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.