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Incidental floating aortic thrombus in severe pulmonary COVID-19 infection
*For correspondence: vineetarathi@yahoo.com
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This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.
A 61 yr old male† presented to the Emergency department at Guru Teg Bahadur Hospital, Delhi, India, in August, 2020, with COVID-19 respiratory failure and elevated D-dimers (1970 ng/ml). His symptoms had started seven days ago. He had right bundle branch block on electrocardiogram (ECG) but no history of metabolic comorbidities or thrombophilia. Chest radiograph revealed bilateral lower lobe consolidation and subpleural ground-glass opacity in right mid zone. Non-invasive ventilation, thromboprophylaxis (enoxaparin 0.4 ml subcutaneously, once daily), intravenous dexamethasone, broad-spectrum antibiotics and aspirin were initiated. He also received convalescent plasma. After three weeks, he complained of chest pain. There was decreased air entry on the right side. ECG and cardiac markers suggested non-ST segment elevation myocardial infarction. A chest contrast-enhanced computed tomography (CECT) revealed right-sided tension pneumothorax (Fig. 1A) with collapse of underlying lung. Lungs showed diffuse ground-glass opacity with septal thickening and patchy consolidation (Fig. 1A). A pedunculated aortic thrombus was detected in the arch of aorta (Fig. 1B). No thrombi were seen in the major branches of aorta in the neck, abdomen and pelvis. A small atherosclerotic plaque with focal calcification was seen in the descending thoracic aorta. (Fig. 2A and B). Cardiac chambers were normal in morphology. CT brain was normal. Aspirin, clopidogrel and warfarin (5 mg once daily) with enoxaparin (0.6 ml subcutaneously twice daily for five days) were given. Warfarin was adjusted to maintain an INR (international normalized ratio) between 2 and 3. An intercostal chest drain was inserted which led to expansion of the right lung. Follow up CT angiogram after four weeks revealed a decrease in the thickness of the pedunculated thrombus (Fig. 1C). Despite being informed about the risks of distal thromboembolism due to the filamentous thrombus, the patient opted for conservative therapy. On follow up at six months, the patient had mild shortness of breath, but no peripheral embolism had occurred. Chest radiograph and echocardiogram were unremarkable except for mild tricuspid regurgitation and pulmonary artery hypertension. Thrombus is rare in a minimally atherosclerotic, non-aneurysmal aorta1. Severe SARS-CoV-2 infection can cause a hypercoagulable state and can rarely be associated with floating aortic thrombus, even with ongoing thromboprophylaxis23.

- (A) Chest computed tomography (CT) shows right-sided tension pneumothorax (star) with collapse of the underlying lung. Both lungs show diffuse ground-glass opacity with septal thickening and patchy consolidation. Intercostal chest drain was inserted. (B) A pedunculated/floating thrombus (red arrow) is seen in the arch of aorta, tethered at one end to its wall. No atherosclerotic plaque or calcification was seen. (C) CT angiogram done four weeks after starting anticoagulants revealed a decrease in thickness of the pedunculated thrombus in the arch of aorta (yellow arrow).

- (A) Non-contrast computed tomography shows focal calcification (orange arrow) in the aortic wall. (B) Contrast-enhanced computed tomography shows a small atherosclerotic plaque (orange arrow) only in the descending thoracic aorta.
Acknowledgment:
Authors acknowledge Drs Nishesh Jain and Abhinav Aggarwal, department of Medicine, UCMS & GTB Hospital, Delhi, for appropriate clinical management of the patient.
Conflicts of Interest: None.
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