SESSION TITLE: Medical Students/Residents' COVID-19
SESSION TYPE: Med Student/Res Case Report
PRESENTED ON: October 18-21, 2020
INTRODUCTION: Coagulopathy in COVID-19 has been associated with increased mortality and can result in deep venous thrombosis/pulmonary embolism, ischemic stroke and disseminated intravascular coagulation (DIC). Herein we present a case of a patient with severe COVID-19 complicated by ischemic stroke despite therapeutic enoxaparin.
CASE PRESENTATION: Our patient was a 48 year-old-male with past medical history of morbid obesity, hypertension and hyperlipidemia who presented with one week history of progressive cough and dyspnea. He was hypoxemic requiring non-rebreather oxygen at 15 liters/minute to maintain saturation's >92%. Blood work was remarkable for an elevated c-reactive protein to 9.86 mg/dL and and high sensitivity d-dimer to 732 ng/dL. Chest x-ray revealed extensive bilateral airspace opacities (Image 1). The patient was admitted to our intensive care unit and transitioned to high-flow nasal cannula oxygen. Initial arterial blood gas revealed PaO2/FiO2 of 71. He was started on deep venous thrombosis prophylaxis with enoxaparin 40mg every 12 hours and continued on his home aspirin, 81mg daily. On hospital day (HD) 1 patients COVID-19 PCR returned positive. He received 400mg of intravenous tocilizumab and a unit of convalescent plasma. Early HD 3 the patients d-dimer trended up to >1000 ng/mg and he was transitioned to therapeutic enoxaparin at a dose of 1mg/kg twice daily. His platelet count remained stable and within normal limits. Late HD 4 he was found to have paralysis of his left upper and lower extremity. STAT imaging revealed large right middle cerebral artery infarction with mid-line shift (Image 2). He was not a candidate for systemic thrombolytic therapy or mechanical thrombectomy. HD 6 patient required right hemicraniectomy for worsening cerebral vasogenic edema. Brain biopsy revealed acute cerebritis characterized by marked perivascular and parenchymal neutrophilic infiltrates and associated acute hypoxic neurons, marked edema and small vessel thrombi (Image 3). Unfortunately the patient’s condition ultimately deteriorated and he expired on HD 13.
DISCUSSION: The case presented is as striking as it is tragic. Despite our patient’s home aspirin dose and therapeutic enoxaparin there was interval development of a devastating cerebral vascular event. The initiation of prophylactic anti-coagulation in patients with COVID-19 is controversial and not currently recommended by the International Society of Thrombosis and Hemostasis. One recent study demonstrated significantly increased inpatient median survival time without a significant change in inpatient mortality in patients with COVID-19 treated with prophylactic anti-coagulation.
CONCLUSIONS: Coagulopathy in COVID-19 predisposes patients to potentially devastating thrombotic events. Further studies will need to be conducted to determine an ideal anti-coagulation strategy to minimize risk of these events.
Reference #1: Tang, Ning, Dengju Li, Xiong Wang, and Ziyong Sun. 2020. “Abnormal Coagulation Parameters Are Associated with Poor Prognosis in Patients with Novel Coronavirus Pneumonia.” Journal of Thrombosis and Haemostasis: JTH 18 (4): 844–47.
Reference #2: Thachil, Jecko, Ning Tang, Satoshi Gando, Anna Falanga, Marco Cattaneo, Marcel Levi, Cary Clark, and Toshiaki Iba. 2020. “ISTH Interim Guidance on Recognition and Management of Coagulopathy in COVID-19.” Journal of Thrombosis and Haemostasis: JTH 18 (5): 1023–26.3.
Reference #3: Paranjpe, Ishan, Valentin Fuster, Anuradha Lala, Adam Russak, Benjamin S. Glicksberg, Matthew A. Levin, Alexander W. Charney, et al. 2020. “Association of Treatment Dose Anticoagulation with In-Hospital Survival Among Hospitalized Patients with COVID-19.” Journal of the American College of Cardiology, May. https://doi.org/10.1016/j.jacc.2020.05.001.
DISCLOSURES: No relevant relationships by Daniel Condit, source=Web Response
No relevant relationships by Rudra Ramanathan, source=Web Response
No relevant relationships by M. Camila Trejo-Paredes, source=Web Response
Consultant relationship with Boston Scientific Please note: $1001 - $5000 Added 06/01/2020 by Patrick Troy, source=Web Response, value=Consulting fee
Advisory Committee Member relationship with Boston Scientific Please note: $1001 - $5000 Added 06/01/2020 by Patrick Troy, source=Web Response, value=Consulting fee