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.