208: Polycythemic Covid-19 With Cerebral Venous Thrombosis as Initial Presentation: Cause or Coincidence?

Abstract

INTRODUCTION:The known range of complications associated with COVID-19 infection is vast. Cerebral venous thrombosis (CVT) has been reported as a complication of the infection with a frequency of 0.08% and 40% in hospital mortality. Here we present an unusual case of COVID-19 in a healthy young male complicated with CVT and polycythemia. CASE DESCRIPTION:A 33-year-old male with no known past medical history presented with agitation. He was noted to be progressively confused and agitated over 2 days prior to presentation as per significant other. He was febrile and tachycardic on presentation. Labs were remarkable for COVID PCR positivity and hemoglobin of 20.8 mg/dL. CT head revealed dural sinus thrombosis. On admission, he had a witnessed tonic-clonic seizure, which broke with 2 mg lorazepam. He was empirically started on vancomycin, ceftriaxone, and acyclovir after a lumbar puncture was performed and additionally loaded with levetiracetam. On hospital day 2, CT venogram confirmed extensive CVT and therapeutic enoxaparin was initiated. Antibiotics were discontinued on hospital day 3 due to negative CSF studies. Polycythemia on admission at 20.8 mg/dL initially improved with hydration to 19 mg/dL. Due to persistent elevation, he underwent phlebotomy with removal of 200 cc of blood on hospital day 2, which reduced Hb to 15 mg/dL. Workup for thrombophilia returned unremarkable, including factor V Leiden and prothrombin gene mutations, DRVVT, ß2 glycoprotein antibodies, cardiolipin IgA, homocysteine levels, proteins C and S, JAK2V617, EPO, JAK2 exon 12. Hemoglobin continued to rise during hospital stay requiring additional phlebotomy with removal of 400 cc on hospital day 7. He was discharged on hospital day 8 on apixaban. Follow-up with Hematology showed Hb of 16.7 mg/dL with complete resolution of encephalopathy. Further workup for thrombophilia and polycythemia is ongoing.DISCUSSION: Given the novelty of COVID-19, the full range of pathologies of the infection is still being uncovered. Hypercoagulable states found with COVID-19 infections have been previously linked to CVT in young adults, however these are more often complicated by anemia. Our patient's unique presentation of CVT underlined by polycythemia was found to be treatable with phlebotomy, leading to complete resolution of acute encephalopathy.