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Table of Contents
LETTER TO THE EDITOR
Year : 2020  |  Volume : 11  |  Issue : 3  |  Page : 169-170

Acute pulmonary embolism in COVID-19: Vigilance is the need of the hour


1 Department of Pulmonary, Critical Care and Sleep Medicine, New Delhi, India
2 Department of Cardiology, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission14-Jul-2020
Date of Acceptance19-Jul-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Dr. Pranav Ish
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJMS.INJMS_83_20

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How to cite this article:
Mahendran AJ, Gupta N, Agstam S, Ish P. Acute pulmonary embolism in COVID-19: Vigilance is the need of the hour. Indian J Med Spec 2020;11:169-70

How to cite this URL:
Mahendran AJ, Gupta N, Agstam S, Ish P. Acute pulmonary embolism in COVID-19: Vigilance is the need of the hour. Indian J Med Spec [serial online] 2020 [cited 2020 Oct 28];11:169-70. Available from: http://www.ijms.in/text.asp?2020/11/3/169/292392



Dear Editor,

A 48-year-old male, hypertensive for 10 years on therapy, presented to emergency department with fever for 2 days, dry cough for 2 days, and rapidly progressive breathlessness for 1 day. He was in shock with systolic blood pressure of 70 mmHg, having tachycardia with pulse rate 130/min regular and febrile with temperature of 38°C. Arterial blood gas analysis was suggestive of respiratory and metabolic acidosis (pH: 7.25, PO2:45, PCO2:75, HCO3:14). The patient was intubated and put on mechanical ventilation. An urgent electrocardiogram was suggestive of suspected SIQ3T3 pattern [Figure 1]. The patient succumbed to his illness within 2 h of his presentation and echocardiography and computed tomography pulmonary angiogram (CTPA) could not be carried out. He was started on enoxaparin, but no thrombolysis could be carried out. His COVID-19 nasopharyngeal swab was positive by a polymerase chain reaction-based test. The patient was eventually a COVID-19 death with underlying hypertension and suspected pulmonary embolism (PE) leading to shock.
Figure 1: A 12-lead standard electrocardiogram showing sinus tachycardia with heart rate of 120/min. Note the “S” wave (blue arrow) in V1, Q wave (yellow arrow) in lead III, and T wave (yellow star) inversion in lead III, suggestive of S1Q3T3. Incomplete Right bundle branch block is present in V1, marked as red star

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COVID-19 has been majorly a mild disease with low mortality.[1] The major causes of death were acute respiratory distress syndrome and cardiomyopathy in initial reported literature.[2] However, emerging data brought out another important etiology-PE. A retrospective study by Grillet from France has shown that 23% patients of COVID-19 had PE. Such patients required mechanical ventilation and had a poorer outcome.[3] Another case–control study by Poissey et al. revealed that PE was twice more common in COVID-19 patients admitted in the intensive care unit.[4] The pathogenesis is debatable, but multiple mechanisms can include cytokine storm (interleukin - 1, 2, 6, 1 β, tumor necrosis factor-α, and interferon-γ), causing a hyperinflammatory state, endothelial injury, and a hypercoagulable state.[5],[6],[7]

PE often goes undetected in COVID-19; lack of suspicion, difficulty to shift such patients for CTPA, lack of a dedicated CT machine, and rapid mortality are few reasons. The International Society of Thrombosis and Hemostasis has formulated guidelines for recognition and management of coagulopathy in COVID-19 patients and recommends measuring D-dimer, prothrombin time, platelet count, and fibrinogen in decreasing order of importance and recommends prophylactic low-molecular-weight heparin in all admitted patients with abnormal values.[7]

However, given the limited availability of data regarding the pathogenesis and diagnosis of PE in COVID-19 patients, a constant vigil for the same is the best weapon to help in early diagnosis and appropriate emergency treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta N, Agrawal S, Ish P, Mishra S, Gaind R, Usha G, et al. Clinical and epidemiologic profile of the initial COVID-19 patients at a tertiary care centre in India. Monaldi Arch Chest Dis 2020;90:10.4081/monaldi.2020.1294. Published 2020 Apr 10. doi:10.4081/monaldi.2020.1294.  Back to cited text no. 1
    
2.
Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China [published online ahead of print, 2020 Mar 25]. JAMA Cardiol 2020;5:802-10. doi:10.1001/jamacardio.2020.0950  Back to cited text no. 2
    
3.
Grillet F, Behr J, Calame P, Aubry S, Delabrousse E. Acute Pulmonary Embolism Associated with COVID-19 Pneumonia Detected by Pulmonary CT Angiography [published online ahead of print, 2020 Apr 23]. Radiology. 2020;201544. doi:10.1148/radiol.2020201544.  Back to cited text no. 3
    
4.
Poissy J, Goutay J, Caplan M, Parmentier E, Duburcq T, Lassalle F, et al. Pulmonary Embolism in Patients With COVID-19: Awareness of an Increased Prevalence. Circulation. 2020;142(2):184-6. doi:10.1161/CIRCULATIONAHA.120.047430.  Back to cited text no. 4
    
5.
Danzi GB, Loffi M, Galeazzi G, Gherbesi E. Acute pulmonary embolism and COVID-19 pneumonia: A random association? Eur Heart J 2020;41:1858.  Back to cited text no. 5
    
6.
Zhang Y, Xiao M, Zhang S, Xia P, Cao W, Jiang W, et al. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. N Engl J Med 2020;382:e38.  Back to cited text no. 6
    
7.
Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost 2020;18:1023-6.  Back to cited text no. 7
    


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