key: cord-269345-5tlyy8jp
authors: Minuz, Pietro; Mansueto, Giancarlo; Mazzaferri, Fulvia; Fava, Cristiano; Dalbeni, Andrea; Ambrosetti, Maria Chiara; Sibani, Marcella; Tacconelli, Evelina
title: High rate of pulmonary thromboembolism in patients with SARS-CoV-2 pneumonia
date: 2020-06-18
journal: Clin Microbiol Infect
DOI: 10.1016/j.cmi.2020.06.011
sha: 
doc_id: 269345
cord_uid: 5tlyy8jp

nan

Recently, thromboembolic events have been reported in 20/81 patients with severe SARS-CoV-2 32 pneumonia admitted to intensive care units (ICUs). About 90% of patients showed an increased 33 coagulation activity, including high D-dimer concentrations, which demonstrated 85% sensitivity 34 and 89% specificity for identifying high-risk groups for thromboembolic events [1] . Moreover During the study period, ten patients underwent a CTPA scan. PTE was detected in six of them, all 52 displaying D-dimer values >10000 µg/L, and a persistent PaO 2 /FIO 2 ratio < 150. Consistently with 53 the diagnosis of viral pneumonia, in all six patients, CTPA scan showed peripherally distributed 54 bilateral ground-glass opacities, reticular opacities, and areas of consolidation in the posterior-55 basal segments. Multiple filling defects involving lobar or segmental and subsegmental branches of 56 pulmonary arteries with subsegmental vessels enlargement were also detected in all patients. 57

These features were bilateral in four patients. One patient showed both principal and segmental 58 pulmonary arteries involvement, with filling defects affecting corresponding pulmonary vein 59

Four out of six patients were males and the median age was 75 (range, 55-86). None of the 61 patients had a previous history of thromboembolic events, four had a history of arterial 62 hypertension, and only one had a relevant risk factor for thromboembolic diseases (cancer). The 63 mean time between COVID-19 symptom onset and hospital admission was 12 days (range, 9-16 64 days) while the mean time between hospital admission and the diagnosis of PTE was 9,3 days 65 (range, 5-17 days). On the day PTE was diagnosed, the PaO 2 /FIO 2 ratio was < 150 in all cases; 66 the leukocyte count ranged between 5970-31480/µL. Five patients showed reduced C-reactive 67

protein values compared to the assessment at the hospital admission. IL-6 levels were increased 68 in three patients (Table 1) . 69

The prevalence of PTE was substantially higher than the ones recorded in the previous three years 70 in the same 60-bed unit, admitting mainly patients with infectious diseases: 1.6% (13/ 801) in 2019, 71

1.4% (11/799) in 2018, and 1.8% (16/869) in 2017. Although the prevalence in our small cohort of 72 non-ICU patients is less than the one recently reported in ICU patients [1] , it seems to confirm the 73 increased risk of PTE in COVID-19 patients. 74

In our case series, the involvement of segmental and subsegmental branches of the pulmonary 75 arteries along with the peculiar multiple and bilateral filling defects distribution, suggest a non-76 embolic origin of the pulmonary arteries thrombosis [4] . Furthermore, the contiguity of most filling 77 defects to the parenchymal opacities suggests a link between the SARS-CoV-2-induced lung 78 inflammation and vascular occlusion, possibly explaining the severe respiratory impairment 79 detected in the patients. 80

Compared to the rates previously reported in patients with pneumonia or other severe infections, a 81 higher prevalence of PTE in patients with SARS-CoV-2 pneumonia might be inferred from this 82 small series. The absence of major risk factors for thromboembolic events in 5 out of 6 patients 83 seems to further confirm the role of bilateral SARS-CoV-2 pneumonia as a risk factor for PTE. 84

Considering that an undiagnosed thromboembolic process might worsen patients´ outcome, we 86 would suggest including a CTPA scan in the diagnostic assessment of patients with Sars-CoV-2 87 pneumonia, high D-dimer, and refractory or rapidly deteriorating hypoxemic respiratory failure. 

Prevalence of venous thromboembolism in patients with 119 severe novel coronavirus pneumonia

Difference of coagulation features between severe pneumonia 121 induced by SARS-CoV2 and non-SARS-CoV2

Abnormal coagulation parameters are associated with poor 123 prognosis in patients with novel coronavirus pneumonia

Pulmonary Thrombosis: A Clinical 126

Attention should be paid to venous 129 thromboembolism prophylaxis in the management of COVID-19