Post COVID-19 complication: A near miss case of pulmonary embolism

Introduction:It is now well established that COVID-19 infection is associated with hypercoagulability especially in those with severe respiratory disease and higher degree of inflammation. We present an unusual case of pulmonary embolism (PE) with atypical symptoms in a COVID-19 survivor.Case Report:A 47-year-old African-American, non-smoker female with a history of hypertension and morbid obesity presented with sudden onset of dizziness associated with nausea and vomiting. The patient was in her usual state of health prior to the onset of symptoms. She described her dizziness as a sensation of room spinning. Review of systems was otherwise normal. She was in no acute distress, vital signs were within normal limits and oxygen saturation was 98% on room air. Physical examination including the Dix-Hallpike maneuver was unremarkable. Laboratory investigations and EKG were normal. A CT angiography of the head and neck did not reveal any cerebral ischemia, however, it disclosed findings concerning PE. A CT angiography of the chest demonstrated bilateral emboli with filling defects confirming PE. Echocardiogram was normal. The patient did not have any risk factors for PE like recent immobilization, travel, surgery, use of oral contraceptives or hormonal therapy, malignancy and personal or family history of thromboembolic disorders. Of note, six months ago she was tested positive for COVID-19 with mild symptoms which did not require hospitalization. COVID-19 test during this admission was negative, but D-dimer was not obtained. In the absence of any other plausible etiology of dizziness, her symptoms were attributed to atypical presentation of PE. She was treated with heparin and discharged on oral anticoagulation therapy with apixaban for one year. Discussion:Although there are several proposed hypotheses, the exact pathogenesis of hypercoagulability in COVID-19 infection is unclear. Thus far, the reported cases of PE as a complication of COVID-19 infection presented within six weeks of disease onset. Our patient developed bilateral PE six months post infection, which was not severe enough to require hospitalization, in the absence of any other risk factors for PE. More recent studies suggest that patients with a BMI greater than 30 kg per meter square, like our patient, have a greater propensity to develop PE but in the setting of severe disease. Physicians should be cognizant of this clinical entity and have a high index of suspicion for PE in patients with prior COVID-19 infection irrespective of the timeline and disease severity especially in those with atypical presentation like our patient.