Case Study: COVID-19 Rule-Out Patient Presenting with Malaise, Dyspnea, & Syncope

This middle-aged, obese female was brought in by EMS following a syncopal event. She reported several days of malaise and progressive dyspnea but denied fevers or a cough. The physical exam was unremarkable. The patient was triaged as a rule-out COVID-19 patient due to recent travel to New York and complaints of malaise and dyspnea.

Imaging & EKG Findings

No acute pathology was noted in either the anterior or posterior lung fields.

The EKG revealed a normal sinus rhythm at 89 bpm, normal axis, an incomplete RBBB, increased QT interval, diffuse t-wave inversions anterolaterally and inferiorly, and an S1Q3T3 pattern.

This FoCUS exam was taken using a cardiac preset. Though limited by image quality, this apical 4C view reveals a small LV with normal LVEF. Diastolic septal flattening was noted, suggestive of RV volume overload. Moderately enlarged RV with akinetic right ventricular free wall was seen, and a McConnell sign was present.

The diameter of the IVC measured ≤ 2.1 cm and displayed > 50% respirophasic collapse, consistent with a RAP of 0 to 5 mmHg.

Application of CWD across the tricuspid valve revealed a deep spectral waveform pattern with TR Vmax measuring 4 m/sec. This translates to a TR PG = 64 mmHg. When combined with the RAP of 0 to 5 mmHg derived from the IVC inlet view, the estimated pRVSP was > 65 mmHg and was consistent with moderate-to-severely elevated right heart pressures.

Integrating Ultrasound Findings into Medical Decision Making

Bedside ultrasound did not reveal evidence of acute lung pathology and normal LVEF was noted. A combination of findings, including a right heart strain EKG pattern, FoCUS exam findings indicating elevated pRVSP, and clinical parameters, all led to a working diagnosis of acute pulmonary hypertension (e.g., acute submassive PE) triggering a syncopal event. The paucity of lung findings argued against any elevation in right heart pressures owing to COVID-19 infection, which has been described in COVID-19 patients with advanced disease such as acute respiratory distress syndrome (ARDS) (Fox et al.).

The patient underwent a CT angio chest (PE protocol) that revealed submassive acute pulmonary emboli involving bilateral upper and lower lobar and segmental pulmonary arteries without evidence of infarct. An enlarged main pulmonary artery with leftward bowing of interventricular septum, concerning for right heart strain, was noted.

The patient was admitted with enhanced droplet precautions to the ICU and underwent COVID-19 testing, which was negative. She was anticoagulated following her initial evaluation in the ED. She responded to anticoagulation therapy and underwent a hypercoagulability evaluation that identified an underlying thrombophilia.

Of note, autopsy studies of COVID-19 patients have revealed gross and histologic findings consistent with ARDS. Findings included (1) diffusely edematous and firm lung parenchyma with patches of hemorrhage and (2) thrombi found in small peripheral (not central) pulmonary vessels with associated dilation of the right ventricle and straightening of the interventricular septum, consistent with elevated right heart pressures (Fox et al., Hanley et al., Xu et al.). The dominant pathophysiologic process appears to involve diffuse alveolar damage with secondary cellular inflammation and small vessel thrombosis with resultant focal alveolar hemorrhage. This has led to hypotheses that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection activates thrombotic and microangiopathic processes due to a maladaptive immune response to the infection (Fox et al., Xu et al.).

Key Points

• Patients with COVID-19 will present with symptoms that overlap with many alternative, commonly encountered medical conditions.
• Focal subpleural consolidation with adjacent overlying pleural thickening and pleural line discontinuity may be an early finding with COVID-19 infection (Chung et al.).
• Additional non-specific lung ultrasound findings in patients with COVID-19 infections include pleural thickening and irregularity, focal and diffuse B-lines, consolidations, and pleural effusions (Huang et al., Peng et al.).
• COVID-19 patients may present with symptoms resulting from cardiac involvement, including acute-onset heart failure, myocardial infarction, myocarditis, and cardiac arrest (Arentz et al., Clerkin et al., Huang et al.).
• COVID-19 patients that develop acute pulmonary hypertension typically suffer from ARDS and/or an acute cardiac complication of SARS-COV-2 infection (e.g., myocarditis) (Fox et al., Xu et al.).
• Two important applications of ultrasound in COVID-positive or rule-out COVID patients is (1) to screen for characteristic COVID-19 ultrasound findings and (2) to seek to identify alternative etiologies for patients’ symptoms (e.g., acute pulmonary hypertension)

Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA. 2020 Mar 19. doi: 10.1001/jama.2020.4326. [Epub ahead of print]

Chung M, Bernheim A, Mei X, et al. CT imaging features of 2019 novel Coronavirus (2019-nCoV). Radiology. 2020 Apr;295(1):202-207. doi: 10.1148/radiol.2020200230. Epub 2020 Feb 4.

Clerkin KJ, Fried JA, Raikhelkar J, et al. Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation. 2020 Mar 21. doi: 10.1161/CIRCULATIONAHA.120.046941. [Epub ahead of print]

Fox SE, Akmatbekov A, Harbert JL, et al. Pulmonary and cardiac pathology in COVID-19: the first autopsy series from New Orleans. MedRxiv 2020.04.06.20050575 [Preprint]. 2020 [cited 2020 Apr 15]. Available from: https://doi.org/10.1101/2020.04.06.20050575

Hanley B, Lucas SB, Youd E, et al. Autopsy in suspected COVID-19 cases. J Clin Pathol. 2020 Mar 20. pii: jclinpath-2020-206522. doi: 10.1136/jclinpath-2020-206522. [Epub ahead of print]

Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. Epub 2020 Jan 24.

Peng, QY, Wang XT, Zhang LN; Chinese Critical Care Ultrasound Study Group. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Medicine. 2020 Mar: 1-2. doi: 10.1007/s00134-020-05996-6. [Epub ahead of print]

Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020; 8:420-422

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