Figure 2. Parenchymal view of the spiral chest CT scan at
admission. (A) Nodule with sharp edges in RUL (green arrow); (B)
Peripheral ground glass opacity (blue arrow) and atelectatic band in the
left lung parenchyma (red arrow)
Due to the extent of thrombosis and failure to increase PTT despite
raising the heparin dose to 1500 U/h, interventional cardiovascular
consultation for local thrombolytic injection was requested for the
patient. However, the patient did not consent to angiography and
thrombolysis. Although IVC filters are also an option when the
thrombosis is free-floating on ultrasound, consultation with the
radiologist indicated that the thrombosis was completely fixed and thus
an IVC filter placement was cancelled. Considering the patient’s
relative resistance to heparin, 80 mg subcutaneous BD injection of
enoxaparin and 7.5 mg warfarin tablets daily were added to his treatment
protocol. Since the prothrombin time (PT), international normalized
ratio (INR), and PTT did not reach the treatment range, hematology
counseling was performed and the dose of warfarin was increased to 10 mg
every other day until the INR stabilized at 2-3. Anticoagulant
injections were then discontinued. On the 13th day of hospitalization,
the patient suffered from shortness of breath, pleuritic chest pain, and
dry cough and his oxygen saturation dropped to 91%. Therefore, a second
PCR test and a spiral chest CT scan without contrast was requested. In
addition to previous CT scan findings, the recent CT scan images showed
the presence of a mild lateral effusion (at a depth of 25 mm) in the
left hemithorax. Alveolar consolidation was observed in the lower lobe
of the left lung and several focal ground-glass opacities were detected
in the peripheral of both lung parenchyma with greater severity in the
left lung. Viral pneumonia (COVID-19) was suggested primarily and
bacterial pneumonia in the differential diagnosis (Figure 3). After
three days, the patient’s PCR was positive, and he was transferred to
the COVID-19 ward and Cefepime Ampule 500 mg BD was started. After 15
days of admission, coagulation tests approached the target (PT: 18.9
Sec, INR: 2.4 Index, PTT: 60 Sec), the patient’s heparin and enoxaparin
were discontinued, but warfarin treatment was continued. The left flank
pain reduced and the hematuria was relieved. The creatinine level
increased to 2.1 mg/dl following COVID-19 treatment. The patient left
the hospital after 17 days of hospitalization with personal consent and
advice to take warfarin. He did not cooperate and did not refer to
follow-up creatinine level after after discontinuation of nephrotoxic
drugs and discharge.