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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 3  |  Page : 174-176

Unexplained pulmonary thrombosis as a sole presentation of COVID-19: A case report


1 Department of Medicine, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
2 Department of Radiodiagnosis, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
3 Department of Medicine, Lagos University Teaching Hospital, Idi-Araba; Department of Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria

Date of Submission05-Sep-2020
Date of Acceptance09-Oct-2020
Date of Web Publication23-Aug-2021

Correspondence Address:
Dr. Obianuju B Ozoh
Department of Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_70_20

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  Abstract 


Recent reports have shown that thrombotic complications occur rather frequently among patients who have the novel coronavirus disease 2019 (COVID-19). Clinical presentation of pulmonary thrombosis is usually in association with moderate to severe symptoms of COVID-19 and manifests with worsening symptoms and features of atypical pneumonia on imaging. We report an unusual case of extensive pulmonary thrombosis in a young otherwise healthy adult without any typical COVID-19 symptom nor features of atypical pneumonia on imaging.

Keywords: COVID 19, Nigeria, pulmonary thrombosis


How to cite this article:
Ekete OA, Ogundare AS, Ifediora NC, Ozoh OB. Unexplained pulmonary thrombosis as a sole presentation of COVID-19: A case report. J Clin Sci 2021;18:174-6

How to cite this URL:
Ekete OA, Ogundare AS, Ifediora NC, Ozoh OB. Unexplained pulmonary thrombosis as a sole presentation of COVID-19: A case report. J Clin Sci [serial online] 2021 [cited 2021 Dec 8];18:174-6. Available from: https://www.jcsjournal.org/text.asp?2021/18/3/174/324405




  Introduction Top


Since the report of the first cases of corona virus disease 2019 (COVID-19) in December 2019 in the Wuhan city of China, the disease has spread globally.[1] The disease caused by the virus Severe Acute Respiratory Syndrome coronavirus-2 (SARs-COV-2) is known to primarily affect the respiratory system causing an atypical pneumonia. A myriad of other presentations have been reported, ranging from asymptomatic cases to manifestations in other systems outside of the respiratory system.[2]

Typically, symptomatic patients present with fever, cough, breathlessness, and fatigue and in severe cases could develop complications including, respiratory failure, renal failure, myocardial infarction, stroke, hyperglycemia, and thrombotic diseases.[2] Thrombotic complications resulting from hypercoagulable states have been reported to occur in COVID-19 particularly in middle aged to elderly patients with severe disease.[3],[4] These patients usually present with typical symptoms of COVID-19 in addition to features of pulmonary thrombosis and often require oxygen supplementation or management in the intensive care unit. Imaging studies are usually consistent with atypical pneumonia in addition to the features of pulmonary thrombosis.[5],[6]

We report an unusual case of a young Nigerian man without typical symptom of COVID-19 or identifiable risk factor for thrombotic disease. He presented with features of pulmonary thrombosis and subsequently tested positive for SAR-COV-2 using the reverse transcriptase polymerase reaction (RT-PCR).


  Case Presentation Top


A 33-year-old man was referred from a peripheral hospital to the emergency department of the Lagos University Teaching Hospital, Lagos, Nigeria. Reason for referral was extensive thrombi within the pulmonary arterial system seen on chest computed tomography (CT) scan. The test was performed following complaints of sudden onset, right side, and pleuritic chest pain. He did not have any of the usual symptoms of COVID-19 nor obvious personal risk or family history of thrombosis or sudden death.

Clinical examination at presentation showed a respiratory rate of 26 cycles/min, body mass index was 24 kg/m2, temperature was 36.5°C and oxygen saturation was 98% while breathing room air. Pulse rate was 108 beats/min and blood pressure 122/80 mmHg.

Complete blood count revealed mild lymphopenia (21.1% of the absolute leucocyte count) and normal platelet count. The liver enzymes were elevated with alanine and aspartate transaminase 4 times the upper limits of normal respectively and Gamma glutamyl transferase 6 times the upper limit of normal. Review of the contrast-enhanced chest CT scan confirmed the presence of an enlarged pulmonary trunk with extensive filling defects within both main pulmonary arteries and their lobar and segmental branches [Figure 1]. He also had lung infarction of the lateral segment of the right middle lobe and posterior basal segment of the left lower lobe [Figure 2].
Figure 1: CT thorax in arterial phase showing an enlarged pulmonary trunk with low density filling defect in both pulmonary arteries. PT = Pulmonary trunk, RPA = Right pulmonary artery, LPA = Left pulmonary artery, t = Thrombus

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Figure 2: Wedge shaped “bubbly” opacity in the lateral segment of the right middle lobe consistent with pulmonary infarction

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In the absence of obvious risk factors for pulmonary thrombosis, this presentation was considered bizarre and he was screened for hereditary risk factors for thrombosis as well as for SARs-COV-2. Protein C activity and antigen were found to be marginally low, 61 (70%–130%) and 69 (72%–160%) respectively (insufficient to be a risk for thrombosis and potentially influenced by deranged liver enzymes), while his protein S, factor V Leiden, prothrombin time, and international normalized ratio were within normal limit. He tested positive to SARS-COV-2 RT-PCR.

Due to his hemodynamic stability, he received anticoagulation using low molecular weight heparin (enoxaparin), prophylactic broad-spectrum antibiotics and analgesics. He remained clinically stable and was subsequently switched to rivaroxaban and discharged after 14 days.


  Discussion Top


This is the first case report of COVID-19 presenting solely as pulmonary thrombosis that we are aware of. The extensive nature of the pulmonary thrombosis without known risk factors in the young man raised a red flag and made it pertinent to screen for SARS-CoV-2 despite the absence of typical symptoms. It is well known that COVID-19 could be asymptomatic particularly in younger patients but presentation with absent symptoms and such severe complication appears unique. It is also noteworthy that the clinical presentation was consistent with acute pulmonary thrombosis, but it did not match the severity and extent of involvement of the pulmonary arterial system.

Previous reports of pulmonary thrombosis in COVID-19 has revealed that most patients were usually severely sick, of middle-to-older age and some had additional risk factors for thrombosis.[5],[6] A few cases that have been reported among young patients were associated with moderate to severe typical symptoms of the COVID-19 and pulmonary thrombosis was diagnosed as a complication.[7]

The frequency of pulmonary thrombosis among patients with COVID-19 has varied across reports. A prospective autopsy finding among 11 patient with COVID-19 revealed varied degree of pulmonary thrombosis in all despite 10 of them receiving prophylactic anticoagulation.[4] In a French retrospective cohort study involving patients hospitalized in the medical ward with confirmed COVID-19 and adequate thromboprophylaxis, 16 (22.5%) and 7 (10%) of 71 patients developed venous thromboembolism and pulmonary thrombosis, respectively.[8]

The pathophysiologic mechanisms of COVID-19 coagulopathy and thrombosis are still evolving. Postulations include widespread endothelial damage by the direct effect of virus binding to the endothelium using the angiotensin 2 receptor through a virus induced autoimmune mechanism.[9] Typical risk factors of reduced venous flow from immobility and prothrombotic changes due to inflammation, particularly in severe disease has been also implicated, as well as the prone positioning used in severe cases.[9]

We believe that our index case is peculiar among the reported cases of COVID-19 and pulmonary thrombosis.[5],[6] He is young, had none of the typical symptoms of COVID-19, no preexisting risk for pulmonary thrombosis and there were no features of COVID-19 pneumonia on imaging. Pulmonary thrombosis was therefore the sole manifestation of COVID-19. However, lymphopenia and elevated liver enzymes in this patient are consistent with COVID-19.[10] This case emphasizes the need for a high index of suspicion for COVID-19 among clinicians particularly when clinical presentation or disease manifestations appear unusual or bizarre. It also buttresses the point that this novel virus indeed has a myriad of clinical presentations and our understanding and knowledge of it continues to evolve.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020;76:71-6.  Back to cited text no. 1
    
2.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 2
    
3.
Klok FA, Kruip M, van der Meer NJ, Arbous MS, Gommers DA, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.  Back to cited text no. 3
    
4.
Lax SF, Skok K, Zechner P, Kessler HH, Kaufmann N, Koelblinger C, et al. Pulmonary arterial thrombosis in COVID-19 with fatal outcome: Results from a prospective, single-center, clinicopathologic case series. Ann Intern Med 2020;173:350-61.  Back to cited text no. 4
    
5.
Ferguson K, Quail N, Kewin P, Blyth KG. COVID-19 associated with extensive pulmonary arterial, intracardiac and peripheral arterial thrombosis. BMJ Case Rep 2020;13:237460.  Back to cited text no. 5
    
6.
Lodigiani C, Iapichino G, Carenzo L, Cecconi M, Ferrazzi P, Sebastian T, et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res 2020;191:9-14.  Back to cited text no. 6
    
7.
Casey K, Iteen A, Nicolini R, Auten J. COVID-19 pneumonia with hemoptysis: Acute segmental pulmonary emboli associated with novel coronavirus infection. Am J Emerg Med 2020;38:1544.e1-00.  Back to cited text no. 7
    
8.
Artifoni M, Danic G, Gautier G, Gicquel P, Boutoille D, Raffi F, et al. Systematic assessment of venous thromboembolism in COVID-19 patients receiving thromboprophylaxis: Incidence and role of D-dimer as predictive factors. J Thromb Thrombolysis 2020;50:211-6.  Back to cited text no. 8
    
9.
Tal S, Spectre G, Kornowski R, Perl L. Venous thromboembolism complicated with COVID-19: What do we know so far? Acta Haematol 2020;143:417-24.  Back to cited text no. 9
    
10.
Fan Z, Chen L, Li J, Cheng X, Yang J, Tian C et al. Clinical features of COVID-19 related liver functional abnormality. Clin Gastroenterol Hepatol 2020;18:1561-1566. doi: 10.1016/j.cgh.2020.04.002.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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