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
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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 1Patient 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.
CCSudden-onset dyspnea × 1 dayProgressively worsening dyspnea × 5 days
History of presenting illnessCC associated with right upper chest pain radiating to the right arm and back preceded by cold symptoms 2 weeks priorCC preceded by myalgia, dry cough, and low-grade fever (T-max 37.7 °C) 4 weeks prior
Pertinent negativesFever, chills, cough, sick contacts, palpitations, diarrhea, immobilization, smoking, use of testosterone therapyChills, headache, sick contacts, chest pain, palpitations, paroxysmal nocturnal dyspnea, wheezing, lower extremity edema/tenderness, diarrhea, immobilization, smoking, use of testosterone therapy
Pertinent historiesNegative for clotting disorders, cancer, or family history of clotting disordersHypertension, prostate cancer (status post prostatectomy: in remission since 2003). Negative for clotting disorders in self or family
Physical examination on admissionTachycardia (HR 122 beats/min), tachypnea (RR 40/min), decreased breath sounds at bilateral bases, mild respiratory distressTachypnea (RR 23/min), decreased breath sounds bilaterally
Laboratory data on admission
While blood cell (4.1 - 11.0 × 103/µL)14.36.5
Lymphocytes (25.0-40.0%)1132
Absolute neutrophils (2.1 - 8.4 × 103/µL)11.53.2
Absolute lymphocytes (1.0 - 4.4 × 103/µL)1.62
HGB (13.5 - 17.5 g/dL)14.316.1
PLT (150 - 400 × 103/µL)267382
Blood urea nitrogen (8 - 24 mg/dL)1217
Creatinine (0.55 - 1.30 mg/dL)0.761.03
Glomerular filtration rate (> 60 mL/min/1.73 m2)> 60> 60
Alanine aminotransferase (12 - 78 U/L)3649
Aspartate aminotransferase (13 - 41 U/L)2156
Albumin (3.5 - 4.8 g/dL)3.72.8
Alkaline phosphatase (45 - 117 U/L)11764
Lactic acid1.9-
Brain natriuretic peptide (< 100 pg/mL)-34
Troponin (ng/mL)< 0.01< 0.01
C-reactive protein (< 3 mg/L)82.495.2
Ferritin (12 - 300 ng/mL)365.1640.9
Procalcitonin (0.10 - 0.49 ng/mL)< 0.050.17
Prothrombin time (11 - 13.5 s)9.811
International normalized ratio (< 1.1)0.91
Partial thromboplastin time (60 - 70 s)26< 21
D-dimer (< 250 ng/mL)1,72016,610
Lactate dehydrogenase (140 - 280 U/L)290464
PSA level (0 - 0.40 ng/mL)-< 0.01
COVID-19 RT-PCRPositivePositive
Blood culturesNo growth of pathogenic bacteriaNo growth of pathogenic bacteria
Chest X-rayLow lung volumes with patchy opacities in the medial left lung base and right upper lobe suggestive of atelectasis or pneumoniaFocal infiltrates in bilateral upper lobes and right lower lobe indicative of infection. No pulmonary edema.
CT pulmonary angiogramAcute 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 extremitiesNegative for deep vein thrombosisNegative for deep vein thrombosis
TreatmentHydroxychloroquine, ceftriaxone, azithromycin, IV heparin (day 1), subcutaneous LMWH (day 2 onwards)Ceftriaxone, azithromycin, IV heparin (day 1), subcutaneous LMWH (day 2 onwards)
DischargePendingNovel oral anticoagulant
Follow-upPendingHypercoagulable workup pending