SESSION TITLE: Medical Student/Resident Critical Care Posters
SESSION TYPE: Med Student/Res Case Rep Postr
PRESENTED ON: October 18-21, 2020
INTRODUCTION: Stroke like lesions has been documented in COVID-19 patients. Although the exact stroke-incidence is unknown, it was reported to be around 5 % in a hospitalized cohort in Wuhan and 1.1 % in a study in New York City.
CASE PRESENTATION: A 73-year-old male with a past medical history of hypertension and hyperlipidemia presents to ER with fever, cough, myalgia, increasing shortness of breath, and confusion for one day. His daughter is known COVID-19 positive. The patient was noted to be febrile, tachypneic, and hypoxic to 90% at room air. Chest X-ray showed bilateral infiltrates and the COVID-19 test was positive. The patient was immediately intubated due to his significant acute respiratory distress. Inflammatory markers were significantly elevated: Troponin T: 5.86, Lactate dehydrogenase: 542, CRP: 350 mg/l, Ferritin: 1878, D-dimer: >20, fibrinogen: 1094, Total Creatinine kinase: 2260 and creatinine: 5.7. His course was complicated by septic shock requiring three vasopressors; acute kidney injury requiring hemodialysis; Enterococcus Faecalis bacteremia treated with Ampicillin, and Klebsiella pneumonia sensitive to ceftriaxone. EKGs showed new onset of atrial fibrillation without ST changes. Echocardiogram showed normal ejection fraction without wall motion abnormalities. His significant troponin elevation was likely due to myonecrosis related to COVID-19 infection and he was started on heparin drip. The patient respiratory status continued to improve however he remained obtunded. Head CT showed acute right frontal hemorrhage and focal hyperdense foci in the left frontal lobe and basal ganglia. Brain MRI showed a 2.8 x 2.4 cm lesion situated in the right sub-frontal region with appearances of abscess versus necrotic tissue and extensive bilateral scattered deep white matter infarcts. Neurosurgery didn’t recommend any intervention due to poor prognosis. After 27 days of intubation, the family requested comfort measures, and the patient was terminally extubated.
DISCUSSION: ‘Sepsis-induced coagulopathy’ is one of the hallmarks of severe COVID-19, usually manifests as a high D-dimer and elevated fibrinogen. It induces a systemic inflammatory response with endothelial dysfunction and microthrombosis predisposing to acute strokes. The risk of developing a cerebrovascular disease is multifactorial and includes cardiovascular risk factors, old age, and severe COVID-19 disease manifestations with sings of hypercoagulability. In this case, the stroke like-lesions could be related to septic emboli with the conversation to hemorrhage due to heparin use in the setting of severe COVID-19 infection.
CONCLUSIONS: Ischemic and hemorrhagic stroke has been reported as a complication of severe COVID-19 infection. The definite mechanism is unknown, but these findings can indicate poor prognosis with potential neurological sequelae and increased mortality.
Reference #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202903/
Reference #2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236667/
Reference #3: https://jamanetwork.com/journals/jamaneurology/fullarticle/2766766
DISCLOSURES: No relevant relationships by Karim Anis, source=Web Response
No relevant relationships by Anastasia Maltseva, source=Web Response
No relevant relationships by Lady Sanchez Fernandez, source=Web Response