A Giant Right-Heart Thrombus-in-Transit in a Patient with COVID-19 Pneumonia

BACKGROUND Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread to more than 200 countries across the world. Studies have shown that patients with COVID-19 are prone to thrombotic disease resulting in increased mortality. We present a case of COVID-19 pneumonia in a warehouse worker with a giant thrombus-in-transit involving the right ventricle and tricuspid valve. We also describe the associated diagnostic and therapeutic challenges. CASE REPORT A 54-year-old man with recent COVID-19 exposure presented with fever, cough, dyspnea, and syncope and was found to be in hypoxic respiratory failure requiring supplemental oxygen. The clinical course deteriorated with worsening respiratory failure and septic shock, requiring mechanical ventilation and pressor support. Further evaluation revealed a positive nasopharyngeal swab for SARS-CoV-2 and an S1Q3T3 pattern on electrocardiogram. A bedside transthoracic echocardiogram was performed due to clinical deterioration and hemodynamic instability, which showed a large thrombus-in-transit through the tricuspid valve into the right ventricle. The patient was treated with low-molecular-weight heparin, hydroxychloroquine, azithromycin, and supportive care. A repeat echocardiogram after 1 week did not show any thrombus. The patient slowly improved over the following weeks but required tracheostomy due to prolonged mechanical ventilation. He was discharged on oral anticoagulation. CONCLUSIONS This case highlights the presence of significant COVID-19-related hemostatic disturbances and the importance of associated diagnostic and therapeutic challenges. A bedside echocardiogram can provide valuable information in patients with suspected high-risk pulmonary embolism and hemodynamic instability. Early diagnosis by keeping a high index of suspicion and prompt treatment is vital to avoid adverse outcomes and increased mortality.