TOPIC: Pulmonary Vascular Disease
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: COVID-19 is associated with a myriad of complications including thromboembolic disease. Recognizing the clinical presentations of post-COVID complications and providing a comprehensive diagnostic evaluation is important to better understand the long-term sequela of the disease.
      CASE PRESENTATION: A 30-year-old non-smoking obese female on no medications presented with a 4-week history of mild, self-resolving COVID-19 infection. Symptoms included gradually worsening dyspnea on exertion, sharp pleuritic chest pain, and a pre-syncopal event after moderate exertion that eventually prompted presentation. On evaluation, she was found to have normal vital signs. Initial laboratory investigation revealed normal troponin and brain natriuretic peptide levels. Electrocardiogram demonstrated normal sinus rhythm with non-specific interventricular conduction abnormality (Figure 1). Chest x-ray had no acute cardiopulmonary abnormality (Figure 2). She was ultimately discharged but re-presented with hypoxemic, requiring 2L oxygen. Contrasted chest computerized tomography (CT) scan was negative for pulmonary embolism. Transthoracic echocardiogram revealed low-normal left ventricular ejection fraction (LVEF) of 50-55% with mild diffuse hypokinesis. Low-normal LVEF raised suspicion for COVID-related myocarditis, which was ruled out with cardiac MRI. Spirometry was normal except for a markedly reduced diffusion capacity (Figure 3). Due to concern for a missed pulmonary embolism, a Ventilatory/Perfusion (V/Q) scan was performed and demonstrated segmental perfusion defect involving the superior segment of the left lower loge and anterior segment of the left upper lobe. Her dyspnea persisted despite the initiation of anticoagulation. An invasive cardiopulmonary exercise testing (iCPET) was subsequently performed that showed normal resting cardiac index and pulmonary vascular resistance (PVR), with paradoxical increase in PVR with activity, as expected with pulmonary vascular dysfunction related to residual clot burden from chronic thromboembolic disease.
      DISCUSSION: About a quarter of patients with COVID-related hospitalization develop thromboembolism (1). CT angiography scans should be evaluated carefully in patients t with symptoms concerning for pulmonary embolism, as they may have subsegmental or distal disease (2). V/Q scanning should always be considered for definitive diagnosis of CTEPH, particularly if patients have persistent symptoms despite at least 3 months of anticoagulation. ICPET utilization in COVID patients with persistent dyspnea on exertion is a valuable testing modality as it can simultaneously appreciate the pulmonary, cardiac, and/or vasculature limitations to exercise (3).
      CONCLUSIONS: Clinical suspicion of pulmonary embolism must remain high in COVID-recovered individuals with concerning clinical features, and V/Q scan should be considered as part of workup.
      REFERENCE #1: Mahmoud Malas, Isaac Naazie, Nadin Elsavad, Asma Mathlouthi, Rebecca Marmor, Bryan Clary. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis. E Clinical Medicine. November 2020.
      REFERENCE #2: Meng Wang, Dayong Wu, Rongzheng Ma, Zongyao Zhang, Hailong Zhang, Kai Han, Changming Xiong, Lei Wang, Wei Fang. Comparison of V/Q SPECT and CT Angiography for the Diagnosis of Chronic Thromboembolic Pulmonary Hypertension. RSNA. May 2020.
      REFERENCE #3: Peter Fedullo, Kim Kerr, Nick Kim, William Auger. Chronic Thromboembolic Pulmonary Hypertension. American Journal of Respiratory and Critical Care Medicine. February 2011.
      DISCLOSURES: No relevant relationships by Andrew Baird, source=Web Response
      No relevant relationships by Syed Bukhari, source=Web Response
      No relevant relationships by Carly Fabrizio, source=Web Response
      No relevant relationships by Gavin Hickey, source=Web Response
      No relevant relationships by Michael Risbano, source=Web Response