Coexistent COVID-19 Pneumonia and Pulmonary Embolism

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Chest clinic 2 1 812 jperiselneris@ 23 May 2020 Published A Revised 2May2020 Received 14 K Hospital, London Medicine, King’s College D D Correspondence to U King’ Hospital, London, Medicine by and permissions. Published commercial re- employer(s)) 2020. © D D Thorax 2020; 75:812–814. S To cite: Chest clinic A ccepted 4May2020 epartment ofRespiratory r JimstanPeriselneris, K ivakumar P, Patrick T, et al. epartment ofRadiology, epartment ofRespiratory A andP B

uthor(s) (ortheir MJ. s CollegeHospital, London, , King’s College S A O arejointfirstauthors. bernethy K, nline First A nhs. pril 2020 use SE U net . S K N 5 9R ee rights o S ,

U K; blood pressure128/75 minute but he was haemodynamically stable with on roomair,rate was28breathsper respiratory with peripheral oxygen saturationlevel of 92% had nomedical history. His temperature was 38°C of yellow sputum with streaks of haemoptysis.He breathless; hiscoughwasoccasionallyproductive by feelingincreasingly was prompted department to theemergency to admission.Hispresentation flight 9weeksprior followed byfevers.Hehadalong respiratory failure with pH7.52,PaCO2respiratory 3.87 and upper zone. An arterial blood gas showed type1 trates withdenserconsolidationintherightlower presented witha2- admitted toKing’s PaO2 8.45 beats perminute. Jimstan Periselneris In earlyMarch2020,a53- Case based ontheclinical historyandserologicaltests. in identifyingconcomitant PEinthispatient group infection. We foundthisstrikinggiventhedifficulty numerous PEeventsinpatients withCOVID-19 our practice, based in London,we have observed was dischargedoffoxygen 5daysafterpresentation. aban after 5daysoftreatment dose enoxaparin and infection. The patientwas switched tooral edox- for viralRT- swab (ARDS). Athird syndrome distress respiratory changes suggestiveofinfective aetiology oracute infarcts andbackground evidence ofpulmonary showed acute bilateral pulmonary emboli (PE) with raphy pulmonary angiogram) was performed. This negative viral swab, a CTPA (computed tomog- and 7 (normal <500 were alsonegative.HisDdimerwas2560 tive. Urinarypneumococcal and legionella antigens on bothday1and2ofadmissionwere nega- from naso- tion polymerase chain reaction) for COVID-19 40 intheformofenoxaparinlism (VTE)prophylaxis monia protocol and given venousthromboembo- infection asperlocal community- target saturations94%–98%,coveredforbacterial Hewasgivenoxygenmonia—likely COVID-19. to demonstrated sinusrhythm. Katrina embolism: challengesinidentifyingdual pathology Coexistent COVID-19 pneumoniaandpulmonary Case baseddis A chestX- Given hisongoing Since this early case of COVID-19 in the UK, in Since this early case of COVID-19 The patientwassuspectedtohaveviralpneu-

ng/L (normal<14 once daily. Viral RT- Abernethy K, et al.Thorax 2020;75 :812–814. doi:10.1136/thoraxjnl-2020-215011 A

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, ‍ reviewed byanexperiencedchestradiologist. 29% compared with 8.5% in those without H1N1. infection, theincidenceofpulmonaryemboluswas critically ill ARDS cohortwithInfluenza A H1N1 ciation between VTE andviralpneumonia.Ina lism is poorly described, there is a strong asso- Though the relationship between SARS- Dis infection disease. tion complicatedbyARDS vs non- infec- in patientswithCOVID-19 higher threefold an overzealous immune responsewithlevels nearly Conversely, IL-6appearscentral to inCOVID-19, promoting neutrophil- phils from virus- sion maybeadvantageousbyprotectingneutro- viral pneumonia. In H1N1infection,IL-6 expres- non- multiple cell types, primarilyimmunecells but also may be secondary totheover- generation andfibrinolysis.Inpart,this thrombin ment; thiswouldsuggestaprocessoflocalised nor haveevidenceofsevereclottingtimederange- lation, patients are not typically thrombocytopenic product. Unlike disseminated intravascular coagu- an elevatedlevelofDdimer, a fibrin degradation striking feature infection,themost COVID-19 damage. beyond critical illness that maybe related to viral These datasuggestamechanismofclotformation and playsa It cytokine interleukin-6(IL-6)whichisproduced coagulopathy a resultantlung- including micro- lation resulting inseverelocal vascular dysfunction process may extend into the adjacent microcircu- an IL-6- tution are detailed in presenting toourinsti- infection inMarch2020 of 10patientsidentifiedwithPEandCOVID-19 PE. ThepatientsummarisedaboveiscaseG. KCH pneumoniaandcoexistent with COVID-19 patients admittedto ical findingsofthefirst10 shown in 1 TanyaPatrick, Coagulopathy is a common feature of severe is acommon Coagulopathy The demographics, clinical The demographics, and imagingfindings We havesummarisedthedemographicsandclin- has both proand anti- c immune tissuesuchasvascularendothelium. ussion 3 At thetimeofwriting,itissuggested that mediated pulmonary and predispositiontopulmonaryembo- figure . key roleintheimmuneresponseto 4

thrombosis 1 centric pulmonary intravascular induced . All scans were retrospectively 1 HastiRobbie, table mediated inflammatory properties death in the lung and

and haemorrhage with 1 . Sample images are hyperinﬂammatory expression ofthe viral clearance. 2

complicated CoV2 by

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Thorax: first published as 10.1136/thoraxjnl-2020-215011 on 23 May 2020. Downloaded from from Downloaded 2020. May 23 on 10.1136/thoraxjnl-2020-215011 as published first Thorax: http://thorax.bmj.com/ on September 30, 2021 by guest. Protected by copyright. by Protected guest. by 2021 30, September on Abernethy K, et al.Thorax 2020;75 :812–814. doi:10.1136/thoraxjnl-2020-215011

Table 1 Summary of 10 cases of COVID-19 pneumonia with pulmonary embolism identified on CT angiography Right Relevant heart Presenting Chest comorbid D-dimer (ng/ Troponin Indication for HIghest level of strain on CT evidence Management Ventilatory Evidence of Case Age Sex history radiograph conditions mL) (ng/L) CTPA PE on CTPA CT of infarcts of VTE support DVT on USS A 56 Male 7 days cough, Bilateral T2DM >8000 8 Chest pain Subsegmental No No DOAC High flow oxygen No fever infiltrates B 64 Male 9 days cough, Bilateral HTN, CKD >8000 – Syncopal Main Yes Yes LMWH High flow oxygen No SOB infiltrates episode C 57 Female 15 days fever, Clear – >8000 309 >3 weeks of Main Yes Yes Thrombolysis High flow oxygen No cough SOB SOB D 71 Male 7 days lethargy, Bilateral – >8000 406 Persistent high Lobar Yes Yes LMWH High flow oxygen No fever, cough infiltrates P/F ratio E 66 Male 9 days cough, Right upper – 4990 13 Persistent high Segmental Yes No LMWH High flow oxygen Yes fever, SOB lobe and left P/F ratio lower zone consolidation F 62 Male 10 days SOB, Bilateral – >8000 37 Chest pain Segmental Yes No LMWH Intubated and No diarrhoea infiltrates Ventilated G 53 Male 13 days cough, Bilateral – 2560 7 Pleuritic chest Lobar Yes Yes DOAC High flow oxygen No fever, SOB consolidative pain. Persistent change high P/F ratio H 71 Male 13 days fever, Unilateral linear T2DM 2490 177 Syncopal Main Yes No LMWH High flow oxygen No coryza atelectasis episode I 63 Male 7 days SOB, Bilateral T2DM, HTN, IHD >8000 21 Clinical Main Yes No LMWH High flow oxygen Yes cough, fever infiltrates evidence of DVT, raised D-dimer J 75 Female Inpatient - 2 Bilateral Bladder cancer >8000 74 Staging CT Subsegmental No No Heparin infusion High flow oxygen Yes days of SOB and infiltrates with ureteric scan increasing oxygen obstruction, requirement COPD DOAC, direct oral anticoagulant; DVT, deep vein thrombosis ; HTN, hypertension; IHD, ischaemic heart disease; LMWH, low-molecular-weight heparin; P/F ratio, ratio of arterial oxygen partial pressure to fractional inspired oxygen; SOB, shortness of breath; T2DM, type 2 diabetes; USS, ultrasound. Chest clinic

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on September 30, 2021 by guest. Protected by copyright. by Protected guest. by 2021 30, September on Chest clinic Chest clinic with lowmolecularweightheparin data from Chinasuggestreducedmortalityin patients treated pulmonary embolus formation. Inclinical practice, retrospective tion. ening, lumen stenosis,occlusion and microthrombosisforma- evidence ofpulmonary mens fromCOVID-19- segmental PEs(arrowed). consolidation (arrowed)withperilobularpattern(arrow). There are as demonstratedbyperipheralgroundglassopacificationand pulmonary angiogram)inpatientDwithsevereCOVID-19 pneumonia (arrowed). (D,E) show axialCTimagesofCTPA (computedtomography (PEs) (arrowed)withawedgeshapedinfarctintherightlowerlobe There areextensivebilateralmainandlobarpulmonaryemboli round peripheralandbronchocentricgroundglassopacities(arrowed). C withmoderateCOVID-19 pneumoniaasdemonstrated bybilateral Figure 1 814 tive ofPEandaveryelevated D dimer. Itislikely that thereare in general, these were identified with highlysugges - symptoms tively evaluated. Chest clinic This notionissupportedbyexaminationofpathologyspeci- We haveidentified10cases of coexistingPEandCOVID-19; 5 However, itisunclear if asimilarprocessresultsin‘insitu’

(A- C) showsampleaxialCTimagesofaCTP infected patientswhichalsodemonstrate vascular changeswithvesselwall thick- 6 butthisisyettobe prospec- A inpatient Jimstan Periselneris http:// non- determined by terms andconditionsfortheduration ofthecovid-19pandemicoruntilotherwise This articleismadefreelyavailable foruseinaccordancewith Provenance andpeerreview Patient consentforpublication Competing interests funding agencyinthepublic, commercialornot- Funding its accuracy. manuscript. Contributor Twitter Parthipan 6 5 4 3 2 , Tignanelli CJ, Jacobs 1 Re Parthipan O notices andtr prognostication, but clinical deteriorationwithincreasingoxygen requirement. elevatedD- admission, grossly of illnessandimmobilitybefore in thosewithaprolongedhistory pneumonia, particularly CT angiography in patients COVID-19 to perform our experiencestodate,wesuggestalowerthreshold is easytooverlookconcomitantVTEinthispatientgroup. chest radiography.infiltrates on D- with anelevatedalveolar- outcome in these patients. Patients typically present tohospital infection, and it is not yetclear whether associated PE affects These caseshighlightadiagnosticchallengeinsevereCOVID-19 pneumonia. larities in presentation between PE and COVID-19 many morecasesofPEthathavebeenmissedduetothesimi- s d o RC Abernethy K, et al.Thorax 2020;75 :812–814. doi:10.1136/thoraxjnl-2020-215011 Haemost 2020;18:1094–9. mortality inseverecoronavirusdisease2019patientswithcoagulopathy. JThromb T pneumonia (C Luo activation syndrome. patients withC Zhao X, 2012;5:258–66. influenza virusbypromotingneutrophilsurvival inthelung. MucosalImmunol 2019;7:317–24. acute respiratory distresssyndromepatients. J Vasc Surg Venous Lymphat Disord associated withdecreasedvenousthromboembolismincriticallyillinfluenza Until large prospectively collecteddataareavailable, Until largeprospectively based on f ang harif K, ienz bi commercial purpose(includingtextanddatamining)providedthatallcopyright I e D iDs r A W, Yu H, GouJ, et al. Clinicalpathologyof criticalpatientwithnovelcoronavirus T N en O

S Zhang , T B RudJG, ivakumar http:// B he authorshavenotdeclaredaspecificgrant forthisresearchfromany ai H, ChenX, et al. A c ridgewood C. s ade marksareretained. ll authorscontributedtotheauthorshipofthismanuscriptandverify es

B K O MJ. You mayuse, downloadandprint thearticleforanylawful, A O B V , andP V S LiP, et al. ID E ID ivakumar @d33panandJimstanPeriselneris @jimstanp aton -19). Pathology &Pathobiology 2020:2020020407. -19: asystematicreview andmeta-

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