjunctive means of surveillance for the development of VTE in patients with COVID-19. In this report, we discuss the clinical utility of POCUS in diagnosing thrombus in transit in COVID 19 populations.

Prevalence, Outcome, and Optimal Management of Free-Floating Right Heart Thrombi in the Context of Pulmonary Embolism, a Systematic Review and Meta-Analysis

“…27 Interestingly, COVID-19 infection was reported as the main risk factor in 3% of cases in the current review. 20,[28][29][30][31][32] Recent evidence suggests that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) interacts with different cellular molecules including enzymes, endothelial cells, platelets, neutrophil extracellular traps, thrombin, and histones, resulting in endothelial damage and formation of microthrombi. 33 In agreement with the prior evidence, 34 we found that combined CVS diseases (including CAD disease, valvular disease, atrial fibrillation, and patent foramen ovale "PFO") to be the most commonly reported comorbidity.…”

“…45 In two cases included in the current review, the initial diagnosis of FFRHT was made by electrocardiogram-gated, contrast-enhanced, multi-slice computed tomography, and point of care ultrasonography. 19,20 The role of point of care ultrasonography as a fast and easy tool for the detection of FFRHT in patients with PE warrants further evaluation in future studies. RV strain on TTE or ECG is one of the risk stratification markers in patients with PE.…”

“…19 In another case, the FFRHT was diagnosed via a point of care ultrasonography. 20 Associated PE was diagnosed by CTPA, V/Q scan, or magnetic resonance imaging (MRI) of the thorax in 60.5%, 37.3%, and 2.2% of cases, respectively. RV strain pattern was reported on electrocardiography (ECG) in 19.4% of cases (Table 1).…”

Point‐of‐care ultrasound in the COVID‐19 era: A scoping review

“…The ASE suggests that vascular POCUS, specifically a DVT study can be done to monitor critically ill COVID‐19 patients 79 . Experts in Italy and the United States have also called for POCUS screening and serial monitoring for DVT in COVID‐19 patients 78,80 . A 2‐point DVT scan and a 2‐region technique have been recommended for such purposes 58 .…”

“…79 Experts in Italy and the United States have also called for POCUS screening and serial monitoring for DVT in COVID-19 patients. 78,80 A 2-point DVT scan and a 2-region technique have been recommended for such purposes. 58 A protocol for observing spontaneous echo contrast has also been developed for COVID-19 patients in the ICU to monitor for venous thromboembolism.…”