RECURRENT ISCHEMIC STROKES IN A PATIENT WITH SEVERE COVID-19 INFECTION AND PHOSPHATIDYLSERINE ANTIBODIES

SESSION TITLE: Fellows' COVID-19 SESSION TYPE: Fellow Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coronavirus 2019 (COVID19) infection has been linked to cardiovascular injury and hypercoagulable state We present a case of viral myopericarditis associated with severe cardiomyopathy, left ventricular thrombus (LVT), and recurrent embolic strokes in the setting of positive phosphatidylserine antibodies CASE PRESENTATION: A 24-year-old female with diabetes mellitus (DM) and polycystic ovarian syndrome (PCOS) on oral contraceptives pills (OCP) presented with progressive dyspnea and pleuritic chest pain for 3 days Vital signs were unremarkable Physical exam revealed bibasilar pulmonary crackles Pertinent laboratory findings included grossly abnormal inflammatory markers D-dimer was 856 ng/ml Cardiac troponin was 34 ng/dl and pro-BNP was 1000 pg/ml Viral PCR was positive for SARS-CoV2 Rheumatologic workup showed elevated anti-phosphatidylserine (aPS) antibodies: 100 MPS IgM and 13 GPS IgG respectively Lupus anticoagulant (LAC), anti-cardiolipin (aCL) and anti-B2 glycoprotein I (aβ2GPI) antibodies were negative EKG had diffuse ST elevations Her chest computed tomography (CT) showed bilateral peripheral ground-glass opacities (Figure 1) Transthoracic echocardiography (TTE) demonstrated left ventricular systolic dysfunction (LVSD) with a 20% ejection fraction (EF) and a large LVT (Figure 2) Diagnosis of COVID19 myopericarditis was made Guideline directed therapy including intravenous heparin was started On day 3, she developed acute right arm weakness Brain CT revealed a left temporoparietal ischemic stroke Heparin was changed to Enoxaparin On day 6, repeat CT for a new focal neurologic deficit showed recurrent ischemic strokes She was transitioned to Apixaban Repeat viral PCR was negative for SARS-Cov2 on day 12 Persistent EF 20% was seen on day 18 She was discharged to rehabilitation on day 29 DISCUSSION: Acute cardiac injury from COVID19 infection has been reported in 22% of ICU patients 1 Our patient's myocardial injury is attributed to COVID19 myopericarditis and LVSD LVT in acute myocarditis has been reported in up to 61 9% of cases 2 COVID19 patients exhibit a prothrombotic state with elevated D-dimer values- a finding linked to poor clinical outcomes 3 Empirically treating these patients with heparin products has shown improved survival 4-5 Interestingly, our patient had cardioembolic strokes despite anticoagulation Elevated aPS antibodies increase venous and arterial clot formation and risk of ischemic stroke 6-7 COVID19 infection, positive aPS antibodies, and PCOS with OCP use augmented thrombosis risk in our patient CONCLUSIONS: Considering COVID19's hypercoagulable state and our patient's underlying comorbidities, we suggest withholding OCP therapy and inclusion of antiphospholipid antibody testing in severe COVID19 infection to aid in detecting high-risk patients and guide anticoagulation therapy- especially in patients with COVID19 -induced cardiac injury Reference #1: Wang D, Hu B, Hu C, et al Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China [published online ahead of print, 2020 Feb 7] JAMA 2020;323(11):1061-1069 doi:10 1001/jama 2020 1585 Reference #2: Uchida Y, Uchida Y, Sakurai T, Kanai M, Shirai S, Nakagawa O Cardioscopic detection of left ventricular thrombi -With special reference to a comparison with left ventriculography and echocardiography- Circ J 2011;75(8):1920-1926 doi:10 1253/circj cj-11-0248 Reference #3: Tang N, Li D, Wang X, Sun Z Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia J Thromb Haemost 2020;18(4):844-847 doi:10 1111/jth 14768 DISCLOSURES: No relevant relationships by Mauricio Danckers, source=Web Response No relevant relationships by Michele Iguina, source=Web Response no disclosure on file for Alwiya Saleh;No relevant relationships by Imran Sayeedi, source=Web Response