COVID-19-INDUCED AORTIC THROMBOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: As of April 2021, Coronavirus disease (COVID-19) has infected over 147 million people and claimed the lives of over 3 million globally. Despite becoming a significant burden on the healthcare community, complications and sequalae of this lethal virus are still not fully known. While primarily being defined as a respiratory illness, COVID-19 has been known to cause venous thrombotic events and less commonly increased arterial clot burden. CASE PRESENTATION: A 63-year-old female with a history of 30 pack year tobacco use presented to the emergency department (ED) complaining of shortness of breath, chest tightness, and right lower extremity pain starting 2-3 hours prior to presentation. In the ED she was noted to be COVID-19 positive and found to be hypoxic with an oxygen saturation of 84% on room air for which she was placed on 4 liters of oxygen per minute via nasal cannula for a goal oxygen saturation of >92%. The remainder of her vitals were unremarkable and physical exam did not reveal any pathology or acute findings. An emergent CT angiogram of the chest, abdomen, and pelvis was obtained which showed a large focus of thrombus in the ascending thoracic aorta measuring up to 2.2 x 1.3 cm in the axial plane, which appears free-floating abutting the anterior wall of the aorta. There were also some smaller scattered eccentric thrombi in the descending thoracic and infrarenal abdominal aorta. A focus of thrombus extending from the distal abdominal aorta into the right common iliac artery results in severe stenosis of the right common iliac artery. Venous doppler studies revealed diminished velocity in the right popliteal and posterior tibial arteries without identified thrombosis. Vascular surgery was consulted however the patient remained clinically stable and was started on a heparin drip prior to being bridged to warfarin with a goal international normalized ratio of 2.5 to 3.5 for a total of 6 months duration. At her 1 and 3 month outpatient follow-up she remained in stable condition and her presenting symptoms resolved. DISCUSSION: COVID-19 is known to bind to the peptidase domain of the angiotensin-converting enzyme 2 receptor leading to severe respiratory disease and an overwhelming activation of cytokines and complements. Through this process, a hypercoagulable state is induced leading to venous and arterial thrombotic events. Our patient had no risk factors for thrombotic disease and hypercoagulable work-up was largely unremarkable leading to the suspicion of COVID-19 infection as the cause. CONCLUSIONS: COVID-19 infection is a lethal viral disease affecting millions of people globally. As this disease continues to spread, it is imperative clinicians become aware of the devastating complications such as venous and arterial thrombosis risk and appropriately anti-coagulate their patients. REFERENCE #1: Ji YL, Wu Y, Qiu Z, et al. The Pathogenesis and Treatment of COVID-19: A System Review. Biomed Environ Sci. 2021;34(1):50-60. doi:10.3967/bes2021.007 REFERENCE #2: Cevik M, Kuppalli K, Kindrachuk J, Peiris M. Virology, transmission, and pathogenesis of SARS-CoV-2. BMJ. 2020;371:m3862. doi: 10.1136/bmj.m3862. DISCLOSURES: No relevant relationships by Abbas Alshami, source=Web Response No relevant relationships by Steven Douedi, source=Web Response No relevant relationships by Mihir Odak, source=Web Response No relevant relationships by Swapnil Patel, source=Web Response