CASE PRESENTATION
77-year-old female with prior medical history includes stroke, diabetes
mellitus, hypertension, and breast cancer in remission presented with
severe dyspnea. She was initially admitted for severe coronavirus
disease-2019 (COVID-19) pneumonia. At index admission, laboratory
studies showed normal leucocyte count, elevated lactic dehydrogenase
(804 U/L), D-dimer (>20.00 µg/mL) and C-reactive protein
(11.7 mg/dL). Echocardiography showed right ventricular enlargement and
hypokinesia with estimated pulmonary artery systolic pressure (PASP) of
37 mmHg. Treatment included hydroxychloroquine, azithromycin,
vancomycin, oxygen, and full-dose unfractionated heparin. She recovered,
and was discharged after 17 days of hospitalization. Upon discharge,
heparin was transitioned to apixaban, however she did not fill a
prescription.
Seven days after hospital discharge, she presented again for severe
dyspnea. She was tachycardiac at 140 bpm, normotensive, hypoxic with
peripheral capillary oxygen saturation of 85% on room air. Repeat
D-dimer was 9.34 µg/mL, higher than that of a week prior (3.67 µg/mL).
Pro-B natriuretic peptide was normal. Electrocardiogram showed sinus
tachycardia and bilateral atrial enlargement (Figure 1). Computed
tomography angiogram revealed a large saddle pulmonary embolism (Figure
2). Echocardiography showed the right ventricular dilatation and
hypokinesia with classic McConnel’s sign (Figure 3A, Video 1). A mobile
sausage-like mass was observed in the right atrium, straggled the patent
foramen ovale, which was consistent with thrombus-in-transit. Color
Doppler showed moderate tricuspid regurgitation (Figure 3B, Video 2).
PASP was estimated as 62 mmHg. Venous duplex Doppler showed acute
occlusive thrombosis in gastrocnemius and popliteal veins of the right
lower extremity. She had no clinical signs and symptoms for stroke.
Heparin infusion was initiated and hemodynamics were closely monitored
in the intensive care unit. Her blood pressure remained stable,
therefore tissue plasminogen activator, extracorporeal membrane
oxygenation, or thrombectomy were deferred. Tachycardia resolved, and
she was discharged home with enoxaparin. Follow up echocardiogram was
scheduled as outpatient.