Dear Editor,
We have read the case presentation of Shi et al. (1) with great interest. They report the clinical and radiological features of a 2019 novel coronavirus (COVID-19) patient presenting with hemoptysis. Serial computed tomography studies revealed the evolution of pulmonary involvement, and microbiological studies confirmed the diagnosis for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, the exact cause and mechanism of hemoptysis in the patient remain to be explained. Hemoptysis is not a typical symptom of COVID-19. Large studies and case-series of COVID-19 have either not reported hemoptysis or have reported very low rates of 0.9–5% (2,3,4).
SARS-CoV-2 is known to cause a proinflammatory and hypercoagulable state with elevated levels of lactate dehydrogenase, D-dimer, C-reactive protein, ferritin, and interleukins (5). Data on thromboembolic complications of the disease are appearing, and there are increasing reports describing thromboembolic events complicating the COVID-19 disease (6). A study from the Netherlands investigated the high incidence of thrombotic complications among 184 COVID-19 patients in the intensive care unit (7). All patients received at least standard doses thromboprophylaxis and the cumulative incidence of the thrombotic complications was reported as 31%, with pulmonary embolism being the most frequent (n = 25, 81%).
While hemoptysis is a very rare presentation in COVID-19 patients, its incidence gets relatively higher reaching up to 13% in patients with pulmonary emboli (8). A very recent article reported a patient with SARS-CoV-2 presenting with hemoptysis (9). In addition to the findings of peripheral ground-glass opacities consistent with COVID-19 pneumonia, a computerized tomography angiography of the chest revealed bilateral segmental pulmonary emboli and an additional area of consolidation in the right lower lobe concerning for infarct.
COVID-19 patient may develop hemoptysis with or without pulmonary emboli; however the former is more likely. Moreover, attempts for delineation of mechanisms underlying this complication in COVID-19 can contribute to a better understanding. Therefore, we postulate that pulmonary emboli should be initially ruled out in all COVID-19 patients presenting with hemoptysis.
References
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