key: cord-0991914-rai0i4ws authors: Pisano, Thomas John; Joki, Jaclyn; Hon, Beverly; Cuccurullo, Sara title: Pulmonary Embolism after Acute Spinal Cord Injury and COVID-19: A Case Report date: 2020-08-28 journal: Am J Phys Med Rehabil DOI: 10.1097/phm.0000000000001578 sha: 96f9c760045651cba5d44026dc206ee9882593d4 doc_id: 991914 cord_uid: rai0i4ws The coronavirus virus disease 2019 (COVID-19) is best known for its pulmonary sequelae. Understanding of the disease process is rapidly growing and the medical community already appreciates a hypercoagulable state associated with COVID-19. Acute spinal cord injury (SCI) has an inherent increased risk for venous thromboembolism (VTE). In this case report the patient presented with bilateral lower extremity weakness and sensory loss secondary to thoracic disc herniation. Incidentally, at the same time as the initial presentation, the patient was also found to have COVID-19 without significant respiratory symptoms. During hospitalization, the patient developed extensive bilateral lower extremity deep vein thrombosis (DVT) despite chemoprophylaxis. Therapeutic anticoagulation was initiated, yet several days later he developed pleuritic chest pain. Computed tomography (CT) angiography revealed bilateral pulmonary emboli. This case highlights the need for clinicians to have elevated vigilance in regards to screening and treatment for VTE in high-risk patients, such as SCI with a concurrent diagnosis of COVID-19. A 48 year old male, with a history of chronic low back pain, presented to an outside hospital emergency department with an exacerbation of back pain. He denied any falls, trauma or recent back injuries. At initial presentation he had no motor or sensory changes and no bowel or bladder involvement. He was discharged to his home on the same day of presentation with a sixday course of oral steroids and nonsteroidal anti-inflammatories. One week later, the patient returned to the outside hospital with new complaints of urinary retention, constipation, lower extremity weakness and sensory impairment. A magnetic resonance imaging (MRI) scan revealed multilevel degenerative disk disease with a T11-12 compressive mass of unclear etiology, for which he was given 10 mg of intravenous (IV) dexamethasone. Acute kidney injury (AKI) was noted with a creatinine of 11.5 mg / dl (normal 0.5 -1.2 mg / dl). A foley catheter was placed and IV fluids were administered. He was found to have polymerase chain reaction (PCR) positivity for SARS-CoV-2. At this time, he denied having any known clinical symptoms consistent with COVID-19 including fever, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting or diarrhea. The patient was transferred to a tertiary facility for higher level of neurosurgical care for his spinal cord compression. Upon arrival at the tertiary center, the patient was afebrile with stable blood pressure, but mildly tachycardic (103 beats per minute) and his oxygen saturation was 96% on room air. The patient appeared comfortable with normal respiratory effort, with equal bilateral breath sounds without rales, wheezes or rhonchi. The patient had no lower extremity motor or sensory function. Initial d-dimer level was 83,881 ng / ml (normal 0 -500 ng / ml) and c-reactive protein (CRP) level was 13.95 mg / dl (normal 0.0 -0.7 mg / dl; see Figure 1A for laboratory value trends). Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. COVID-19 status was confirmed via SARS-CoV-2 PCR. Chest radiography on admission revealed bibasilar opacities consistent with atelectasis ( Figure 1B ). Intermittent pneumatic compression devices were used for mechanical VTE prophylaxis as chemoprophylaxis was held given pending neurosurgery. The patient underwent a T10-L1 decompressive laminectomy with removal of a large extruded T11-12 herniated disc performed by neurosurgery on hospital day two, without other intraoperative pathology noted, and was started on VTE chemoprophylaxis with heparin 5000 units administered subcutaneously three times a day after clearance by neurosurgery on hospital day three. Physiatry was consulted on hospital day six and neurological examination showed the patient had T11 American Spinal Injury Association Impairment Scale (AIS) A paraplegia. AKI from urinary retention secondary to neurogenic bladder had resolved with creatinine returning to normal range. Neurogenic bladder management options were discussed including continuous indwelling foley versus training with intermittent straight catheterization program. Increased DVT risk in SCI was also discussed with the primary team. Indwelling foley catheter was continued for neurogenic bladder management. The patient was without any significant clinical signs or symptoms of DVT and was continued on VTE chemoprophylaxis. On hospital day ten the patient developed a fever (102.4 F temperature maximum) with tachycardia (120 beat per minute maximum) but was not in any acute respiratory distress (96-100% oxygen saturations on room air with 18-20 respirations per minute). Urinary tract infection (UTI) from Escherichia coli was diagnosed and treatment with antibiotics was initiated. Bilateral lower extremity venous duplex ultrasound was performed and extensive DVT of the left leg Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. involving the femoral, popliteal, gastrocnemius, soleal, posterior tibial and peroneal veins were found; DVT of the right peroneal and soleal veins were also noted ( Figure 1C ). Within two hours of DVT diagnosis and with clearance from neurosurgery, his anticoagulation was changed from chemoprophylaxis dosing to therapeutic dosing using a heparin algorithm infusion (1650 units/hour) with a partial thromboplastin time (PTT) target range of 50-70 seconds. No bolus on initiation of algorithm and no heparin boluses throughout treatment were given. One day later his PTT increased from 30 to 48 seconds. His D-dimer was still abnormally high but was downtrending; however, it had doubled from two days prior ( Figure 1A ). On hospital day fourteen the patient developed new right lower pleuritic chest pain. He was maintaining oxygen saturation percentages between 96-98% on room air without complaints of dyspnea. A computed tomography angiogram (CTA) found pulmonary emboli involving the left lower lobe and right middle lobe pulmonary arteries as well as segmental involvement in the right lower lobe ( Figure 1D ). His heparin algorithm infusion was changed to 1650 units/hr with a PTT goal of 60-100 seconds. Anticoagulation was transitioned to oral 15 mg rivaroxaban at a dose of 15 mg two times per day on hospital discharge. The patient was discharged home on hospital day sixteen with home care services and outpatient follow up. A major social challenge of this case was that the patient was an This is the first published case report in the United States of acute SCI with COVID-19. The patient presented with bladder and bowel dysfunction, as well as lower extremity motor and sensory loss from acute SCI secondary to a large compressive lower thoracic disk herniation. After neurosurgical laminectomy and discectomy, the patient's neurological function did not significantly improve, continuing with T11 AIS A paraplegia. Concurrently, the patient was PCR positive for SARS-CoV-2 virus, both at an outside hospital and at a tertiary hospital, without clinically apparent COVID-19 symptoms. It is now understood that a substantial number of patients can be asymptomatic carriers of SARS-CoV-2 12 and second the aforementioned hypercoagulability secondary to COVID-19 4 . Further evidence of his prothrombotic state was a d-dimer level at presentation of 83,881 ng / mL (over 150 times the upper limit of normal). Immensely elevated d-dimers are also consistent with reports of COVID-19 patients 25 . Interestingly, just before the diagnosis of the DVT and UTI there was an increase in both d-dimer and CRP ( Figure 1A ). There have been several methods utilized in VTE prophylaxis in SCI including vena cava filters and chemoprophylaxis 21 . In this patient's case, standard dosing of heparin for chemoprophylaxis failed to prevent DVT formation. The patient was switched to a therapeutic level of anticoagulation using a heparin algorithm infusion after diagnosis of DVT. Yet, several Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study WHO Timeline -COVID-19 Incidence of thrombotic complications in critically ill ICU patients with COVID-19 Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia COVID-19 presenting as stroke. Brain Behav Immun Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young Primary prevention of deep venous thrombosis and pulmonary embolism in acute spinal cord injured patients Pulmonary embolism and deep vein thrombosis COVID-19 tsunami: the first case of a spinal cord injury patient in Italy A Patient with Acute Cervical Cord Injury and COVID-19: A First Case Report Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19). Epidemiology Covid-19: four fifths of cases are asymptomatic, China figures indicate A Review of Coronavirus Disease-2019 (COVID-19) COVID-19-Related Severe Hypercoagulability in Patients Admitted to Intensive Care Unit for Acute Respiratory Failure. Thromb Haemost. patient with mild clinical expression of COVID-19 Venous thromboembolism prophylaxis with unfractionated heparin in the hospitalized medical patient: the case for thrice daily over twice daily dosing ISTH interim guidance on recognition and management of coagulopathy in COVID-19 WACEM Consensus Paper on Deep Venous Thrombosis after Traumatic Spinal Cord Injury Deep vein thrombosis in acute spinal cord injury Venous thromboembolism in acute spinal cord injury patients Coagulation changes in elective surgery and trauma D-dimer levels on admission to predict in-hospital mortality