key: cord-0055655-kg4haban authors: Pla, Jordi Juanola; Rodriguez, Berta Ferreiro; Tirado, Concepció Falga title: Free-floating right heart thrombus with pulmonary embolism in SARS-CoV-2 patient date: 2020-11-13 journal: Med Clin (Engl Ed) DOI: 10.1016/j.medcle.2020.06.025 sha: fa988484f9ead0fa2f4b376ce77f96d2688f88ce doc_id: 55655 cord_uid: kg4haban nan Infection with SARS-COV-2 generates alterations in coagulation factors, mainly elevation of D-dimer values. These coagulation disorders jointly with activation of inflammatory factors trigger thrombotic events such as pulmonary embolism. 1 Although, presence of free floating right heart thrombus is unusual situation in patients with massive pulmonary embolism. A 56-year-old caucasian male with morbid obesity (BMI 45 kg/m 2 ), with 15-day history of dyspnea, myalgia and dry cough, was admitted to emergency room. First rapid SARS-CoV-2 PCR was negative, but with high clinical suspicion, pharmacological treatment was started. Tachypnea and dry crackles were observed at physical examination. Laboratories studies showed white-cell count 15.80 × 10 9 /L (12% lymphocytes), lactate dehydrogenase 425 UI/L, C-reactive protein 3.82 mg/dl and D-dimer 32,000 mcg/L. Arterial blood gas PaO 2 55 mmHg at room air. CT pulmonary angiography (CTPA) could not be performed due to patient's anthropometry. According to high probability of pulmonary embolism (PE), a transthoracic echocardiogram was practiced, revealing multiple thrombus at the right atrium and right ventricle, severe dilatation of the right cavities with signs of overload right ventricle and significant PAH (pulmonary arterial pressure 110 mmHg). Low molecular weight heparin was initiated. Despite negative PCR results, up to three SARS-CoV-2 PCR kept negative results. After a significant weight loss, CTPA could be performed showing filling defects in the main pulmonary artery consistent with pulmonary embolism and ground-glass areas in both upper lobes and left lower lobe. Patient rest instable with severe respiratory failure, subsequently thrombolysis with reteplase was performed with good outcomes. Echocardiogram after procedure showed the absence of intracardiac thrombus and reduced PAH (60 mmHg). Even though having three negative rapid SARS-CoV-2 PCR, 10 days later, serologies showed positive results for IgG (Elisa technique), which confirmed Covid-19 pulmonary affection diagnosis. SARS-COV-2 infection generates coagulation disorders with elevated D-dimer values, due to systemic pro-inflammatory cytokine to activate procoagulant factors, which predispose to thromboembolic events like PE. 2 Obesity (BMI > 35 kg/m 2 ) is widely reported as a risk factor for thromboembolic disease (especially pulmonary embolism and deep venous thrombosis). Thromboembolic mechanisms generated in morbid obesity include increased platelet activity, procoagulant states, altered fibrinolysis, and endothelial cell activation. 3 Dyspnea, as a prevailing symptom of COVID19 pneumonia, makes clinical recognition of PE quite challenging, therefore diagnostics tests are needed for rapid management, and imaging techniques such CT pulmonary angiography are conveniently. In patients with PE, the existence of intracardiac thrombosis in right cardiac cavities is unusual unless atrial fibrillation is set, occurring between 4 and 18% in cases of massive PE. Combination of massive PE an intracardiac thrombosis it's a medical emergency with increased mortality, which requires an urgent treatment. Thrombolysis is usually the best choice due to the double target of the therapy, the PE and the cardiac thrombus. 4 The diagnostic challenge that arises is that, even with the clinical suspicion of COVID19 infection, with acute respiratory failure and massive PE with intracardiac thrombosis, needing urgent diagnosis and treatment, plus a negative result of a PCR test cannot stop the attitude and management to follow up. The Real-Time reversetranscriptase polymerase chain reaction (RT-PCR) can present false negatives due to the low viral charge obtained in the sample, requiring the detection of antibodies for the diagnostic. Jin et al. show a sensitivity higher than 90% in IgM and IgG test compared to molecular detection, after 5 days since the realization of serological tests. 5 In conclusion, although obesity is an independent risk factor for thromboembolic events, other factors must be considered, especially coagulation disorders caused by COVID19 infection. Then, the presence of negative PCR for SARS-COV-2 healthcare providers should not neglect the disease, so a subsequent serological study may confirm the diagnosis. Authors declare no conflicts of interest. Dear Editor, The health crisis triggered by the SARS-CoV-2 (COVID-19) pandemic and its rapid onset have placed humanity in combat with a pathogen that cannot be won at this moment with any pharmacological treatment that boasts sufficient scientific evidence. 1 While awaiting the results of ongoing clinical trials with different therapeutic options and looking forward to a vaccine that allows population immunity to be achieved, intermediate, fast, safe and verifiable solutions are necessary with limited research effort. A recent study reports that patients affected by COVID-19 have a high viral load in the oropharynx, especially during the first week after the onset of symptoms, which would partly explain its high transmission rate, its contagiousness and its rapid geographical spread. 2 It is also known that different antiseptics (povidone iodine) have virucidal action on skin and mucosa, and are well tolerated for short-term treatments. 3 In 2015, a study reported that the in vitro application of antiseptic products with povidone iodine achieved a decrease in the titres of the MVA (Modified Vaccinia Ankara) and MERS-CoV (Middle East Respiratory Syndrome) viruses, corresponding to a viral inactivation greater than 99% after 30 and 15 s of applying the mouthwash product (1% concentration) in MVA and MERS-CoV, respectively. 4 These investigations were later expanded and with similar results both in the case of bacteria (Klebsiella pneumoniae Y Streptococcus pneumoniae) and with other viruses (SARS-CoV, influenza A-H1N1 and rotavirus). These findings are summarised in another publication in August 2019, prior to the epidemic situation. 5 It would be feasible to hypothesise that treatment with mouthwashes/gargling with antiseptics (povidone iodine or others) could contribute to reducing the viral load of COVID-19 in sick patients, as well as reducing contagiousness through respiratory droplets towards other persons and the environment. 4 This hypothesis could be tested quite simply and quickly by applying the scientific method with a study designed with paired data (cross-over or within patient), which would require a smaller number of patients. The viral load would be assessed before and after (at different times) the application of the oral antiseptic. Relevant questions to be resolved would be: an estimation of the minimum concentration necessary for the product to obtain positive results while minimising adverse effects; and determining the time during which the viral load in the oropharynx is low enough to have a protective effect for the It should be noted that the studies cited above 4,5 were sponsored by a specific manufacturer of povidone iodine, therefore future studies should ensure the independence of the research groups to avoid conflicts of interest. The proposition of other possible prophylactic/therapeutic options would also be of importance, especially as an alternative to those subjects with COVID-19 infection in which povidone iodine presents some contraindication or precaution (pregnant women, children, goiter or hyperthyroidism), as stated in the product's technical data sheet: . If positive results are obtained, this therapeutic option could be a practical and safe solution, pending more effective therapies or an adequate vaccine. It could be indicated for relatively short periods (1−2 weeks), coinciding with the greatest contagious wave. The application by the patient (in home isolation or during a hospital stay) would be simple to learn and to carry out. Additionally, antiseptics are easily accessible and are low cost, so this alternative could be feasible for countries with low economic resources. This proposal has been sent to Spain's Ministry of Health on behalf of the Drug Use Working Group of the Spanish Society of Family and Community Medicine (semFYC). Family practitioners are on the front line caring for patients with COVID-19 and trying to manage the elevated level of uncertainty in general and especially regarding the use of current drugs, that are all 'off-label' and lack the 'backing' of scientific evidence. 1 Possible solutions such as the one proposed, if its effectiveness is confirmed, even though modest, would contribute to improving the management of SARS-CoV-2 infection in both primary care and hospitals. In the current situation of health crisis, any step forward is a great step forward. 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