J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

Volume 11, Number 6, June 2020, pages 174-177

Pulmonary Embolism in COVID-19 and the Unanswered Questions

**Table 1.** Pertinent Patient Characteristics, Histories, Laboratory Findings, and Imaging Results
	Patient 1	Patient 2
CC: chief complaint; HR: heart rate; RR: respiratory rate; HGB: hemoglobin; PLT: platelet; PSA: prostate-specific antigen; COVID-19: coronavirus disease 2019; RT-PCR: reverse-transcriptase polymerase chain reaction; CT: computerized tomography; IV: intravenous; LMWH: low-molecular-weight heparin.
Age	43	64
Gender	Male	Male
CC	Sudden-onset dyspnea × 1 day	Progressively worsening dyspnea × 5 days
History of presenting illness	CC associated with right upper chest pain radiating to the right arm and back preceded by cold symptoms 2 weeks prior	CC preceded by myalgia, dry cough, and low-grade fever (T-max 37.7 °C) 4 weeks prior
Pertinent negatives	Fever, chills, cough, sick contacts, palpitations, diarrhea, immobilization, smoking, use of testosterone therapy	Chills, headache, sick contacts, chest pain, palpitations, paroxysmal nocturnal dyspnea, wheezing, lower extremity edema/tenderness, diarrhea, immobilization, smoking, use of testosterone therapy
Pertinent histories	Negative for clotting disorders, cancer, or family history of clotting disorders	Hypertension, prostate cancer (status post prostatectomy: in remission since 2003). Negative for clotting disorders in self or family
Physical examination on admission	Tachycardia (HR 122 beats/min), tachypnea (RR 40/min), decreased breath sounds at bilateral bases, mild respiratory distress	Tachypnea (RR 23/min), decreased breath sounds bilaterally
Laboratory data on admission
While blood cell (4.1 - 11.0 × 10³/µL)	14.3	6.5
Lymphocytes (25.0-40.0%)	11	32
Absolute neutrophils (2.1 - 8.4 × 10³/µL)	11.5	3.2
Absolute lymphocytes (1.0 - 4.4 × 10³/µL)	1.6	2
HGB (13.5 - 17.5 g/dL)	14.3	16.1
PLT (150 - 400 × 10³/µL)	267	382
Blood urea nitrogen (8 - 24 mg/dL)	12	17
Creatinine (0.55 - 1.30 mg/dL)	0.76	1.03
Glomerular filtration rate (> 60 mL/min/1.73 m²)	> 60	> 60
Alanine aminotransferase (12 - 78 U/L)	36	49
Aspartate aminotransferase (13 - 41 U/L)	21	56
Albumin (3.5 - 4.8 g/dL)	3.7	2.8
Alkaline phosphatase (45 - 117 U/L)	117	64
Lactic acid	1.9	-
Brain natriuretic peptide (< 100 pg/mL)	-	34
Troponin (ng/mL)	< 0.01	< 0.01
C-reactive protein (< 3 mg/L)	82.4	95.2
Ferritin (12 - 300 ng/mL)	365.1	640.9
Procalcitonin (0.10 - 0.49 ng/mL)	< 0.05	0.17
Prothrombin time (11 - 13.5 s)	9.8	11
International normalized ratio (< 1.1)	0.9	1
Partial thromboplastin time (60 - 70 s)	26	< 21
D-dimer (< 250 ng/mL)	1,720	16,610
Lactate dehydrogenase (140 - 280 U/L)	290	464
PSA level (0 - 0.40 ng/mL)	-	< 0.01
COVID-19 RT-PCR	Positive	Positive
Blood cultures	No growth of pathogenic bacteria	No growth of pathogenic bacteria
Imaging
Chest X-ray	Low lung volumes with patchy opacities in the medial left lung base and right upper lobe suggestive of atelectasis or pneumonia	Focal infiltrates in bilateral upper lobes and right lower lobe indicative of infection. No pulmonary edema.
CT pulmonary angiogram	Acute bilateral PE with predominant clot burden in the right lower lung. Bibasilar consolidation greater in posterior right lower lobe, suggestive of developing pulmonary infection.	Mild to moderate occlusive/partially occlusive pulmonary emboli in the right lower lobe and left lingula. Moderate subpleural/peribronchial ground-glass infiltrates in bilateral lungs with mild interlobular septal thickening. Mild mediastinal lymphadenopathy.
Venous Doppler bilateral lower extremities	Negative for deep vein thrombosis	Negative for deep vein thrombosis
Treatment	Hydroxychloroquine, ceftriaxone, azithromycin, IV heparin (day 1), subcutaneous LMWH (day 2 onwards)	Ceftriaxone, azithromycin, IV heparin (day 1), subcutaneous LMWH (day 2 onwards)
Discharge	Pending	Novel oral anticoagulant
Follow-up	Pending	Hypercoagulable workup pending

Table 1. Pertinent Patient Characteristics, Histories, Laboratory Findings, and Imaging Results

Patient 1

Patient 2

CC: chief complaint; HR: heart rate; RR: respiratory rate; HGB: hemoglobin; PLT: platelet; PSA: prostate-specific antigen; COVID-19: coronavirus disease 2019; RT-PCR: reverse-transcriptase polymerase chain reaction; CT: computerized tomography; IV: intravenous; LMWH: low-molecular-weight heparin.

Age

Gender

Male

Sudden-onset dyspnea × 1 day

Progressively worsening dyspnea × 5 days

History of presenting illness

CC associated with right upper chest pain radiating to the right arm and back preceded by cold symptoms 2 weeks prior

CC preceded by myalgia, dry cough, and low-grade fever (T-max 37.7 °C) 4 weeks prior

Pertinent negatives

Fever, chills, cough, sick contacts, palpitations, diarrhea, immobilization, smoking, use of testosterone therapy

Chills, headache, sick contacts, chest pain, palpitations, paroxysmal nocturnal dyspnea, wheezing, lower extremity edema/tenderness, diarrhea, immobilization, smoking, use of testosterone therapy

Pertinent histories

Negative for clotting disorders, cancer, or family history of clotting disorders

Hypertension, prostate cancer (status post prostatectomy: in remission since 2003). Negative for clotting disorders in self or family

Physical examination on admission

Tachycardia (HR 122 beats/min), tachypnea (RR 40/min), decreased breath sounds at bilateral bases, mild respiratory distress

Tachypnea (RR 23/min), decreased breath sounds bilaterally

Laboratory data on admission

While blood cell (4.1 - 11.0 × 10³/µL)

14.3

6.5

Lymphocytes (25.0-40.0%)

Absolute neutrophils (2.1 - 8.4 × 10³/µL)

11.5

3.2

Absolute lymphocytes (1.0 - 4.4 × 10³/µL)

1.6

HGB (13.5 - 17.5 g/dL)

14.3

16.1

PLT (150 - 400 × 10³/µL)

267

382

Blood urea nitrogen (8 - 24 mg/dL)

Creatinine (0.55 - 1.30 mg/dL)

0.76

1.03

Glomerular filtration rate (> 60 mL/min/1.73 m²)

> 60

Alanine aminotransferase (12 - 78 U/L)

Aspartate aminotransferase (13 - 41 U/L)

Albumin (3.5 - 4.8 g/dL)

3.7

2.8

Alkaline phosphatase (45 - 117 U/L)

117

Lactic acid

1.9

Brain natriuretic peptide (< 100 pg/mL)

Troponin (ng/mL)

< 0.01

C-reactive protein (< 3 mg/L)

82.4

95.2

Ferritin (12 - 300 ng/mL)

365.1

640.9

Procalcitonin (0.10 - 0.49 ng/mL)

< 0.05

0.17

Prothrombin time (11 - 13.5 s)

9.8

International normalized ratio (< 1.1)

0.9

Partial thromboplastin time (60 - 70 s)

< 21

D-dimer (< 250 ng/mL)

1,720

16,610

Lactate dehydrogenase (140 - 280 U/L)

290

464

PSA level (0 - 0.40 ng/mL)

< 0.01

COVID-19 RT-PCR

Positive

Blood cultures

No growth of pathogenic bacteria

Imaging

Chest X-ray

Low lung volumes with patchy opacities in the medial left lung base and right upper lobe suggestive of atelectasis or pneumonia

Focal infiltrates in bilateral upper lobes and right lower lobe indicative of infection. No pulmonary edema.

CT pulmonary angiogram

Acute bilateral PE with predominant clot burden in the right lower lung. Bibasilar consolidation greater in posterior right lower lobe, suggestive of developing pulmonary infection.

Mild to moderate occlusive/partially occlusive pulmonary emboli in the right lower lobe and left lingula. Moderate subpleural/peribronchial ground-glass infiltrates in bilateral lungs with mild interlobular septal thickening. Mild mediastinal lymphadenopathy.

Venous Doppler bilateral lower extremities

Negative for deep vein thrombosis

Treatment

Hydroxychloroquine, ceftriaxone, azithromycin, IV heparin (day 1), subcutaneous LMWH (day 2 onwards)

Ceftriaxone, azithromycin, IV heparin (day 1), subcutaneous LMWH (day 2 onwards)

Discharge

Pending

Novel oral anticoagulant

Follow-up

Pending

Hypercoagulable workup pending