Pulmonary thromboembolism with multiple right heart mural thrombus in a patient with COVID-19

Abstract

Hypercoagulation state during COVID-19 disease has been confirmed recently. Herein we present a 40-year-old hypertensive otherwise healthy male who was admitted with complaints of myalgia, low grade fever, dry cough, leg swelling, and exacerbating dyspnea in the last two weeks with history of recent recovery from COVID-19 in his wife. At presentation, he was afebrile with stable vital signs (blood pressure: 114/81 mmHg, respiratory rate: 16/minute, heart rate: 75 bpm) despite hypoxemia (SPaO2 of 74% on room air, 94% on nasal O2 therapy). Coarse crackles in the lung fields, symmetric pitting leg edema and elevated jugular venous pressure were noticed in clinical exam with low voltage QRS, extreme right axis deviation and negative T waves in the precordial leads in electrocardiogram (Fig. 1a). Chest CT scan demonstrated pericardial and pleural effusions, filling defects in right atrium (RA) and right ventricle (RV) cavities, peripheral based ground glass opacities (compatible with COVID involvement), wedge-shaped pulmonary infarct and pulmonary arterial branch thrombosis (Fig. 1b, supplementary video1). No deep vein thrombosis was found. Transthoracic and transesophageal echocardiography showed preserved left ventricular systolic function, flattened interventricular septum, moderate right atrium (RA) and right ventricular (RV) enlargement and dysfunction, plethoric inferior vena cava with two large mural thrombi (4 cm × 2.5 cm) in RA appendage and RV apex (Fig. 1c, d, supplementary videos 2, 3).