scholarly journals 216 The ‘inflammatory perfect storm’: a case of COVID-19 pneumonia complicated by pulmonary embolism

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Maria Colangelo ◽  
Lidia Colangelo ◽  
Paola Paone ◽  
Roberto Ceravolo
Keyword(s):  
Pulmonary Embolism ◽  
Troponin I ◽  
White Blood Cells ◽  
Right Ventricular Dysfunction ◽  
Haemodynamic Instability ◽  
Conduction Time ◽  
Bundle Branch Block ◽  
Reactive Protein ◽  
Thrombotic Complications ◽  
Perfect Storm

Abstract Aims The inflammatory ‘cytokine storm’ that distinguishes COVID-19 pneumonia is associated with a state of systemic hypercoagulability, which leads to thrombotic complications on the venous, arterial, and microvascular side. Indeed, in patients with COVID-19, systemic inflammation, coagulation activation, hypoxemia, and immobilization expose a high risk of pulmonary embolism, which significantly worsens the prognosis of these patients. Methods and results In this report, we discuss the case of a 71-year-old female, with no prior medical history, admitted to the emergency department for syncope, dyspnoea, and fever started 48 h earlier. At presentation, ear temperature was 37 °C, oxygen saturation was 96% on oxygen therapy (6 l/min), the patient appeared hypertensive (160/80 mmHg) and tachycardic (114 b.p.m.). Laboratory tests revealed normal white blood cells count (10 000/μl) and increased C reactive protein (5.60 mg/dl), troponin I (0.417 ng/ml), and d-dimer levels (15743 ng/ml). Electrocardiogram showed sinus tachycardia at HR of 120/min, normal atrioventricular conduction time, new onset right bundle branch block, and inverted T waves on DIII. Considering the symptoms, CTPA was performed, revealing massive acute bilateral pulmonary embolism with peripheral ground glass opacities. Those findings were suggestive of COVID-19 pneumonia. Indeed, the patient was positive for SARS-CoV-2 infection, and a diagnosis of COVID-19 pneumonia complicated by pulmonary embolism was made. Treatments included oxygen, subcutaneous low molecular weight heparin (LWMH), and corticosteroids have been administrated according to current international guidelines. Since no haemodynamic instability was observed during hospitalization the patient was discharged on Warfarin therapy for 6 months. Conclusions In COVID-19 patients treated in a hospital the incidence of pulmonary embolism (PE) is very high. Patients with COVID-19 infection have respiratory symptoms, which often may not be distinguishable from pulmonary embolism symptoms. So, unexpected respiratory worsening, signs of right ventricular dysfunction on transthoracic echocardiogram, and ECG changes should lead to suspicion of the co-presence of pulmonary embolism. This case report shows how COVID-19 infection can be strongly associated with thrombotic complications. For this reason, the guidelines recommend anticoagulation at standard prophylactic doses in all patients admitted with COVID-19 infection.

scholarly journals Erysipelas Complicated with Acute Exudative Pericarditis

Medicina ◽  
2020 ◽  
Vol 56 (11) ◽  
pp. 571
Author(s):  
Akvilė Gečaitė ◽  
Aušra Vainalavičiūtė ◽  
Daiva Emilija Rekienė ◽  
Laima Jankauskienė ◽  
Albinas Naudžiūnas
Keyword(s):  
Troponin I ◽  
Epigastric Pain ◽  
White Blood Cells ◽  
Pericardial Fluid ◽  
C Reactive Protein ◽  
St Segment Elevation ◽  
Pericardial Cavity ◽  
Reactive Protein ◽  
St Segment ◽  
The Face

Erysipelas is a common skin infection of the upper dermis. Its most common complications are local; these include abscess formation, skin necrosis, etc. In the present article, we introduce a case of a 75-year-old patient with erysipelas of the face complicated with acute exudative pericarditis. The patient came to Kaunas Clinical Hospital complaining of extreme fatigue and fever, oedema of the left side of the face, and erythema typical for erysipelas. The patient also felt sternum and epigastric pain, especially during breathing, and dyspnoea. Heart work was rhythmic 100 bpm; blood pressure was 142/70 mmHg. Pericardial friction rub was heard over the left sternal border. There were no alterations in other systems. In the electrocardiogram, concave ST segment elevation in leads II, III, and aVF was identified. In addition, during hospitalisation, the patient experienced atrial fibrillation paroxysm, which was treated with amiodarone intravenously. The blood test showed C-reactive protein: 286 mg/L; white blood cells: 20 × 109/L; troponin I was within the normal range. During echocardiography, pericardial fluid in pericardial cavity was identified. As no changes in troponin I were observed, according to the ST segment elevation, the woman was diagnosed with erysipelas of the left side of the face complicated with acute exudative pericarditis. Antibacterial treatment of cephalosporins was administered. After the treatment, C-reactive protein decreased to 27.8 mg/L; whereas, in the electrocardiogram, the return of the ST segment to the isoline was observed, and pericardial fluid resorbed from the pericardial cavity. To the best of the authors’ knowledge, this case is a rare combination of erysipelas complicated with acute exudative pericarditis.

scholarly journals The first experience of treatment applied to patients with pulmonary embolism that developed on the COVID-19 background

2021 ◽  
Vol 98 (8) ◽  
pp. 612-618
Author(s):  
S. A. Fedorov ◽  
A. P. Medvedev ◽  
A. L. Maksimov ◽  
N. Yu. Borovkova ◽  
M. B. Sukhanova ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Troponin I ◽  
Diastolic Pressure ◽  
Systolic Pressure ◽  
Systemic Thrombolysis ◽  
Reactive Protein ◽  
Results Of Treatment ◽  
The Moment ◽  
The Right

The aim of the study was to evaluate the immediate results of treatment of high-risk PE developed against the background of COVID-19, and to analyze the features of the clinical course. Material and methods. The study is based on the experience of treatment applied to three patients with pulmonary embolism (PE) that developed against the background of COVID-19. The group under consideration is represented by males. The average age was 41 ± 3.1 years old. Verification of the primary diagnosis of COVID-19 was based on positive results of polymerase chain reaction, supplemented by the results of computed tomography. The formation of high-risk PE was noted on the 5th–7th day from the moment of hospitalization. There was also a decrease in SO2 below 85%, РаО2 — below 76 mm Hg, Borg index > 8, which required non-invasive high-flow ventilation. Catheterization of the right chambers of the heart with a Swan–Ganz catheter revealed an increase in systolic pressure in the right ventricle to 57 ± 1.2 mm Hg, and diastolic pressure to 13 ± 0.34 mm Hg. Pulmonary hypertension increased up to 70 mm Hg. Changes in the biochemical analysis of blood consisted in increasing the level of troponin I to 0.65 ± 0.14 ng/ml, С reactive protein — to 5.42 ± 2.1 mg/l, and creatine phosphokinase — to 324 ± 23.1 units. An increase in the D-dimer level was observed (0.68 ± 0.11 mg/l). Systemic thrombolysis actilyse was performed in all the cases. Results. Positive clinical dynamics was observed up to 15 hours after thrombolytic therapy. The level of SO2 came back to the initial values and was in the range 93–96% and RaO2 — from 86–92 mm Hg by the end of the first day after the intervention. The average pressure gradient in the pulmonary artery was 32 ± 4.12 mm Hg at the time of discharge, and at the peak — 44 ± 5.3 mm Hg.

scholarly journals Pulmonary Embolism with Floating Right Atrial Thrombus Successfully Treated with Streptokinase

2017 ◽  
Vol 7 (1) ◽  
pp. 60-63
Author(s):  
Sahela Nasrin ◽  
Mohammad Salahuddin ◽  
Fathima Aaysha Cader ◽  
Md Jabed Iqbal ◽  
Tahera Nazrin ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Ventricular Dysfunction ◽  
Right Ventricular Dysfunction ◽  
Recombinant Tissue Plasminogen Activator ◽  
Right Atrial ◽  
Haemodynamic Instability ◽  
Atrial Thrombus ◽  
Pulmonary Angiogram ◽  
Right Atrial Thrombus

Massive Pulmonary Embolism (PE) is associated with significant mortality, especially if compounded by haemodynamic instability, right ventricular dysfunction and right atrial thrombus. Thrombolysis can be lifesaving in patients with major embolism and cardiogenic shock, and accelerates the resolution of thrombus. Only three fibrinolytic agents - namely streptokinase, urokinase, and recombinant tissue plasminogen activator (Alteplase) have been approved in the treatment of PE, with studies demonstrating similar safety profiles. We report the case of a 33 year old Bangladeshi female with a history of recent ankle fracture and immobilization, who presented with massive PE, leading to cardiac arrest. Upon rapid resuscitation, urgent echocardiogram revealed right ventricular dysfunction with floating right atrial thrombus, and she was successfully treated with 1.5 million IU of Streptokinase over 2 hours as per accelerated regimen recommended by the European Society of Cardiology (ESC) guidelines, resulting in successful resolution of the right heart thrombus, and significant clinical improvement. Subsequent CT Pulmonary Angiogram confirmed the diagnosis of PE, and she was anticoagulated to a PT/INR of 2.0 to 3.0.Anwer Khan Modern Medical College Journal Vol. 7, No. 1: Jan 2016, P 60-63

Mechanical circulatory assist for pulmonary embolism

Perfusion ◽  
2000 ◽  
Vol 15 (6) ◽  
pp. 527-529 ◽  
Author(s):  
Yoshio Misawa ◽  
Katsuo Fuse ◽  
Tsutomu Yamaguchi ◽  
Tsutomu Saito ◽  
Hiroaki Konishi
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
Acute Pulmonary Embolism ◽  
Ventricular Dysfunction ◽  
Right Ventricular Dysfunction ◽  
Haemodynamic Instability ◽  
Cardiopulmonary Support ◽  
Attractive Option ◽  
Surgical Embolectomy ◽  
Poor Outcomes

Optimal management of acute pulmonary embolism remains controversial, despite advances in thrombolytic therapy. Haemodynamic instability and, in particular, right ventricular dysfunction is associated with poor outcomes. Urgent surgical embolectomy has been the treatment of choice in this category of patients. We present two cases in which percutaneous cardiopulmonary support (PCPS) was used as an adjunct to thrombolytic therapy for progressive circulatory collapse secondary to massive acute pulmonary embolism. This experience suggests that PCPS may offer an attractive option for a condition which continues to carry significant morbidity and mortality.

scholarly journals Impact of cancer on the effectiveness of cardiac Troponin I to predict right ventricular dysfunction in acute pulmonary embolism

2015 ◽  
Vol 6 (5) ◽  
pp. 584-588 ◽  
Author(s):  
Karsten Keller ◽  
Martin Geyer ◽  
Johannes Beule ◽  
Meike Coldewey ◽  
Jörn Oliver Balzer ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Cardiac Troponin ◽  
Acute Pulmonary Embolism ◽  
Ventricular Dysfunction ◽  
Troponin I ◽  
Right Ventricular Dysfunction ◽  
Cardiac Troponin I

scholarly journals Thrombolytic Therapy in Normotensive Patients with Pulmonary Embolism (Data from the Retrospective Study)

2020 ◽  
Vol 16 (5) ◽  
pp. 742-748
Author(s):  
N. A. Сherepanova ◽  
I. S. Mullova ◽  
A. R. Kiselev ◽  
T. V. Pavlova ◽  
S. M. Khokhlunov ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
Right Ventricular ◽  
Ventricular Dysfunction ◽  
Troponin I ◽  
Varicose Veins ◽  
Right Ventricular Dysfunction ◽  
Number Of Patients ◽  
Group 2 ◽  
Group 1

Background. The thrombolytic therapy is absolutely recommended for patients in shock or hypotension because the benefits are clearly outweighing the risks. However, in hemodynamically stable patients, including those with acute right ventricular dysfunction and/or myocardial damage, thrombolysis has a significantly lower evidence level.Aim. To study the criteria based on which doctors decide to conduct thrombolytic therapy in normotensive patients in real clinical practice according to the retrospective data.Material and methods. A single-center retrospective cohort study analyzed medical records of patients hospitalized in 2006-2017 with a verified diagnosis of pulmonary embolism (PE) and who had a systolic blood pressure >90 mm Hg at the time of admission.Results. The present study population included 299 patients with a verified diagnosis of PE from 2006 to 2017 years. Patients were divided into two groups: with thrombolysis (group 1) and without thrombolysis (group 2). Logistic regression analysis showed that age younger than 60 years, the presence of varicose veins of the lower extremities, skin cyanosis, syncope in the debut of PE were independent clinical factors that significantly influence the doctor's decision to perform thrombolysis. Increased troponin I, right ventricular dysfunction, and the severity of PE according to the PESI score showed no significant impact on this decision. In-hospital mortality in the group 2 was 1.9% (5 patients), while there were no deaths in the group 1. But the analysis of the association of thrombolysis with survival was difficult to perform due to the low incidence of deaths and the small number of patients in the group with thrombolysis (odds ratio 0.34; 95% confidence interval 0.03-8.18; р=0.856). No major bleeding was registered in any group.Conclusion. We were not able to clearly identify independent clinical or instrumental factors that influence the decision to perform thrombolysis in patients with PE outside the framework of evidence-based medicine. Further research is needed.

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