Case Report
A 15-year old obese female with a measured weight of 105 kilograms (BMI 34.29 kg/m2) with a past medical history of asthma who underwent a laparoscopic appendectomy 3 days prior to admission presented to an emergency department at an outside hospital with shortness of breath and 2 episodes of syncope. She had a respiratory rate of 50 breaths per minute with oxygen saturations of 100% on non-rebreather mask along with hypertension to 150/111 millimeters of mercury (mmHg). She suddenly became bradycardic followed by multiple asystolic cardiac arrests with brief return of systemic circulation (ROSC) lasting a total of 40 minutes requiring chest compressions and multiple epinephrine doses. After ROSC, she was intubated for cardiorespiratory failure, started on norepinephrine for hypotension, and given systemic tissue plasminogen activator (tPA) for concerns of pulmonary embolism (PE). Computed tomography angiography (CTA) of the chest showed multiple bilateral pulmonary emboli in the secondary and tertiary branches of the pulmonary arteries and potential thrombus in the superior vena cava. CT of the abdomen showed post-operative changes from the recent appendectomy and CT of the brain was normal. Post arrest, she had a lactic acidosis to 17 millimoles per liter with a pH of 6.819. Her serum laboratory values were also significant for leukocytosis, hyperglycemia and hypoalbuminemia as well as elevated troponin-I, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), alanine transaminase (ALT) and aspartate transaminase (AST), D-dimer, blood urea nitrogen (BUN), and creatinine (Cr) (Table 1). She was transferred to a tertiary care facility for further management.
Upon arrival, she was noted to be febrile and had supraventricular tachycardia (SVT) at 220 beats per minute (bpm) which converted to sinus rhythm after 2 doses of adenosine. Blood pressures were maintained on an epinephrine infusion. Echocardiogram showed moderately depressed right ventricular function. She was emergently taken for cardiac catheterization which showed severely elevated right atrial pressures of 20mmHg. Right ventricular pressure was a systolic of 32 mmHg with a severely elevated end diastolic pressure of 24mmHg. Patient had low cardiac output with a measured cardiac Index of 2.6 liters per minute per meter squared. Bilateral uni-fuse catheters were placed in the left and right pulmonary arteries for localized TPA infusion. She received 24 hours of localized TPA therapy at 0.5 milligrams per hour via each catheter along with heparin infusion (Figure 1). Lactic acid level and right ventricle function normalized on the echocardiogram 2 days after admission, and CTA of the chest showed resolution of bilateral PE on day 3 of admission. She was successfully extubated after 12 days and required hemodialysis for kidney failure for 7 days. She had multiple episodes of fevers throughout her admission, and further infectious workup showed SAR-CoV2-IgM to be positive. SAR-CoV2 PCR was negative on a total of six tests during admission, and the SAR-CoV2-IgG remained negative on a total of three tests. There was no deep venous thrombosis found on ultrasonography, and the hypercoagulable workup only showed elevated homocysteine levels likely due to kidney failure. She suffered from neurological devastation with spasticity from hypoxic ischemic injury noted on magnetic resonance imaging of the brain in the occipital, parietal, frontal gray-white matter bilaterally. Gastrostomy tube was placed for feeding. She was discharged to an inpatient neurological rehabilitation center.