key: cord-1015471-dpgk9bvc authors: Graziani, A.; Domenicali, M.; Zanframundo, G.; Palmese, F.; Caroli, B.; Graziani, L. title: Pulmonary artery thrombosis in COVID-19 patients date: 2020-08-24 journal: Pulmonology DOI: 10.1016/j.pulmoe.2020.07.013 sha: 22b0a3d1a375eb08f850c9270d6241e481fcc98a doc_id: 1015471 cord_uid: dpgk9bvc nan COVID-19 has been accurately described as the cause for a proinflammatory and hypercoagulable state with marked elevations seen in Lactate Dehydrogenase, Ferritin, C-reactive protein, D-Dimer, and Interleukin levels [2] . The inflammatory response, including production of inflammatory cells and cytokines, induces a procoagulant effect and diffuse endothelial damage that predisposes thrombotic vascular lesions and Disseminated Intravascular Coagulation (DIC) [3] . D-Dimer is related to the severity of the disease and an increased value is associated with the worst .prognosis. Retrospective studies demonstrated that patients admitted to Intensive Care Unit (ICU) had an elevated D Dimer value and, in this setting, some Authors recommended a therapeutic heparin doses for the patients with higher values [4] . A recent ICU obs ervation reported an increased risk of Pulmonary Embolism (PE) in COVID-19 compared to the historical control group even in patients that had undergone the Low Molecular Weight Heparin prophylaxis [5] . We evaluated 138 patients with COVID 19 admitted to our Institution between March 2020 and May 2020. All patients were COVID 19 positive according to clinical diagnostic criteria reversetranscription-polymerase chain-reaction (RT-PCR) and Chest Thoracic tomography. On admission, most of them were haemodynamically stable (78%) and febrile (87%). During hospitalization, some developed progressive respiratory failure and received oxygen supplementation (41%). Four of them were started on Continuous Positive Airways Pressure (CPAP) but two died because of worsening Respiratory Failure. All patients were treated with hydroxycloroquine (400 mg/day), darunavir/ritonavir (800/100 mg/day) and enoxaparin (4000 UI/day). Some patients (26 pts) received additional therapy with IL- In Table 1 negative control group [7] . Another Study reported that the prevalence of Venous Thromboembolism Events (VTE) was higher in ICU compared to general wards patients: 47% vs 3% [8] . High blood values of the procoagulant factor levels including fibrinogen and D-dimers have been associated with the worst prognosis and higher mortality. Kaminetzky and coworkers compared the results of a cohort of 62 patients who underwent CTPA for suspected PE prior to the first case of COVID 19, with 62 patients COVID 19 positive [9] . CTPA was positive for PE in 37% of COVID 19 patients (14,5 % in pre COVID patients), D-Dimer was associated with a higher prevalence of thromboembolic events and correlated with the degree of PE severity. In a group of patients admitted to non-ICU wards, DU failed to detect DVT independently of the severity of their condition and length of in-hospital bed rest. The Authors observed that this is apparently in contrast with the relatively frequent reports of PE in hospitalized COVID-19 patients It is possible that local thrombi in the lungs may be the cause of pulmonary arterial manifestations [10] . In this paper we reported COVID-19 patients with interstitial pneumonia admitted in our non-ICU Ward. During the course of hospitalization, in eleven of them, we observed a progressive increase of D-Dimer over three times the normal value, associated with low or normal values of other coagulation or inflammatory blood parameters (CRP, LDH, Ferritin, fibrinogen, INR, aPTT). Nine CTPA demonstrated a distal thrombosis of the lower pulmonary arterial branches. The mainly basal localization where the pulmonary inflammation is most diffuse and the loss of signs of DVT may suggest a pulmonary thrombosis rather than an embolism. It is noteworthy that no patients had any signs of respiratory worsening and some of them did not receive oxygen therapy and they were breathing room air. Further studies will need to better define the meaning of these preliminary observations. J o u r n a l P r e -p r o o f Table 1 . Laboratory parameters in patients with Pulmonary Artery Thrombosis (PAT) and the patients without PAT. (*) P< 0,05 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan Thromboinflammation and the hypercoagulability of COVID-19 Ematological findings and complications of COVID-19 Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy Pathological findings of COVID-19 associated with acute respiratory distress syndrome Disseminated intravascular coagulation in patients with 2019-nCoV pneumonia Pulmonary Embolism in COVID-19 Patients: Awareness of an Increased Prevalence Incidence of venous thromboembolism in hospitalized patients with COVID-19 Pulmonary Embolism on CTPA in COVID-19 Patients Incidence of thrombotic complications in critically ill ICU patients with COVID-19 Pulmonary Embolism or Pulmonary Thrombosis in COVID-19? Is the Recommendation to Use High-Dose Heparin for Thromboprophylaxis justified?