Upper-extremity deep venous thrombosis and bilateral pulmonary embolism in a patient with COVID-19 under prophylactic anticoagulation: A case report

The COVID-19 infection induces coagulation dysfunction resulting in an increased incidence of pulmonary embolism (PE) and deep venous thrombosis (DVT), mostly in the lower extremities. While upper-extremity DVT is less frequent than lower-extremity DVT, the thrombosis of internal jugular vein or brachiocephalic (innominate) vein is an uncommon presentation. All the current studies concerning the thrombotic risk linked to hospital COVID-19 indicate that therapeutic anticoagulation does not improve the clinical prognosis in the intensive care unit. Standard prophylactic anticoagulation is therefore recommended. But again, thrombotic complications of COVID-19 infection are still frequently reported nowadays despite anticoagulation therapy, as we can see in this case report. Here we report a rare case of a 50-year-old woman with a previous history of dyslipidemia, admitted for COVID-19 related acute respiratory failure. The patient developed during hospitalization an acute bilateral PE, with upper-extremity DVT including thrombosis of the left brachiocephalic vein extended to the left internal jugular vein, while under prophylactic anticoagulation since hospital admission, leading finally to the patient's death from respiratory failure. At present, the pathophysiology of the hypercoagulable state related to COVID-19 infection is poorly understood. The significant rate of thrombosis despite preventive and therapeutic dosage anticoagulation raises the possibility of a pathophysiology unique to COVID-19. This rare case highlights the importance of thrombotic morbidity and mortality associated with the SARS-CoV-2 epidemic, and the need for further studies to better understand the physiopathology behind the thrombotic state of COVID 19 infection and establish a more efficient way to deal with these complications. •Thromboembolic complications are commonly associated with COVID-19 infection.•Thrombosis can occur at different location, requiring minutious examination and close interpretation of imaging.•Current recommendations indicate prophylactic anticoagulation for the thrombotic risk linked to hospital COVID-19 patients.•Thromboembolic complications of COVID-19 infection are frequently reported despite anticoagulation therapy.•The thrombotic state of COVID-19 infection may be related to a unique pathophysiology, wich may require specific therapy that is more effective than standard heparin anticoagulation.