Chest pain mimicking pulmonary embolism may be a common presentation of COVID‐19 in ambulant patients without other typical features of infection

Abstract

Background Radiological and pathological studies in severe COVID‐19 pneumonia (SARS‐CoV‐2) have demonstrated extensive pulmonary immunovascular thrombosis and infarction. This study investigated whether these focal changes may present with chest pain mimicking pulmonary emoblism (PE) in ambulant patients. Methods CTPAs from outpatients presenting with chest pain to Leeds Teaching Hospital NHS Trust 1st March to 31 May 2020 ( n = 146) and 2019 ( n = 85) were compared. Regions of focal ground glass opacity (GGO), consolidation and/or atelectasis (parenchymal changes) were determined, and all scans were scored using British Society for Thoracic Imaging (BSTI) criteria for COVID‐19, and the 2020 cohort was offered SARS‐CoV‐2 antibody testing. Results Baseline demographic and clinical data were similar between groups with absence of fever, normal lymphocytes and marginally elevated CRP and D‐Dimer values. Evidence of COVID‐19 or parenchymal changes was observed in 32.9% (48/146) of cases in 2020 compared to 16.5% (14/85) in 2019 ( P = 0.007). 11/146 (7.5%) patients met BSTI criteria for COVID‐19 in 2020 compared with 0/14 in 2019 ( P = 0.008). 3/39 patients tested had detectable COVID‐19 antibodies (2 with parenchymal changes and 1 with normal parenchyma) however 0/6 patients whose CTPA met BSTI criteria “likely/suspicious for COVID‐19” and attended antibody testing were SARS‐CoV‐2 antibody positive. Conclusions 32.8% ambulatory patients with suspected PE in 2020 had parenchymal changes with 7.5% diagnosed as COVID‐19 infection by imaging criteria, despite the absence of other COVID‐19 symptoms. These findings suggest that localized COVID‐19 pneumonitis with immunothrombosis occurs distal to the bronchiolar arteriolar circulation, causing pleural irritation and chest pain without viraemia, accounting for the lack of fever and systemic symptoms.

A tricompartmental model of lung oxygenation disruption to explain pulmonary and systemic pathology in severe COVID-19

“…[17][18][19] Recently, we reported that patients with chest pain-which might lead to suspicion of pulmonary embolism-who presented in the outpatient setting during the COVID-19 pandemic era and who had CTPA negative for pulmonary embolism were more likely to have ground glass opacities in the lung periphery than were patients presenting in the same way in 2019, highlighting the vascular disease component in early COVID-19. 20 In addition to showing severe alveolitis, several autopsy studies have confirmed extensive in-situ thrombosis of the capillary networks and adjacent microcirculation, and larger vessel thrombosis in COVID-19, corresponding to areas of ground glass opacities demonstrated on CT. 10,21,22 This localised form of pulmonary immuno thrombosis, which we have termed pulmonary intravascular coagulopathy (PIC), 23,24 is a discrete entity in COVID-19 that is characterised by capillary and larger pulmonary vessel thrombosis as the dominant feature-a pattern less common in influenza and other viral pneumonias. 7 The typical lung abnormalities on CT in the early stages of severe COVID-19 are peripherally located, with a dominant posterior distribution and occasionally a reversed halo sign (the so-called atoll sign), 16,25 a finding previously reported in acute thromboembolic pulmonary infarction.…”

SARS‐CoV‐2 infection of companion animals in Egypt and its risk of spillover

“…This thrombocytopenia may be due to pulmonary embolism and/or systemic thrombosis (Harrison et al, 2021). Additionally, we detected a significant lymphocytopenia with SARS-CoV-2 infection.…”

“…Our clinical findings revealed a significant thrombocytopenia in SARS‐CoV‐2‐infected cats and dogs compared with negative group. This thrombocytopenia may be due to pulmonary embolism and/or systemic thrombosis (Harrison et al., 2021 ). Additionally, we detected a significant lymphocytopenia with SARS‐CoV‐2 infection.…”

New Onset Autoimmune Diseases after the Sputnik Vaccine

“…Other authors reported a predominance of thromboembolic events and vaccine-induced immune thrombocytopenia and thrombosis (VITT) after the application of the A-Z vaccine in a systematic review [16]. These infrequent side effects resemble those of critical SARS-CoV-2 infection, with systemic immunothrombosis affecting several territories [17,18]. While natural SARS-CoV-2 infection is mediated by antigens like single-stranded RNA, vaccine-associated immunothrombosis is related to DNA adenovirusvectored platforms [19].…”