COVID with DVT and Pulmonary Embolism

41 year old female. COVID-19 positive. SOB • Xray of the Week

41 yo female COVID-19 positive with LLE edema and Shortness of breath.

Figure 1. Describe the abnormalities.

Figure 2.

A. Bilateral lower lobe peripheral ground-glass opacities (GGO) with confluent patchy consolidation (blue arrows).

B. Loss of color flow in left popliteal vein (red arrow).

C. Thrombosed non-compressible left common femoral vein (red arrow).

D. and E. Axial and coronal CT showing partially occlusive left lower lobe pulmonary embolism (orange arrows)

Discussion:

The SARS-CoV-2 novel virus was first isolated in Wuhan, China. [1,2] In the United States, COVID-19 has been the cause of more than 380,000 deaths as of Jan 12, 2021 [3]. Patients typically present with fever, tachypnea, cough, and sore throat. Severe complications like pulmonary embolism (PE), multiorgan failure, and death can occur [2]. The radiologist plays a vital role in the COVID-19 pandemic due to the importance of imaging in diagnosis and management. The exact pathophysiology and management of this virus is still evolving, however COVID-19 is known to cause a hypercoagulable state with abnormal D-dimer, IL-6, and fibrinogen levels leading to an increased incidence of thrombotic events [1]. In hospitalized COVID-19 patients, the incidence of thrombotic events is between 7.7-49%. Among these, the most commonly occurring thrombotic event is venous thromboembolism [4]. A meta-analysis reported that the incidence of deep vein thrombosis (DVT) patients is 27% and PE is 15% in COVID-19 positive hospitalized patients [5]. If a DVT is suspected, compression ultrasonography of the lower extremity will often show an enlarged, noncompressible vein with corresponding loss of color flow if thrombus is occlusive [6].

The virus’ preferred access to host cells is via angiotensin-converting enzyme 2 (ACE-2) found in the respiratory epithelium. Therefore, the lungs are the most affected organ and visible signs of disease are typically present on imaging [1]. Chest x-rays may demonstrate diffuse ground-glass opacities, however, CT scans are more sensitive for these findings and are considered the first-line imaging modality. CT scans most often demonstrate peripherally distributed ground-glass opacities with reticular and/or interlobular septal thickening, with consolidation [7]. If associated pulmonary embolism is suspected, CT pulmonary angiography will demonstrate a complete or partial filling defect. The “polo mint” sign of partial filling defects is caused by the partial defect surrounded by contrast material [8]. Management of COVID-19 is a work in progress however, hospitalized patients confirmed to have COVID-19 should be on prophylactic anticoagulation unless contraindicated to prevent VTE. Typically low-molecular-weight heparin (LMWH) is preferred for anticoagulation prophylaxis and VTE management but unfractionated heparin can be an alternative, and Fondaparinux can be used in cases of heparin-induced thrombocytopenia (HIT). Tissue plasminogen activator (tPA) can be used as indicated in severe complications of COVID-19 such as limb-threatening DVT or massive PE [9].

References:

1. Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood. 2020;135(23):2033-2040. doi:10.1182/blood.2020006000

2. Zheng P, Bao L, Yang W, Wang J. Clinical symptoms between severe and non-severe COVID-19 pneumonia: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2020;99(33):e21618-. doi:10.1097/MD.0000000000021618

3. Johns Hopkins Coronavirus Resource Center. 2020. Home - Johns Hopkins Coronavirus Resource Center. https://coronavirus.jhu.edu/ [20 October 2020].

4. Hajra, A., Mathai, S.V., Ball, S. et al. Management of Thrombotic Complications in COVID-19: An Update. Drugs 80, 1553–1562 (2020). doi:10.1007/s40265-020-01377-x

5. Lu Y, Pan L, Zhang W-W, et al. A meta-analysis of the incidence of venous thromboembolic events and impact of anticoagulation on mortality in patients with COVID-19. International journal of infectious diseases. 2020;100:34-41. doi:10.1016/j.ijid.2020.08.023

6. Karande GY, Hedgire SS, Sanchez Y, et al. Advanced imaging in acute and chronic deep vein thrombosis. Cardiovascular diagnosis and therapy. 2016;6(6):493-507. doi:10.21037/cdt.2016.12.06

7. Zhao W, Zhong Z, Xie X, Yu Q, Liu J. Relation Between Chest CT Findings and Clinical Conditions of Coronavirus Disease (COVID-19) Pneumonia: A Multicenter Study. American journal of roentgenology (1976). 2020;214(5):1-6. doi:10.2214/ajr.20.22976

8. Wittram C, Maher MM, Yoo AJ, Kalra MK, Shepard J-AO, McLoud TC. CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis. Radiographics. 2004;24(5):1219-1238. doi:10.1148/rg.245045008

9. Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up. Journal of the American College of Cardiology. 2020;75(23):2950-2973. doi:10.1016/j.jacc.2020.04.031

Nirali Dave is a medical student at Medical University of Lublin in Poland, currently doing clinical rotations in New York. Before that she completed her undergraduate education at Rutgers University, and worked as a medical scribe. Nirali was first exposed to basic radiologic imaging while scribing, and was very quickly taken by the field. Her passion for radiology comes from the bridging of anatomy, health technologies, and patient care. In the future, she hopes to complete a diagnostic radiology residency and stay committed to clinical research and patient education.

Follow Nirali Dave on Twitter @ndave08

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Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

Follow Dr. Rice on Twitter @KevinRiceMD

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