Aortic Arch Thrombus and Pulmonary Embolism in a COVID-19 Patient

P, Gandotra; A, Supariwala; S, Selim; G, Garra; L, Gruberg

Abstract: Background Coronavirus disease 2019 (COVID-19) is associated with endothelial inflammation and a hypercoagulable state resulting in both venous and arterial thromboembolic complications. We present a case of COVID-19 associated aortic thrombus in an otherwise healthy patient. Case Report A 53-year-old woman with no past medical history presented with a 10-day history of dyspnea, fever and cough. Her pulse oximetry on room air was 84%. She tested positive for SARS-CoV-2 infection and chest radiography revealed moderate patchy bilateral airspace opacities. Serology markers for cytokine storm were significantly elevated with a serum D-dimer level of 8180 ng/mL (normal <230 ng/mL). Computer tomography (CT) of the chest with IV contrast was positive for bilateral ground glass opacities, scattered filling defects within the bilateral segmental and sub segmental pulmonary arteries, and a large thrombus was present at the aortic arch. The patient was admitted to the intensive care unit and successfully treated with unfractionated heparin, alteplase 50 mg, and argatroban 2 mcg/kg/min. Why should an emergency physician be aware of this? Mural aortic thrombus is a rare but serious cause of distal embolism and typically discovered during an evaluation of cryptogenic arterial embolization to the viscera or extremities. Patients with suspected hypercoagulable states such as that encountered with COVID-19, should be screened for thromboembolism, and when identified, aggressively anticoagulated.