Recurrent massive pulmonary embolism following catheter directed thrombolysis in a 21-year-old with COVID-19: a case report

Background Coronavirus Disease-2019 (COVID-19) has been associated with increased incidence of pulmonary embolism (PE), even among patients at low risk for venous thrombo-embolic (VTE) events. Case summary We present the case of a 21-year-old male, with no previous medical history, who presented with cough, fevers, shortness of breath, pleuritic chest pain, and 1 day of dizziness with near syncope as well as acutely worsened dyspnoea. He was subsequently diagnosed with COVID-19 and massive PE. He underwent successful catheter-directed thrombolysis (CDT), and his clinical status improved. One day following initial CDT, he developed acute respiratory failure and hypotension and was diagnosed with recurrent massive PE. He was treated with repeat CDT and extracorporeal membrane oxygenation (ECMO) to provide time for right ventricular recovery. The patient was able to be weaned off ECMO after 9 days and was eventually extubated and discharged to an acute rehabilitation facility. Discussion Beyond COVID-19, no hypercoagulable risk factors were identified despite thorough investigation. This case highlights the thrombogenic potential and morbid sequelae of SARS-CoV-2 infection, even in young patients. It also highlights the use of CDT and ECMO among patients with massive PE and COVID-19. To date, this is the youngest reported patient to develop massive PE in the setting of COVID-19.