PE and COVID-19 Co-presentation

Clinical Question

What do we know about co-presentation of pulmonary embolism and COVID-19 (since both present with similar symptoms)?

Key Findings

  • Patients with PE and COVID-19 have similar presentations.
  • There are case reports of COVID-19 patients who are diagnosed with PE, and PE should be considered in COVID-19 patients who fail to improve, have very high D-dimer, or other clinical suspicion of PE.
  • Microthrombi and thrombi may be contributing sources to hypoxia/refractory hypoxia in COVID-19

Summary of Information

The issue of identifying a pulmonary embolism in the setting of underlying pneumonia is a known challenge.[1] Patients with COVID-19 pneumonia caused by the SARS-CoV-2 virus can present with dyspnea, tachycardia, and hypoxia, symptoms that overlap with the presentation of PE. Additionally, COVID-19 is now widely known to be associated with elevated serum d-dimer levels. Due to the potential similarities in the presentation and the emphasis of d-dimer as a marker in COVID-19 pneumonia, it is important to consider at what frequency COVID-19 may be complicated by PE.

One case report from Wuhan, China describes two patients who presented with laboratory confirmed COVID-19 pneumonia who were found to have PE on CT angiography.[2] Both patients had elevated serum d-dimer levels along with fever, cough, and dyspnea, and both patients had deteriorated after admission. However, it is unclear how many other patients with similar presentations were tested with CT angiography and did not have PE. A retrospective analysis from China looks at the d-dimer levels of 25 COVID-19 patients who were suspected to have PE and underwent CTA.[3] The average d-dimer level of patients found to have PE was 11.07 ug/ml vs 2.44 ug/ml in the patients without PE (p-value < 0.05). D-dimer was the only statistically significant laboratory difference between the two groups.

However outside of these cases reported from China, PE is not addressed as a common clinical manifestation or complication of COVID-19 pneumonia. It is also not discussed as a known finding on autopsy of COVID-19 patients.[4] Of note, during the SARS outbreak in 2003, there were multiple reports of PE in critically ill patients and on autopsy findings.[5][6] At this time, Italian guidelines for managing COVID-19 patients only recommend CTA to look for PE for critically ill or clinically unstable patients for whom there is clinical suspicion of PE.[7] PE may in fact be an underreported complication, if use of CTA and autopsy is limited.

More recently, microthrombi have been proposed as a potential cause for the treatment-resistant hypoxemia sometimes found in COVID-19 (causing tissue perfusion defects). A lit review of this concept is pending and will be published as a separate document.

Author Information

Authors: Natalie Oberhauser-Lim, MS3 UC San Diego School of Medicine
Completed on: March 31, 2020
Last revised on: April 14, 2020

Reviewed by: Sara Baird MD

Reviewed on: April 8, 2020

This summary was written as part of the CoRESPOND Earth 2.0 COVID-19 Rapid Response at UC San Diego. For more information about the project, please visit http://earth2-covid.ucsd.edu

References

  1. Paparoupa M, Spineli L, Framke T, et al. Pulmonary Embolism in Pneumonia: Still a Diagnostic Challenge? Results of a Case-Control Study in 100 Patients. Dis Markers. 2016;2016:8682506.  [PMID:27313336]
  2. Xie Y, Wang X, Yang P, Zhang S. COVID-19 Complicated by Acute Pulmonary Embolism. Radiol Cardiothorac Imaging. 2020;2(2):e200067. doi:10.1148/ryct.2020200067
  3. Chen J, Wang X, Zhang S, et al. Findings of Acute Pulmonary Embolism in COVID-19 Patients. Rochester, NY: Social Science Research Network; 2020. doi:10.2139/ssrn.3548771
  4. Hanley B, Lucas SB, Youd E, et al. Autopsy in suspected COVID-19 cases. J Clin Pathol. 2020;73(5):239-242.  [PMID:32198191]
  5. Chong PY, Chui P, Ling AE, et al. Analysis of deaths during the severe acute respiratory syndrome (SARS) epidemic in Singapore: challenges in determining a SARS diagnosis. Arch Pathol Lab Med. 2004;128(2):195-204.  [PMID:14736283]
  6. Umapathi T, Kor AC, Venketasubramanian N, et al. Large artery ischaemic stroke in severe acute respiratory syndrome (SARS). J Neurol. 2004;251(10):1227-31.  [PMID:15503102]
  7. Nicastri E, Petrosillo N, Bartoli TA, et al. National Institute for the Infectious Diseases "L. Spallanzani", IRCCS. Recommendations for COVID-19 clinical management. Infect Dis Rep. 2020;12(1):8543.  [PMID:32218915]