Case of right ventricular and aortic thrombi in a patient with severe COVID-19

Abstract

Emerging evidence suggests that novel COVID-19 is associated with increased prothrombotic state and risk of thromboembolic complications, particularly in severe disease. COVID-19 is known to predispose to both venous and arterial thrombotic disease. We describe a case of a 61-year-old woman with history of type II diabetes, hypertension and hyperlipidaemia who presented with dry cough and acute abdominal pain. She was found to have a significantly elevated D-dimer, prompting imaging that showed thrombi in her right ventricle and aorta. She had rapid clinical deterioration and eventually required tissue plasminogen activator with subsequent durable clinical improvement. This case highlights a rare co-occurrence of venous and arterial thrombi in a patient with severe COVID-19. Further studies are needed to clarify the molecular mechanism of COVID-19 coagulopathy, the utility of D-dimer to predict and stratify risk of thrombosis in COVID-19, and the use of fibrinolytic therapy in patients with COVID-19.

Keywords: COVID-19; haematology (incl blood transfusion); venous thromboembolism.

Figure 1

Chest X-ray showing multifocal bilateral patchy opacities with confluent opacities in the right upper lobe.

Figure 2

CT chest pulmonary angiogram (axial view) (A) showing bilateral peripheral ground-glass opacities with intralobular septal lines and areas of denser consolidation (B) showing an area of hypoattenuating focus within the right ventricular apex as well as thoracic aorta concerning for thrombi.

Figure 3

CT angiogram abdomen/pelvis (coronal view) showing filling defects within the thoracic and abdominal aorta (yellow arrows) likely representing thrombi.

Figure 4

Pre-tissue plasminogen activator: bedside point-of-care ultrasound showing a mass of echoes measuring 19×14 mm in the right ventricular cavity most consistent with thrombus.

Figure 5

Thirty-three hours post-tissue plasminogen activator: formal trans-thoracic echocardiogram showing a mobile echodensity (14×5 mm) in the right ventricular apex near the moderator band, most likely thrombus.