key: cord-0886848-35ztf49r
authors: Guillén, Lucía; Telenti, Guillermo; Botella, Ángela; Masiá, Mar
title: Disnea y dolor torácico pleurítico durante la pandemia de la COVID-19
date: 2020-07-04
journal: Enferm Infecc Microbiol Clin
DOI: 10.1016/j.eimc.2020.06.009
sha: 5574dd853a323bd0a8d697dbca4d8bb7c495ade8
doc_id: 886848
cord_uid: 35ztf49r

nan

Case description:

A 45-year-old man, active smoker and intranasal cocaine user, presented to the emergency department with a 5-day history of general discomfort, dyspnea and pleuritic chest pain. He reported hemoptysis in the last 24 hours. On physical examination, the patient was afebrile, his blood pressure was 110/60 mmHg, the heart rate 60 beats per minute, and the oxygen saturation 94% while breathing room air. Laboratory tests showed a C-reactive protein of 18.7 mg per liter, a D-dimer of 3.58 ug per milliliter, 12,480 leukocytes per microliter and 1,200 lymphocytes per microliter. The arterial blood gas test showed hypoxemia with an arterial oxygen pressure of 67.8 mmHg while breathing room air. A chest radiography was performed showing a pleural-dependent cuneiform opacity at the right lower lobe ( Figure 1A) . Treatment was initiated with low molecular weight heparin at a dose of 1 mg per kilogram every 12 hours, hydroxychloroquine, azithromycin and lopinavir/ritonavir. The patient had a satisfactory clinical outcome, and on day 7 he reported complete resolution of the pulmonary symptoms, and his blood oxygen saturation while breathing room air was 98%.

This patient had deep venous thrombosis as the first manifestation of COVID-19. The incidence of thrombosis might be increased in patients with severe acute respiratory syndromecoronavirus (SARS-CoV)-2 disease (COVID-19) 1 .In SARS outbreak occurred in 2003, an incidence of deep vein thrombosis up to 20.5% and of pulmonary thromboembolism (PTE) of 11.3% were reported 2 . COVID-19 has been associated with elevated levels of D-dimer, which have been linked with severe disease, clinical progression, and poor prognosis 3, 4 . In a case series of 107 patients with COVID-19 pneumonia admitted to the intensive care unit (ICU), the cumulative incidence of PTE was 20%, twice higher than the frequency of historical ICU controls 1 . PTE has also been reported after initial improvement, during the recovery phase after the cytokine storm 5 but, to the best of our knowledge, it had not been described as the initial manifestation leading to the diagnosis of COVID-19. Most of previous cases of venous thromboembolism have been reported in severe patients, when the cytochemical storm syndrome has developed [6] [7] .

Some of the mechanisms potentially contributing to explain the higher risk of thromboembolic complications observed in severe forms of COVID-19 are local inflammation, haemodynamic changes, and the induction of procoagulant factors driven by the enhanced systemic proinflammatory response 3 . Vascular endothelial injury leading to disseminated intravascular coagulation has also been proposed as a potential subjacent mechanism involved in the state of hypercoagulability, based on autopsy findings showing microthrombi in the lungs 8 .

This case in a patient without apparent predisposing factors highlights the importance of maintaining the suspicion of COVID-19 disease during the pandemic in the presence of nontypical initial clinical manifestations, especially in those with underlying thrombotic phenomena, and encourages to deepen into the underlying pathophysiological mechanism involved in COVID-19-related coagulopathy. The First Autopsy Series from New Orleans. Preprint from medRxiv and bioRxiv. 

Pulmonary Embolism in COVID-19 Patients: Awareness of an Increased Prevalence

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Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

D-dimer is Associated with Severity of Coronavirus Disease 2019: A Pooled Analysis

Pulmonary Embolism and Increased Levels of d-Dimer in Patients with Coronavirus Disease. Emerg Infect Dis

Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia