Thrombus in Transit on Point-of-Care Ultrasound in COVID-19 Pneumonia: A Cause of Refractory Hypoxia Requiring Systemic Thrombolysis.

Coronavirus disease 2019 (COVID-19) is predominantly a pulmonary disease due to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with underlying systemic involvement associated with coagulopathy. The reported number of events of venous thromboembolism and refractory hypoxia remains high despite being maintained on prophylactic or therapeutic doses of anticoagulation in patients with a high clinical indication, which has shown a reduction in mortality otherwise. This report is of a case of severe COVID-19 pneumonia in a 37-year-old Hispanic man who developed coagulopathy with left popliteal vein thrombosis and subsequently a right ventricle thrombus in transit diagnosed by point-of-care ultrasound requiring systemic thrombolysis. Although patients with severe COVID-19 pneumonia are routinely given therapeutic anticoagulants, this case has shown that monitoring acute thrombotic events, D-dimer levels, and the presence of refractory hypoxia may indicate a thrombotic event that requires further intervention. This report has demonstrated the value of point-of-care ultrasound in the diagnosis of thromboembolism and venous thrombosis in a patient with severe COVID-19 pneumonia.

Predictors of Poor Outcomes for COVID-19-Associated Pneumonia in a Minority Population.

Background In December 2019, an unprecedented outbreak of pneumonia of unknown etiology emerged in Wuhan City, Hubei province in China. A novel coronavirus was identified as the causative agent and was subsequently termed COVID-19 by the World Health Organization (WHO). It rapidly became a pandemic, and it has been a significant challenge to healthcare providers to predict outcomes of the infected patients.  Objective  The aim of this study was to investigate the clinical characteristics of patients admitted for COVID-19 infection in an Inner-City Hospital in New York City, to assess the correlation between inflammatory markers and outcomes prediction in a high-risk population. Methods  We identified 235 patients who were admitted to our Hospital in NYC between March 19th and April 25th, 2020 with laboratory confirmed COVID-19 diagnosis with associated pneumonia and who also had documented inflammatory markers (D-dimer, C-reactive protein, lactate dehydrogenase, ferritin, procalcitonin) during their hospital stay.  Results  The study population was predominantly non-Hispanic black. There was no statistically significant difference between survivors and non-survivors by race and/or ethnicity (P = 0.69). Thirty-five percent of the patient population had died by the end of this study and those that died had a higher mean age compared to survivors (69.5 ± 13.6 vs 63.8 ± 15.2, P = 0.004). There is a significant difference in the D-dimer levels in patients who survivedwhen compared to those who died (P = 0.002). A higher proportion of patients that died were admitted to the ICU, (23.7% vs 55.4%, P < 0.0001) and/or intubated (18.4% vs 51.8%, P < 0.0001). Conclusion Our study demonstrated that patients who died had a significantly higher D-dimer (>3,000) when compared with survivors. Higher mean age was associated with increased mortality and admission to ICU and/or intubation.

Primary Hepatic Lymphoma Masquerading as Symptomatic Hypercalcemia.

Primary lymphoma of the liver is extremely rare, and is more common among immunocompromised patients. It typically occurs after the fifth decade of life and has a male predominance. It often presents with diagnostic difficulties to both clinicians and pathologists as most cases have a solitary or multiple mass lesions in the liver with normal alpha-fetoprotein levels. Chemotherapy is the standard of therapy. Here, we describe a unique case of primary hepatic lymphoma in an elderly immunocompetent female who presented with symptomatic hypercalcemia.

Acute Presentation of Simultaneous Liver Abscesses Caused by Streptococcus constellatus.

Simultaneous liver abscesses are rarely seen and reported. We are reporting a case of two simultaneous, complex liver abscesses in a patient who had no evidence of liver abscess on cross-sectional imaging close to three months prior to this presentation. These abscesses were 7-8 cm in size, large, and septated. Microbiological studies were positive for Streptococcus constellatus, which is a known cause of pyogenic liver abscess. In our patient, pyogenic liver abscesses were associated with bacteremia and sepsis. This patient was managed with broad spectrum parenteral antibiotics and percutaneous drainage with improvement in clinical condition. This patient was discharged home with a peripherally inserted central catheter (PICC) line in place to complete a six-week course of parenteral antibiotics. A complete history and physical with pertinent examination findings are key to diagnosis of liver abscess. S. constellatus should be considered in the differential diagnosis of patients with liver abscess and sepsis.