Chest imagingCase Type
Luis Gregorio Chávez Marroquin, Rocío Aubán Pariente, María Vaño Molina.Patient
65 years, male
A 65-year-old male patient with a past medical history of hypertension and dyslipidemia presented to the emergency department with a 5-day history of cough and fever, associated with dyspnoea in the last 48 hours. Initial laboratory tests showed a normal white cell count, elevated C-reactive protein (118 mg/L, normal range 0-5 mg/L), elevated D-dimer (1,0 mcg/ml, normal range 0-0,5 mcg/ml), elevated interleukin-6 (76,6 pg/ml, normal range < 3,4 pg/ml) and elevated ferritin (1639 ng/ml, normal range 22-322 ng/ml). The day after admission the patient developed acute respiratory distress, was emergently intubated and transferred to the ICU.
Chest X-ray at admission showed a patchy airspace opacities in both basal and central pulmonary areas (Fig 1).
Chest X-ray controls showed no worsening, but D-dimer continued to rise until reaching a peak of 23,4 mcg/L (normal range 0-0,05 mcg/ml) on 18th day of hospitalization without clinical suspicion of deep venous thrombosis in lower limbs. ICU physicians requested a chest CT scan to rule out Pulmonary Embolism (PE).
A chest CT scan with contrast (pulmonary angiogram) was performed on 19th day of hospitalization and showed a filling defect in segmental arteries of both inferior lobes and the beginning of the superior left lobe artery. The filling defect was central and non-occlusive in almost all arteries, and only the anterior segmental artery of the left lower lobe was totally occupied (occlusive emboli) (Fig 2). No cardiac compromise was described.
In the lung window were observed patchy and peripheral areas of ground-glass opacities in pulmonary parenchyma of all pulmonary lobes with a focal consolidative process in the inferior right lobe and a crazy-paving appearance in the middle right lobe associated (Fig 3-5). Findings were compatible with moderate COVID-19 involvement .
The coronavirus disease 2019 (COVID-19) its caused by a new coronavirus named SARS-CoV-2, that belongs to the coronaviruses family, a broad family of RNA viruses that are capable of mutation and recombination, and can lead to a respiratory infection and severe complications, probably due to the hyperinflammatory syndrome [2,3,4]
COVID-19 has been recently associated with an increased risk for venous thromboembolism, probably due to the proinflammatory and hypercoagulable state evidenced by the increase in values in C-reactive protein, D-Dimer, Ferritin and interleukin levels. Most of the current publications relate a value of D-Dimer > 1 mcg/L with increased mortality [4, 5, 6]. In a retrospective study in China find that patients with COVID-19 and PE had a median D-dimer of 11,07 mcg/ml. Therefore, a remarkable increase of D-Dimer values should lead to suspicion of a thrombotic event such as PE. 
Chest CT scan with contrast (pulmonary angiogram) could be useful in patients with COVID-19 and clinical/analytic suspicion of PE. First, it allows to rule out PE, and secondly, it allows to evaluate the pulmonary parenchyma involvement. In 10 patients with COVID-19 and PE described in a retrospective study, the lesions were only found in the small branches of each lobe artery [7, 8].
The patient was treated with hydroxychloroquine and Ritonavir/Lopinavir since admission and required corticosteroids and a single dose of Tocilizumab at the ICU because of clinical worsening. Bemiparin was initiated as a prophylactic measure in the ICU, and after PE was diagnosed, Enoxaparin at full dose was initiated (8000 IU every 12 hours) and the D-Dimer values gradually descended in the following days (last value 4 mcg/mL). The patient recovered and was discharged home 30 days after hospital admission, full-dose Enoxaparin was maintained.
Take-Home Message / Teaching Points
Elevated D-Dimer values in COVID-19 patients has been related to high risk of death and probably a risk of thrombotic events (venous and arterial), despite thromboprophylaxis since up to 31% of ICU patients can develop a thrombotic complication [4,5,6]. However, high values of D-dimer may be due to other conditions as sepsis, acute myocardial infarction, advanced age or immobilization.
Thus, when to consider a D-dimer value remarkable increased remains a reasonable question. In 138 patients with COVID-19 analyzed in Wuhan showed that ICU patients had a median value of D-dimer of 0,4 mcg/L and non-UCI patients had 0,1 mcg/L. Other study made in France about the relationship between D-dimer levels and PE in patients with COVID-19 showed that a D-dimer value >2,6 mcg/mL had a sensitivity of 100% and a specificity of 67% for PE on CT scan. [9,10]
Therefore, suspicion of PE should be considered when D-dimer values abnormally increases in the analytical monitoring above the median values in a patient with COVID-19, and it’s important to rule out it with a chest CT scan with contrast (pulmonary angiogram) because of an accurate diagnosis influence the treatment and probably the clinical outcome. [7,8,10]
Written informed patient consent for publication has been obtained.
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