key: cord-0790542-nm34bfsl authors: Mahan, Keenan; Kabrhel, Christopher; Goldsmith, Andrew J. title: Abdominal pain in a patient with COVID-19 infection: A case of multiple thromboemboli date: 2020-05-26 journal: Am J Emerg Med DOI: 10.1016/j.ajem.2020.05.054 sha: 94de4d3d88cbbe972ed21f153d6118403c6636fc doc_id: 790542 cord_uid: nm34bfsl The novel coronavirus SARS-CoV-2 (COVID-19) pandemic has created diagnostic uncertainty with regards to distinguishing this infection from pulmonary embolism (PE). Although there appears to be an increased incidence of thromboembolic disease in patients with COVID-19 infection, recommendations regarding anticoagulation are lacking. We present the case of a 61-year-old woman with clinically significant venous and arterial thromboemboli in the setting of COVID-19 infection requiring tissue plasminogen activator (tPA). The novel coronavirus pandemic has had widespread global impact with over 3.3 million cases and 238,000 deaths as of early May. [1] Many COVID-19 patients requiring hospitalization have symptoms indistinguishable from conditions such as pulmonary embolism (PE). [2, 3] To further complicate the clinical situation, many patients have D-dimer elevations and are at increased risk of thromboembolic complications. [4] [5] [6] [7] [8] [9] [10] [11] [12] Given the virulence of COVID-19, further radiological testing beyond chest radiography (CXR) is debated. In addition, there is no clear guidance as to whether anticoagulation should be initiated for emergency department (ED) patients with presumed COVID-19 and elevated D-dimer. We thereby present a patient who was found to have significant venous and arterial thromboembolic disease in the setting of COVID-19 infection. A 61-year-old woman with a pertinent medical history of type II diabetes mellitus presented to the ED with three days of dry cough and one day of non-radiating abdominal pain. She reported sharp, severe, periumbilical pain which began acutely that morning. On review of symptoms she denied nausea, vomiting, diarrhea as well as fevers, shortness of breath and chest pain. Of note, her husband was diagnosed with COVID-19 the day before. In the ED, her initial vital signs were notable for tachypnea at 34 respirations per minute, hypoxemia to 87% on room air, tachycardia to 112 beats per minute, and a blood pressure of 144/83. Her hypoxemia improved to 96% with 4L/min of supplemental oxygen via nasal cannula. On exam, the patient was speaking in full sentences and had periumbilical tenderness without rebound or guarding. Based on her symptoms we ordered laboratory work, a chest x-ray (CXR), a COVID-19 reverse transcription polymerase chain reaction (RT-PCR) test, and a computerized tomography (CT) scan of the abdomen and pelvis. The patient's CXR demonstrated bilateral peripheral opacities consistent with COVID-19 infection ( Figure 1 ) and her D-dimer returned elevated at 8,264ng/mL. Based on the patient's hypoxemia, persistent tachycardia, and marked D-dimer elevation, we ordered a CT pulmonary angiogram which revealed multiple filling defects in the thoracic and abdominal aorta representing thromboemboli as well as diffuse bilateral ground glass opacities in the lungs (Figure 2) . The CT scan also revealed a right ventricular (RV) filling defect concerning for thrombus, which was later confirmed on transthoracic echocardiogram ( Figure 3 ). Her CT abdomen/pelvis revealed no additional acute pathology. We initiated therapeutic unfractionated heparin and admitted the patient. Within 24 hours, she developed worsening dyspnea and hypoxemia and received tissue plasminogen activator to treat her RV clot-in-transit and presumed PE. The COVID-19 RT-PCR returned positive the same day. In our patient, an elevated D-dimer led us to order a CT pulmonary angiogram that found multiple venous and aortic thromboemboli. In COVID-19, elevated D-dimer levels are common and thought to be secondary to the inflammatory response causing a hypercoagulable state. [3, 10, 13] Studies suggest D-dimer levels >5x normal are associated with poor outcomes, including thromboembolic complications. [4, [6] [7] [8] 14, 15] However, no guidance regarding further imaging and anticoagulation is provided. COVID-19 Map -Johns Hopkins Coronavirus Resource Center Clinical Characteristics of 138 Hospitalized Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Hematological findings and complications of COVID-19 Clinical features and treatment of COVID-19 patients in northeast Chongqing Critically Ill COVID-19 Infected Patients Exhibit Increased Clot Waveform Analysis Parameters Consistent with Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis Pulmonary Embolism or Pulmonary Thrombosis in COVID-19? Is the Recommendation to Use High-Dose Heparin for Thromboprophylaxis Justified? Comparison of clinical and pathological features between severe acute respiratory syndrome and coronavirus disease Zhonghua Jie He He Hu Xi Za Zhi Incidence of thrombotic complications in critically ill ICU patients with COVID-19 Clinical course and risk factors for mortality of J o u r n a l P r e -p r o o f adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy ISTH interim guidance on recognition and management of coagulopathy in COVID-19 COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents Diagnosing centrally located pulmonary embolisms in the emergency department using point-of-care ultrasound J o u r n a l P r e -p r o o f