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Published on: December 19, 2020
Opportunistic Diagnosis of Extensive Pulmonary Embolus Following "COVID-19 Blood Battery" in Very Frail Older
M M C O'Brien1, J M McLoughlin, E C Mulkerrin
1Dr. Michelle Mary Clare O'Brien, Galway University Hospital, Galway, Ireland, drmichelleobrien@gmail.com, 091-544-000.
Insights
Elevated D-dimer levels in frail elderly patients with negative COVID-19 tests may indicate venous thromboembolism. Further investigation is crucial for accurate diagnosis and management of these critical conditions.
Area of Science:
- Geriatrics
- Internal Medicine
- Diagnostic Medicine
Background:
- D-dimer is a key biomarker for venous thromboembolism (VTE), commonly used to rule out the diagnosis.
- Age-adjusted D-dimer testing enhances specificity, potentially reducing unnecessary CT pulmonary angiograms and radiation exposure in older adults.
- The COVID-19 pandemic introduced new diagnostic pathways, including blood tests like D-dimer, which can be elevated in infections.
Observation:
- Three frail elderly patients (>75 years) with comorbidities presented with non-specific illness and negative COVID-19 swabs.
- These patients, triaged through a COVID-19 pathway, incidentally had markedly elevated D-dimer levels.
- Despite initial negative swabs and other potential diagnoses, all were ultimately diagnosed with extensive pulmonary emboli.
Findings:
- The study highlights cases where elevated D-dimer in frail elderly patients with negative COVID-19 tests masked underlying pulmonary emboli.
- It suggests the possibility of false-negative COVID-19 swabs in some severely unwell patients.
- Markedly elevated D-dimers in frail older patients lacking clinical improvement warrant further investigation for VTE.
Implications:
- This case series emphasizes the importance of considering thromboembolic disease in frail older patients, even with negative COVID-19 results.
- It supports the utility of D-dimer testing in frail elderly patients presenting with non-specific symptoms and comorbidities, especially when other conditions are treated without improvement.
- Prospective evaluation for VTE is recommended in COVID-19 patients, particularly those with persistent or severe symptoms, to prevent diagnostic delays and improve outcomes.
Abstract:
D-dimer is routinely measured to exclude the diagnosis of venous thromboembolism and is its main biomarker. Appropriate age-adjusted D-dimer testing improves D-dimer specificity, could decrease inappropriate CT pulmonary angiograms in the older person, and prevent unnecessary radiation exposure. A "COVID-19 blood battery", designed to increase the efficiency of evaluation of COVID-19 suspected patients is used in our institution. It includes D-dimers which are elevated in COVID-19 infections and potentially an index of severe infection. These 3 very frail patients presented late to the emergency department, all acutely and non-specifically unwell, with high prevalence of comorbidities and were transferred in by ambulance. They were triaged to the COVID-19 pathway of our hospital, and subsequently had negative COVID-19 swabs. All had an incidental finding of markedly elevated D-dimers, with potential causes of their symptoms other than pulmonary embolus. They were transferred to an acute geriatric ward specifically designated to manage older patients (>75years) who had negative nasopharyngeal swab results. They were all ultimately diagnosed with extensive pulmonary emboli with evidence of raised pulmonary pressures on CTPA and/or echocardiogram. It is possible that these patients had false negative COVID-19 swabs. Allowing for the novel nature of COVID-19, prospective evaluation for new symptoms and complications such as thromboembolic disease in those affected by milder symptoms should be considered. In the absence of clinical improvement following treatment of other conditions in frail older patients, D-dimer testing could be indicated with pursuit of specific diagnostic evaluation for venous thromboembolism when significantly elevated.
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