key: cord-0700257-ge99l6d6
authors: Dagar, Saloni; Rathi, Vinita
title: Incidental floating aortic thrombus in severe pulmonary COVID-19 infection
date: 2021
journal: Indian J Med Res
DOI: 10.4103/ijmr.ijmr_4590_20
sha: 4885c6fe6be28eb31867f31868f8faaedcfb5e4f
doc_id: 700257
cord_uid: ge99l6d6

nan

A 61 yr old male † presented to the Emergency department at Guru Teg Bahadur Hospital, Delhi, India, in August, 2020, with COVID-19 respiratory failure and elevated D-dimers (1970 ng/ml). His symptoms had started seven days ago. He had right bundle branch block on electrocardiogram (ECG) but no history of metabolic comorbidities or thrombophilia. Chest radiograph revealed bilateral lower lobe consolidation and subpleural ground-glass opacity in right mid zone. Non-invasive ventilation, thromboprophylaxis (enoxaparin 0.4 ml subcutaneously, once daily), intravenous dexamethasone, broad-spectrum antibiotics and aspirin were initiated. He also received convalescent plasma. After three weeks, he complained of chest pain. There was decreased air entry on the right side. ECG and cardiac markers suggested non-ST segment elevation myocardial infarction. A chest contrast-enhanced computed tomography (CECT) revealed right-sided tension pneumothorax ( Fig. 1A) with collapse of underlying lung. Lungs showed diffuse ground-glass opacity with septal thickening and patchy consolidation (Fig. 1A) . A pedunculated aortic thrombus was detected in the arch of aorta (Fig. 1B) . No thrombi were seen in the major branches of aorta in the neck, abdomen and pelvis. A small atherosclerotic plaque with focal calcification was seen in the descending thoracic aorta. ( Fig. 2A and B) . Cardiac chambers were normal in morphology. CT brain was normal. Aspirin, clopidogrel and warfarin (5 mg once daily) with enoxaparin (0.6 ml subcutaneously twice daily for five days) were given. Warfarin was adjusted to maintain an INR (international normalized ratio) between 2 and 3. An intercostal chest drain was inserted which led to expansion of the right lung. Follow up CT angiogram after four weeks revealed a decrease in the thickness of the pedunculated thrombus (Fig. 1C) . Despite being informed about the risks of distal thromboembolism due to the filamentous thrombus, the patient opted for conservative therapy. On follow up at six months, the patient had mild shortness of breath, but no peripheral embolism had occurred. Chest radiograph and echocardiogram were unremarkable except for mild tricuspid regurgitation and pulmonary artery hypertension. Thrombus is rare in a minimally atherosclerotic, non-aneurysmal aorta 1 . Severe SARS-CoV-2 infection can cause a hypercoagulable state and can rarely be associated with floating aortic thrombus, even with ongoing thromboprophylaxis 2,3 .

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