PC1188: Pulmonary Embolism in Pediatric Patients with Recent COVID-19 Infection: A Case Series

Introduction: COVID-19 has been reported to induce a prothrombotic state in the adult population. However, reports of thromboembolic complications, specifically pulmonary embolism (PE), following SARS-CoV-2 infection in pediatric patients remain rare. Here, we describe three cases of PE seen in unvaccinated adolescent males with recent COVID-19 infection and prothrombotic risk factors including obesity and Protein S deficiency.

Case Description: Case 1: A 14-year-old male (body mass index (BMI) >99th percentile) presented to the emergency department (ED) with left-sided chest pain that worsened on inspiration, cough, and dyspnea on exertion. COVID-19 testing was positive two weeks prior but negative on admission. Initial serum laboratory values are detailed in Table 1. Chest computed tomography angiogram (CTA) demonstrated bilateral lower lobe occlusive pulmonary emboli. Additional imaging findings are detailed in Table 2. The patient was started on enoxaparin and intravenous (IV) fluids and given one dose of dexamethasone. He was discharged after 24 hours, continued enoxaparin for 5 days, and then transitioned to oral dabigatran for three months with hematology follow-up.

Case 2: A 15-year-old male (BMI >99th percentile), with a past medical history (PMH) of asthma, presented to the ED with two days of chest pain and dyspnea. COVID-19 testing was positive ten days prior (Table 1). Chest CTA showed pulmonary embolism with a large thrombus burden (Table 2). The patient was treated initially with heparin and then with enoxaparin, remdesivir, albuterol, azithromycin, and IV solumedrol. On day 9, he was discharged on enoxaparin therapy for three months with hematology follow-up.

Case 3: A 15-year-old male (BMI 88th percentile), with PMH significant for Protein S deficiency, presented to the ED with a one-day history of palpitations, stabbing chest pain, dyspnea, and cough. COVID-19 testing was positive 19 days prior and negative on admission (Table 1). Chest CTA showed bilateral pulmonary emboli (Table 2). He was started on heparin, transitioned to enoxaparin therapy, and subsequently oral rivaroxaban due to insurance coverage. On day 4, he was discharged on rivaroxaban with planned anticoagulation of three months and potential for lifelong anticoagulation per hematology follow-up.

Discussion: Evidence-based guidelines for pediatric PE management are lacking, and current practices are extrapolated from adult data. With increased thromboembolic complications associated with COVID-19, further studies are necessary to better guide diagnosis, management, and follow-up of pediatric patients with COVID-19 infection and significant risk factors for venous thromboembolism (VTE). We acknowledge elevated BMI as a significant risk factor and report the first case of PE in a pediatric patient with Protein S deficiency and COVID-19 infection.

Conclusion: These three cases emphasize that pediatric patients with identifiable prothrombotic risk factors are at risk for developing serious complications secondary to COVID-19 infection, and as such, increased suspicion for VTE development should be present in these situations.