Chest pain mimicking pulmonary embolism may be a common presentation of COVID-19 in ambulant patients without other typical features of infection

Abstract

Background: Radiological and pathological studies in severe COVID-19 pneumonia (SARS-CoV-2) have demonstrated extensive pulmonary immunovascular thrombosis and infarction. This study investigated whether these focal changes may present with chest pain mimicking pulmonary emoblism (PE) in ambulant patients.

Methods: CTPAs from outpatients presenting with chest pain to Leeds Teaching Hospital NHS Trust 1st March to 31 May 2020 (n = 146) and 2019 (n = 85) were compared. Regions of focal ground glass opacity (GGO), consolidation and/or atelectasis (parenchymal changes) were determined, and all scans were scored using British Society for Thoracic Imaging (BSTI) criteria for COVID-19, and the 2020 cohort was offered SARS-CoV-2 antibody testing.

Results: Baseline demographic and clinical data were similar between groups with absence of fever, normal lymphocytes and marginally elevated CRP and D-Dimer values. Evidence of COVID-19 or parenchymal changes was observed in 32.9% (48/146) of cases in 2020 compared to 16.5% (14/85) in 2019 (P = 0.007). 11/146 (7.5%) patients met BSTI criteria for COVID-19 in 2020 compared with 0/14 in 2019 (P = 0.008). 3/39 patients tested had detectable COVID-19 antibodies (2 with parenchymal changes and 1 with normal parenchyma) however 0/6 patients whose CTPA met BSTI criteria "likely/suspicious for COVID-19" and attended antibody testing were SARS-CoV-2 antibody positive.

Conclusions: 32.8% ambulatory patients with suspected PE in 2020 had parenchymal changes with 7.5% diagnosed as COVID-19 infection by imaging criteria, despite the absence of other COVID-19 symptoms. These findings suggest that localized COVID-19 pneumonitis with immunothrombosis occurs distal to the bronchiolar arteriolar circulation, causing pleural irritation and chest pain without viraemia, accounting for the lack of fever and systemic symptoms.

Keywords: infectious disease; noncardiac chest pain; radiology; thromboembolism.

Fig. 1

Flowchart illustrating patient selection for the study. Key: CTPA = CT pulmonary angiogram; PE = pulmonary embolus.

Fig. 2

Examples of lung parenchymal changes on CT pulmonary angiogram (CTPA). Parenchymal changes are indicated by the yellow arrows. a = 2020 CTPA positive for PE with associated parenchymal changes [ground glass opacities (GGOs)]; b = 2020 CTPA negative for PE with multiple peripherally distributed GGOs; c = 2020 CTPA negative for PE with a single peripheral GGO; d = 2019 CTPA negative for PE with peri‐bronchial GGOs; e = 2020 CTPA negative for PE with right lower lobe consolidation; f = an example of more extensive parenchymal changes in a patient who had a positive PCR test for COVID‐19.