Pulmonary venous thrombosis in a patient with COVID-19 infection

Abstract

Objectives: Infection with the SARS-COV2 virus (COVID-19) may be complicated by thrombotic diathesis. This complication often involves the pulmonary microcirculation. While macrovascular thrombotic complications of the lung may include pulmonary artery embolism, pulmonary artery thrombus in situ has also been hypothesized. Pulmonary vein thrombosis has not been described in this context.

Methods/results: Herein, we provide a case of an otherwise healthy male who developed an ischemic stroke with left internal carotid thrombus. Further imaging revealed pulmonary emboli with propagation through the pulmonary veins into the left atrium. This left atrial thrombus provides a source of atypical "paradoxic arterial embolism".

Conclusions: Thrombotic outcomes in the setting of severe COVID 19 pneumonia may include macrovascular venous thromboembolism, microvascular pulmonary vascular thrombosis and arterial thromboembolism. Pulmonary vein, herein described, provides further mechanistic pathway for potential arterial embolic phenomenon.

Keywords: COVID-19; Pulmonary vein thrombosis; Stroke; Venous thromboembolism.

Fig. 1

Large left middle cerebral artery stroke. A large region of hypoattenuation (Panel a) involving the left frontal, insular, parietal, and temporal lobes consistent with a left MCA territory infarct (thick arrow). An area of associated intraparenchymal hemorrhage in the anterior left frontal lobe is also noted (thin arrow). Near-occlusive thrombus (yellow arrows) in the left carotid bulb extending into the proximal internal carotid artery (Panel b) accentuated by color Doppler (Panel c). Minimal underlying atherosclerotic plaque was noted in the carotid arterial wall

Fig. 2

Venous thromboembolism. Large burden acute bilateral pulmonary thromboemboli (arrows) are noted in cross-sectional (Panel a) and coronal images (Panel b). Acute deep vein thrombosis is noted in the right popliteal vein (Panel c and d)

Fig. 3

Pulmonary vein thrombus. Filling defect in the inferior right pulmonary vein (arrow) consistent with pulmonary vein thrombus in cross-sectional (Panel a) and coronal imaging (Panel b)