Case report
71-year-old-woman with past history of Chronic kidney disease, presented to ER with acute dyspnea for 3 hours duration. Patient had history of low-grade fever 3 days before presentation, no cough, no expectoration and no Hemoptysis. Patient was fully conscious, but tachypneic (Respiratory rate 24 breath/min), pulse oximetry showed 90% on room air. Blood pressure 90/50 mmHg and heart rate 110 b/min. Chest Xray was normal, Electrocardiography (ECG) show sinus tachycardia with new right bundle branch block (figure 1).
Arterial blood gas analysis in ambient air confirmed type 1 respiratory failure (PaO2 9.4 kPa). As a case of acute dyspnea bed side BLUE ultrasound protocol applied where there was normal lung sliding with A-profile of lung Ultrasound (figure 2), no B-lines and no any sub-pleural consolidations.
According to BLUE protocol sequences we proceeded to assess lower limb veins and unfortunately there was bilateral femoral vein thrombosis. At this point the main differential diagnosis was pulmonary embolism (PE), We modified the BLUE protocol by adding Focused cardiac ultrasound (FECHO) assessment, that confirm the diagnosis of PE as it shows Right ventricular dilation, Positive McConnell’s sign and pulmonary hypertension (Pulmonary artery systolic pressure equal 50 mmHg). Such LUS and FECHO findings during the current pandemic raised the suspicion of COVID-19 infection as a cause of the patient’s clinical presentation.
Laboratory findings were significant for mild leucocytosis with lymphopenia, raised D-dimer, troponin I and pro-BNP, and evidence of acute kidney injury.