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.