key: cord-0905262-euyoj9v2 authors: Cohen, Clay T.; Riedl, Ruth A.; Gowda, Srinath T.; Sartain, Sarah E.; Bashir, Dalia A. title: Pulmonary embolism in pediatric and adolescent patients with COVID‐19 infection during the SARS‐CoV‐2 delta wave date: 2022-04-19 journal: Pediatr Blood Cancer DOI: 10.1002/pbc.29721 sha: 3d04906a583cf0694bb1bcb935a7af23497b3a10 doc_id: 905262 cord_uid: euyoj9v2 Coronavirus disease 2019 (COVID‐19) infection in children has been associated with thrombosis, though few cases of COVID‐associated pulmonary embolism (PE) have been described. We performed a retrospective review of the nine cases of COVID‐19‐associated PE during the B.1617.2 variant surge at Texas Children's Hospital. The patient cohort largely contained unvaccinated obese adolescents. All patients were critically ill with two requiring catheter‐directed thrombolysis in addition to anticoagulation. Eight of the nine patients had COVID pneumonia along with PE. This report stresses the importance of maintaining a high index of suspicion for PE in pediatric COVID‐19 infection and vaccinating obese adolescent patients. Coronavirus disease 2019 (COVID-19) infection has been associated with the development of micro-and macrovascular thrombosis due to inflammation-driven endothelial dysfunction and a hypercoagulable state. 1, 2 Children and adolescents have increased markers of inflammation and coagulopathy (elevated D-dimer, fibrinogen, and prothrombin time) and rates of thrombosis in acute COVID-19 infection. [3] [4] [5] Clinicians caring for critically ill children hospitalized with COVID-19 or those with underlying thrombotic risk factors should consider thromboprophylaxis to prevent the thrombotic complications of COVID infection. [6] [7] [8] [9] Hospitalized older children (12 years and over) have the highest risk of COVID-associated thrombosis, with an incidence of 2.1%. 3 This study was undertaken to review the clinical characteristics of pediatric COVID-19-associated pulmonary embolism (PE) diagnosed and treated at Texas Children's Hospital (TCH) during the B.1617.2 delta variant wave. We report a case series of patients admitted to TCH with COVID- All patients were critically ill requiring intensive care admission, with eight (88.9%) presenting with hypoxia, and three (33.3%) requiring invasive mechanical ventilation. Hypoxia was considered multifactorial from PE, COVID-19 pneumonia, and possible pulmonary infarction. The median number of days from COVID-19 diagnosis to PE diagnosis, and admission to PE diagnosis was 9 (range 0-16), and 0 (range 0-8), respectively. The median length of intensive care admission was 4 days (range 1-15). Anticoagulation was administered to all patients following PE diagnosis, though only one patient was receiving prophylactic anticoagulation prior to PE diagnosis. See Supporting Information for further details of thromboprophylaxis in this cohort. Four patients had evidence of myocardial dysfunction, as evidenced by echocardiography findings and elevations in myocardial enzymes. Two of the four patients had evidence of severe right ventricular heart dysfunction with hemodynamic instability and inotropic requirement, therefore undergoing catheter-directed thrombolysis (0.5-1 mg/h for 12 hours) for management of massive PE. An example of the computed tomography (CT) and echocardiogram findings in a 14-year-old patient with heart dysfunction secondary to PE is demonstrated in Figure 1 . Two patients had extremity thrombi in addition to their PE. Five of the seven who were not diagnosed with extremity DVT had screening Doppler sonograms of their extremities, while two did not. There were no deaths in the cohort. Two clinically relevant, nonmajor bleeding events (episodes of hemoptysis and epistaxis) occurred in two patients while receiving anticoagulation, though neither received thrombolysis. COVID-19 pneumonia, in addition to PE, was diagnosed via imaging in eight (88.9%) of the patients. A breakdown of each patient's presentation, PE, and treatment course is demonstrated in Table 1 . Follow-up and PE outcome information is presented in Supporting Information. The COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection Pulmonary embolism and deep vein thrombosis in COVID-19: a systematic review and meta-analysis. Radiology Rate of thrombosis in children and adolescents hospitalized with COVID-19 or MIS-C Are children with SARS-CoV-2 infection at high risk for thrombosis? Viscoelastic testing and coagulation profiles in a case series of pediatric patients Children and young adults hospitalized for severe COVID-19 exhibit thrombotic coagulopathy Consensus-based clinical recommendations and research priorities for anticoagulant thromboprophylaxis in children hospitalized for COVID-19-related illness Severe acute respiratory syndrome coronavirus 2 clinical syndromes and predictors of disease severity in hospitalized children and youth How we approach thrombosis risk in children with COVID-19 infection and MIS-C. Pediatr Blood Cancer COVID-19-associated pulmonary embolism in pediatric patients Metabolic syndrome and COVID 19: endocrine-immune-vascular interactions shapes clinical course Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease Pulmonary embolism in pediatric and adolescent patients with COVID-19 infection during the SARS-CoV-2 delta wave. Pediatr Blood Cancer. 2022;e29721 The authors declared that there is no conflict of interest. Clay T. Cohen https://orcid.org/0000-0001-6819-4049