Massive Pulmonary Embolism and Deep Vein Thrombosis in COVID-19 Pneumonia: Two Case Reports

Coronavirus disease 2019 (COVID-19) is known to cause a severe acute respiratory syndrome with increased morbidity and mortality due to multiorgan involvement. COVID-19 is associated with an increased risk of venous thromboembolism (VTE), ranging from asymptomatic to potentially fatal presentations. Predictors of VTE in COVID-19 are not fully defined, and the role of anticoagulation in these patients is debatable. Here we discuss two cases of COVID-19, who initially presented with mild COVID-19 symptoms and later with potentially fatal VTE within 30 days of initial presentation. The first case is of a 42-year-old gentleman with a history of sarcoidosis and a recent diagnosis of COVID-19 pneumonia who was in isolation at home and presented with syncope and worsening shortness of breath. He was hemodynamically unstable and resuscitated with fluid management in the emergency department. The chest angiogram imaging studies showed massive pulmonary embolism with right heart strain, which was confirmed with bedside point-of-care ultrasound. The patient deteriorated clinically and received an intravenous tissue plasminogen activator in the emergency. He was discharged home under stable condition on oral anticoagulation. The second patient is a 63-year-old gentleman with chronic obstructive pulmonary disease, obesity, sleep apnea, and a recent diagnosis of COVID-19 pneumonia, which was complicated with an ischemic stroke, who presented with worsening complaints of shortness of breath and palpitation. The chest angiogram imaging showed bilateral pulmonary embolism. An echocardiogram showed mild right heart strain. The lower extremity duplex ultrasound showed bilateral deep vein thrombosis. The patient underwent catheter-directed thrombolysis and discharged on oral anticoagulation. There is a need to develop stronger predictors to provide thromboprophylaxis in COVID-19 pneumonia to prevent life-threatening VTE.