key: cord-0863557-tgrori7s authors: Espinoza, Javier Alejandro Lecca; Júnior, Jorge Elias; Miranda, Carlos Henrique title: Atypical COVID–19 presentation with Budd-Chiari syndrome leading to an outbreak in the emergency department date: 2021-02-01 journal: Am J Emerg Med DOI: 10.1016/j.ajem.2021.01.090 sha: 0f0dd99eed72731e81c33abc183ef6d5ec05c6c1 doc_id: 863557 cord_uid: tgrori7s We described a case report of a 50 years-old-woman admitted to the emergency department with abdominal pain associated with febrile hepatosplenomegaly with the final diagnosis of suprahepatic vein thrombosis secondary to COVID-19. Initially, this patient stayed out of a private room because of this atypical presentation and caused a COVID-19 outbreak in the emergency department. The SARS-CoV-2 virus infection causes a broad spectrum of presentation, ranging from asymptomatic or mild upper airway symptoms to acute respiratory failure. (1) The recognition of a vascular involvement associated with a hypercoagulable state allows atypical clinical presentation with any vascular territory involvement. (2, 3) We describe an atypical presentation of coronavirus disease 2019 (COVID-19) with Budd-Chiari syndrome due to hepatic vein thrombosis without respiratory symptoms during the early phase that causes an emergency department outbreak because this patient was not initially placed into a private room. A 50-years-old woman was admitted to the emergency department with severe right upper quadrant abdominal pain for six days associated with nausea and vomiting. She observed both jaundice and unmeasured fever two days before hospitalization. The patient has a previous asthma diagnosis and uses an inhalator corticoid. She denied pregnancy, oral contraceptive use, and alcohol consumption. On physical examination, we observed jaundice and pain during palpation of the right upper quadrant abdominal. Her vital signals on presentation showed a blood pressure of J o u r n a l P r e -p r o o f Journal Pre-proof 110/70 mmHg, a pulse of 95 beats per minute, respiratory rate of 20 cycles per minute, and arterial oxygen saturation of 96% on room air. Initially, she denied any respiratory symptoms. The general laboratory tests are shown in Table 1 . Abdominal ultrasound showed hepatomegaly and enlarged spleen, without biliary tract obstruction and ascites. Firstly, the differential diagnosis was performed among some infectious or autoimmune diseases. However, the laboratory tests for infectious and autoimmune diseases were negative. Table 1 On the third day of hospitalization, the patient started with a sore throat and a runny nose. At this moment, she was placed Figure 1 The patient received anticoagulation with rivaroxaban 20 mg/day. Laboratory evaluation for thrombophilia was performed, and the tests did not confirm this diagnosis, except for the presence of low levels of anti-cardiolipin IgM. Table 1 The patient presented a good clinical evolution with normalization of the liver biochemical tests. A new MRI was performed three months later and showed complete resolution of thrombosis of the left suprahepatic vein, and the repeated anti-cardiolipin IgM was negative. This patient's clinical presentation was compatible with a Budd-Chiari syndrome, and since no other predisposing factor was found, we believe that this event was related to SARS-CoV-2 infection. Initially, because of this atypical presentation, this patient stayed out of a private room. After this, twenty healthcare workers of the emergency department were confirmed for J o u r n a l P r e -p r o o f Journal Pre-proof SARS-CoV-2 infection in the next two weeks. We hypothesized that this patient could have been the index case of this hospital outbreak. COVID-19 is associated with a hypercoagulable state. (2) High rates of thrombotic These events associated with COVID-19 seem to be related to in situ thrombosis caused by multifaceted mechanisms included activated coagulation, endotheliopathy, up-regulated innate and adaptive immunity, and the activated complement system. (2) Post-mortem liver biopsies from 48 patients died from severe pulmonary COVID-19 disease confirm that liver failure is not a main concern and this organ is not the target of significant inflammatory damage. On the other hand, the findings are highly suggestive for marked derangement of intrahepatic blood vessel network secondary to systemic changes induced by the virus. (14) The emergency physician needs to recognize these atypical manifestations and place patients with similar presentations immediately into the private room while waiting for RT-PCR for SARS-CoV-2 virus results to avoid emergency department outbreaks. Thrombosis of an abdominal vessel (portal vein, suprahepatic vein, mesenteric vein, etc.) should be remembered as a differential diagnosis in patients with undefined abdominal pain and elevated liver biochemical tests in the department emergency during COVID-19 pandemic. COVID-19-associated vasculitis and vasculopathy Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis Abdominal pain in a patient with COVID-19 infection: A case of multiple thromboemboli Gastric ischemia and portal vein thrombosis in a COVID-19-infected patient Acute Portal Vein Thrombosis in SARS-CoV-2 Infection: A Case Report Portal vein thrombosis in a patient with COVID-19 Hepatobiliary and Pancreatic: A fatal case of extensive splanchnic vein thrombosis in a patient with Covid-19 Inferior mesenteric vein thrombosis and COVID-19 The Budd-Chiari syndrome Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19 Liver histopathology in severe COVID 19 respiratory failure is suggestive of vascular alterations The authors declare no conflict of interest.