Hypercoagulability in COVID-19: A rare case of DIC in SARS-CoV2 in the Emergency Department
Although SARS-CoV2 is increasingly being considered a systemic disease, there have been very few case reports documenting DIC as a rare but fatal consequence of the SARS-CoV2 syndrome. We present our patient scenario as an example of severe COVID sepsis in the ED and DIC. 67-year old nursing home resident with CAD, DM, HTN, and seizures presents to our ED resus room with altered mental status and hypoxia after a reported fall from bed. He was tachycardic to 110 and required a nonrebreather at 15L saturating at 96%. His physical exam revealed GCS 10, no focal neurologic deficits, dry mucous membranes, clear lung sounds, and soft abdomen. He was swabbed for COVID-19, and his 1-view CXR revealed multifocal hazy opacities. ECG showed new T-wave inversions in V2-V3 with prolonged QTc 512. He was empirically treated with vancomycin, ceftriaxone, and flagyl for MRSA/aspiration pneumonia. Prominent labs were as follows: Cr. 1.51 (baseline 0.4), CRP 14.0, ESR 20, WBC 13.9, hemoglobin 13.2, platelets 52, LDH 2005, Tbili 3.0, INR 2.68, PT 27.8, PTT 44, and hs-troponin 1649. Bedside ECHO demonstrated normal LV function but with slightly enlarged RV and mild septal bowing, no pericardial effusion. Although there was concern for pulmonary embolism, he had a severe contrast allergy and therefore could not undergo CTPE. CT head showed 2 small subacute R parietal and cerebellar infarcts, but his encephalopathy was deemed out of proportion to the stroke findings by the neurology team. He was not on any anticoagulants, and his encephalopathy, AKI, thrombocytopenia, and elevated hemolytic labs were concerning for TTP vs. DIC. His DIC panel later revealed D-dimer >20.0 and fibrinogen <60. His COVID-19 PCR swab also resulted as positive. Hematology determined that his elevated coagulation parameters and clear COVID sepsis precipitant were more indicative of DIC. He was given 2U cryoprecipitate and admitted to MICU.DIC is rarely seen in the ED and can be difficult to diagnose, but early detection is paramount to tailoring treatment strategies and as a valuable prognostic indicator at the time of admission. Our patient had presented with multi-organ dysfunction, and this included a pathologic hemostatic system in the form of DIC. Hypercoagulability has been associated with COVID-19, but the progression to DIC in critically ill COVID patients warrants further in-depth research and clinical attention.