A 31-Year-Old Man with COVID-19-Associated Empyema and Lupus Anticoagulant

Yarlagadda, Keerthi; Mi, Kaihong; Sendil, Selin; Koons, Connie L.; Komanduri, Saketram; Cinicola, John T.

Patient: Male, 31-year-old Final Diagnosis: COVID provoked thromboembolism • COVID-19 Symptoms: Bleeding • thrombosis Medication: — Clinical Procedure: Thoracentesis • video-assisted thoracoscopic surgery (VATS) Specialty: Hematology • Infectious Diseases OBJECTIVE: Unknown ethiology • Unusual clinical course BACKGROUND: COVID-19 was declared a pandemic in March 2020 in the United States. It has been associated with high mortality and morbidity all over the world. COVID-19 can cause a significant inflammatory response leading to coagulopathy and this hypercoagulable state has been associated with worse clinical outcomes in these patients. The published data regarding the presence of lupus anticoagulant in critically ill COVID-19-positive patients is limited and indicates varying conclusions so far. CASE REPORT: Here, we present a case of a 31-year-old man who was admitted to the hospital with COVID-19 pneumonia, complicated with superadded bacterial empyema and required video-assisted thoracoscopic surgery with decortication. This patient also had prolonged prothrombin time on preoperative labs, which was not corrected with mixing study. Further workup detected positive lupus anticoagulant and anti-cardiolipin IgM along with alteration in other coagulation factor levels. The patient was treated with fresh frozen plasma and vitamin K before surgical intervention. He had an uneventful surgical course. He received prophylactic-dose low molecular weight heparin for venous thromboembolism prophylaxis and did not experience any thrombotic events while hospitalized. CONCLUSIONS: COVID-19 infection creates a prothrombotic state in affected patients. The formation of micro-thrombotic emboli results in significantly increased mortality and morbidity. Routine anticoagulation with low molecular weight heparin can prevent thrombotic events and thus can improve patient outcomes. In patients with elevated prothrombin time, lupus anticoagulant/anti-cardiolipin antibody-positivity should be suspected, and anticoagulation prophylaxis should be continued perioperatively for better outcomes.