Pulmonary embolism in patient with COVID-19 infection

A 74-year-old woman with an episode of 3 days of shortness of breath, asthenia and low-grade fever.  She was tested for COVID in the second day with negative result. Chest X-rays and a CT-pulmonary angiogram were performed during her hospital admittance.

In the first chest X-ray performed (Figure 1), we can see the characteristic bilateral peripheral infiltrates of this infection, bilateral alveolar pulmonary consolidation in right mid-and lower zones and in the left lower region.

The patient was admitted to the hospital and remained stable, with antiretroviral and steroid treatment. But the D-dimer figures were on the rise, up to 18032 ng/mL (normal: £500 ng/mL), so a CT-pulmonary angiogram was performed to rule out concomitant pulmonary embolism.

In the CT images, we have widespread bilateral ground-glass opacities with a posterior predominance. (Figures 2 and 3)

The suspected pulmonary embolism was demonstrated as well; emboli occupied the left inferior artery as well as branches of the right superior lobar pulmonary arteries. (Figure 4 and 5).

Heparin at anticoagulant dose was administered and the patient remains stable 10 days after admittance, with improvement of the shortness breath and disappearance of the fever.

RT-PCR became positive after five days of symptoms. She was discharged after 15 days of admittance to follow isolation at home.

Late 2019, a new virus which got named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), caused in Wuhan China, multiple cases of severe pneumonia and several deaths. Since then, the virus has become pandemic in most countries, especially Italy and Spain.

The most common clinical features of the disease are fever and respiratory symptoms. The most common laboratory finding is lymphopenia.[1]. However, in almost 10% of cases, generally with older people or with comorbidities, it can evolve into respiratory failure for diffuse alveolar damage, multiorgan failure, shock and death. As the disease is easily spread and numerous people get infected, ICUs face great challenges as the number of new patients can exceed the maximum capacity.

At the moment the mortality rate is estimated to be around 3%. [2]

RT-PCR is typically used to diagnose a COVID-19 infection. Sensitivity ranges from 60% up to 97% in the known literature [3]. In the cases, where the characteristic clinical presentation characteristic and the pandemic scenario we have in Spain, make it a probable case, where imaging can be of assistance.

Imaging can help also in the event of complications.

Chest CT studies can show at early stage (1-5 days) ground-glass opacity and consolidation in the basal and peripheral of bilateral lungs, evolving into crazy paving and consolidation peaking around 9–13 days.

Pulmonary embolism as a complication of the COVID infection is being reported [4]. The mechanism for pulmonary embolism remains unknown and is under study and may be different as to the thrombi originated in the lower extremities. But it can be a cause for additional shortness of breath in these patients that can impair the course of the infection. Other thrombotic complications have been reported such as strokes and visceral infarction.

 Chest CT plays an important role in the diagnosis, especially when RT-PCR is not yet positive, follow-up and complication monitoring of this new type of viral pneumonia.

Written patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.