AUCTORES
Globalize your Research
case report | DOI: https://doi.org/10.31579/2639- 4162/072
1 Cardiology Department Guglielmo Da Saliceto Hospital; Piacenza, Italy.
2 Anesthesiology and ICU department Guglielmo da Saliceto Hospital; Piacenza, Italy.
*Corresponding Author: Francesco Di Spigno, MD, Cardiology Department Guglielmo Da Saliceto Hospital, Via Taverna Giuseppe, 49, 29121 Piacenza, Italy.
Citation: Francesco Di Spigno, Geza Halasz, Felice Perrino, Matteo Villani, Daniela Aschieri, (2022). Three Cases of Severe SARS-CoV 2 Pneumonia Complicated by Combined Venous and Arterial Thrombotic Events. J. General Medicine and Clinical Practice. 5(3); DOI:10.31579/2639- 4162/072
Copyright: © 2022 Francesco Di Spigno, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 25 July 2022 | Accepted: 05 August 2022 | Published: 12 August 2022
Keywords: arterial thromboembolic events; SARS-COV-2 pneumonia; venous thromboembolic events
Several studies suggested that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with a hypercoagulable state leading to multisystem organ dysfunction. The present article describes three cases of patients with SARS-Cov-2 pneumonia complicated by venous and arterial thromboembolism. Case1 is a 51 year- old-man not vaccinated with severe SARS-Cov-2 pneumonia who developed extensive arterial thromboses and pulmonary embolism after few days from symptoms onset. Laboratory panel at hospital admission showed sign of ongoing inflammation and a severe Hypercoagulable state. Case2 is a 58 year-old-man not vaccinated at low cardiovascular risk with severe SARS-Cov-2 pneumonia complicated by anterior STEMI due to acute thrombotic occlusion of left coronary artery and massive bilateral pulmonary thromboembolism. Subsequently the patient presented an acute ischemic stroke despite being treated with triple antithrombotic therapy low molecular weight heparin (LMWH), aspirin and clopidogrel. Case 3 is a 75 year old man with an history of arterial hypertension that developed severe SARS-Cov-2 bilateral pneumonia. Doppler ultrasound of lower limb veins showed deep vein thrombosis of right main femoral vein. CT angiography of the chest ruled out sign of pulmonary embolization and underlined the presence of thrombus in the aortic arch. Physicians should be aware of these complications and remain vigilant for signs of VTE and ATE in the contextof the current
Learning points
In Covid-19 we need to be aware of thromboembolic events in the healing phase of the disease. Patients with Covid-19 may benefit from long-term anticoaugulation.
Several case reports [1-2] have demonstrated that venous thromboembolic events (VTEs) are prevalent in individuals hospitalized with SARS-Cov-2 pneumonia.
Few recent researches [3-5] have shown an increased incidence of arterial thromboembolic events in these patients, implyingthat systemic inflammation, long-established risk factors for VTE, as well as possible endothelial dysfunction predispose patients with severe SARS–CoV2pneumonia to VTE and arterial thromboembolic events (ATE). Here, we describethree cases of male patientswithout pathological conditionswho developed a severe form of SARS–CoV2 pneumonia complicated both by VTE and ATE.
Patient 1
A 51-year-old male returned from Equador with no prior SARS-COV2 vaccinations and no historyof cardiovascular diseasepresented to the Emergency Department/ED complaining of dyspnea and fever. The cardiac exam was unremarkable. A 12-lead electrocardiogram revealed sinus tachycardia with incomplete right bundle brunch. On admission, D-dimer was 28470 ng/ml (normal range 0-500 ng/ml) and serum C-reactive protein was 14.49 mg/dl (normal range 0-0.5 mg/dl). The nasofaringeal swab for SARS COV 2 was positive with subsequent genomic sequentation that validatedthe presence of equadoriant variant. Transtoracic echocardiography TTE revealed a left ventricular ejection fraction/LVEF of 55%, right ventricle enlargement (telediastolic diameter/DTD 42 mm), and two thromboticstratifications spanning the right ventricle's apex and right atrium (dimensions of 3 cm and 1 cm, respectively). Thoracic CT revealed bilateral interstitial pneumonia (visual score of 60%, figure n. 1a), and angio sequences confirmed the existence of right ventricular and atrial thrombi,as well as additional thrombotic apposition at the level of aortic istmus (figure n. 1b).
Figure 1a: HRCT at the time of pulmonary embolism.
Figure 1b: Angio-CT showing thrombotic apposition at the level of aortic istmus
Due to the low risk of neurological embolization of aortic thrombus, the cardiac surgeon ruled out any invasive procedures. As a result, the patientwas treated in the Intensive Care Unit/ICU with intravenous unfractionated heparin/UFH and a large dosage of steroids. During the hospitalization, the patient'sventilatory parameters progressively deteriorated, and he was intubatedand pronated. Aspergillus was found in a broncoalveolar lavage/BAL. Unfortunately after few days the patient died.
Patient 2
A 58-year-old male with no prior SARS-COV2 vaccination and no history of cardiovascular illness presented to the emergency department with chest discomfort and dyspnea. The nasofaringeal swab tested positive for SARS COV 2, and furthergenomic sequencing confirmedthe presence of the deltavariant. A 12-leadelectrocardiogram revealed anteriorST elevation consistent with STEMI. Coronary angiography revealed acute thrombotic occlusion of the left coronary artery/LAD (figure n. 2a), which was successfully treated by primary coronary angioplasty and stent implantation (Synergy 3,5 x 32 mm @ 18 atm). The final angiography was suboptimal because of a substantial thrombotic burden in the distal LAD with TIMI 0 low. Across the procedure, a glycpprotein Iib/IIa inhibitor (tirofiban) and a loading dose of ticagrelor were provided. TTE revealed a 35% LVEF with apical, lateral, and anterior wall akinesia in the medio-distal segments in the presence of biatrial thrombotic apposition. Additionally, the patient receivedintravenous UFH and was intubated as a result of acuterespiratory syndrome/ARDS. Thoracic computed tomography demonstrated bilateral interstitial pneumonia (visualscore of 70%), and angiograms revealed severe bilateral pulmonary thromboembolism, indicating the presence of additional thrombotic apposition at the level of the left atrium and left pulmonary veins (figure n. 2b).
Figure 2a : Coronary Angiography showing acute thrombotic occlusion of LAD
Figure 2b: Angio TC showing Filling defects at the level of right and left pulmonary artery
There was even an intercurrent sepsis caused by Staphylococcus aureuswith parossistic atrial fibrillation/FAP. Followingweaning from mechanical ventilation, the patient complained of right hemisome weakness. Without contrast agent, head CT revealedtwo ischemic lesionsin the left parietal lobe and right cerebellar lobe, both of which were cardioembolic in origin and were treated conservatively. The patient presented with a minor muscle deficit in the right hemisphere upon discharge, and contrast echocardiography demonstrated full clearanceof cardiac thrombotic apposition. Because the patient declinedwarfarin-based anticoagulation, dabigatran was administered in conjunction with dual antiplatelet treatment (cardioaspirin + clopidrogel) [6].
Patient 3
A 75-year-old male with a history of arterial hypertension who had previously been vaccinated againstSARS-COV2 (Vaxzevria, two injections) went to the emergency department complaining of dyspnea.Cardiac examination revealedno abnormalities. A 12-lead electrocardiogram exhibited a sinus rhythm. The D-dimer level was 1897 ng/ml (normalrange:0-500 ng/ml), while the serum C-reactive protein level was 4.91 mg/dl (normal range: 0-0.5 mg/dl). Doppler ultrasonography of the lower limb veins detected right main femoral vein thrombosis. The nasofaringeal swab for SARS COV 2 was positive, and a CT pulmonary angiography revealed bilateral interstitial pneumonia (visual score of 45%, figure n. 3a) and thrombus (maximal diameter of 10 mm) in the aortic arch, lower than the origin of the left subclavian artery(figure 3b). Any invasive treatments have been ruledout by the cardiac surgeon.Additionally, the patientreceived low molecular weight heparin/LMWH, as well as a high dosage of steroids and remdesivir. Warfarin was prescribed upon discharge.
Figure 3a: HCRT on admission showing a diffuse bilateral“crazy paving” pattern with subpleural and peribronchial consolidation
Figure 3b: AngioTc showingthrombus (diameter of 10 mm) at the level of aortic arch, lower than left subclavian artery origin
Severe SARS-CoV-2 infectionis associated with arterial and venous thrombotic complications including myocardial infarction (MI), ischemic stroke, and venous thromboembolism (VTE) [7].
The majority of studies have focused on venous thromboembolism, with the pulmonary circulation having substantially greater event rates than arm orleg veins [8].
Venous thrombotic complications occurred in 2.6 percent of 229 non- critically hospitalized patients and 35.3 percent of 170 critically ill hospitalized patients in a US registry of COVID-19 patients [9]. In two recent prospective researches from Italy, arterial thrombotic events had an incidence of roughly 10% [10].
Many patients with severe COVID19have an earlier stage of sepsis- associated disseminated intravascular coagulation (DIC) characterized as "sepsis-induced coagulopathy," according to the International Society of Thrombosis and Haemostasis (ISTH) (SIC) [11].
Thrombotic complications have been shown to have a significant impact in determining a patient's prognosis. Microthrombi seen in the lungs,heart, and kidneys after autopsy show that severe COVID-19 patients may suffer from multisystem organ failure due to thrombosis [12].
This disease-specific hypercoagulable state is thoughtto be caused by cytokine-mediated diffuse microvascular damage and, in some circumstances, reactive thrombocytosis. Obesity,advanced age, and hospitalization-related immobilization can all increasethe risk of thrombosis and pulmonary embolism [13].
Furthermore, Stress-induced cardiomyopathy (Takotsubo cardiomyopathy), paroxysmal atrial fibrillation, or paradoxical embolization through a patent foramen ovale in the context of pulmonary hypertension caused by acute lung injury could all be sourcesof embolism to the brain, splanchnic circulation, or peripheral arteries.In these critically ill individuals, vasospasmcaused by pressortreatment, iatrogenic artery damage, or spontaneous dissection are all possible explanations [14].
Moreover, elevated D-dimer levels levels have been found in COVID 19 patients,with a strong relation betweenelevated D-dimer levels on admissionand in-hospital mortality, raising concerns about potentially undetected pulmonary embolism in these patients[15].
Pulmonary embolism can also occur late in the course of the disease raisingthe possibility that the hypercoagulable state persist over the activeinflammation phase and cytokine storm [1].
In conclusion, our case studies highlight important cardiovascular consequences associated with COVID-19 pneumonia. The occurrence of arterial and venous thrombosis at the same time increases the risk of poor survival due to multisystem organ failure. The cytokine storm-related mechanism for this disease-specific hypercoagulable condition has been highlighted, and it may persist in the late stages of infection. Anticoagulant and antiplatelet therapy are required in this situation, however the time though they must be discontinued is unclear. Close radiologic (angio-CT, transtoracic echocardiography) and laboratory (dosage of D-dimer and C- reactive proteinlevels) follow-up is required after discharge in good clinicalpractice.
Ethics approval and consentto participate:
Not applicable
Consent for publication
All the patients involved in the current manuscript gave their consent for publication
Availability of data and materials
Data sharing is not applicable to this articleas no datasets were generated or analysed duringthe current study.
Competing interests
None
Funding
Azienda Ospedaliera di Piacenza with fiscal receipt. Below all the references.
Authors' contributions
GH, FDS, MV, FP collected the data and draft the manuscript. MP revised the final manuscript and contributed substantially to the study manuscript design. All authors read and approvedthe final manuscript."
Acknowledgements
None
Conflict of Interest
None declared.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
