Risk stratification for PE and decisions about treatment dose anticoagulation are complex and need to be made at the bedside of the patient. The absolute value of the D-Dimer has no role in this. D-Dimer is often significantly raised in COVID-19 without large vessel thrombosis. There is likely to be significant microvascular thrombosis. However if PE is considered likely then I perform CTPA to exclude this.

In those patients in whom PE is not suspected my practice is to use double the prophylactic dose of enoxaparin for inpatients with COVID-19 if D-Dimer is raised (and there are no contraindications). I continue the standard prophylactic dose of enoxaparin for 14 days post discharge.

On the basis of the information provided antiviral therapy for SARS-CoV-2 is not required (>11 days since onset of infection). Oxygen therapy is generally indicated to maintain saturations 92-98%. Therefore supplemental oxygen is not required unless the patient desaturates on exertion.

Apart from 4 Ts - tracking, tracing, testing and treating, masking and physical distancing are the urgent needs to fight.

The medical part needs to be taken care by qualified doctors. Ehab Mudher Mikhael

I recommend spiral lung CT. His lung is infiltrated.

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D-Dimer is a fibrin degradation product. Therefore we see it not only in COVID-19 but also in other inflammatory processes. Note that in your patient's context your administration of rivaroxaban is more of a secondary preventive nature, since you don''t know if there is PE....... have in mind that bleeding can be induced.

Conducting a CT-Thorax (if available) will probably not aid, since you would probably not terminate Rivaroxaban anyways, even in absence of pulmonary embolism. I would conduct Doppler ultrasound for ruling out deep venous thrombosis. Likeliness of PE is super low in absence of DVT.

However, you should follow up on the patient. A four fold increase of D-Dimer in COVID-19 patients is associated with a higher mortality.

• Antiviral medication not indicated
• Oxygen not indicated

Thanks all for their comments

Dear, Benito Jonas Baldauf , if duplex study show no DVT, then do you mean that there is no need for the prophylactic anticoagulant?

Dear Ehab Mudher Mikhael

if you can rule out DVT by duplex, pulmonary embolism is very very unlikely...given what we know about the classic development of PE. This could be different in COVID-19. But we do not know this at the moment!

Therefore, I would suggest: You do not need to alter the amount of Rivaroxaban (would be 15mg bidaily initially and 20mg daily longterm in PE). However, until your COVID-19 patient has recovered I would keep up secondary prevention as you are conducting it at the moment or like Rajkumar Rajendram proposed (Enoxaparin).

Why?

We observed a rise in PE during the first "wave " in our centre in about 30% of COVID-19 patients irrespective of D-Dimer concentration in their blood. Therefore a thrombogenic potential can be suspected in some COVID-19 individuals. Additionally a recent review has seen a high risk of DVT and PE in COVID-19. However this was mainly in critical ill patients.

https://venousnews.com/systematic-review-finds-high-risk-of-deep-vein-thrombosis-and-pulmonary-embolism-in-covid-19-patients/

I hope this is of any help to you. In general you did everything right!

We will see if we can generalize secondary preventive measures in COVID-19 with data from ongoing trials. As long as we do not know more, we have to stick to algorithms we have good data on.

The pathogenesis of COVID-19 seems to involve immunothrombosis. So it is possible to get PE without DVT in patients with COVID-19. In the presence of DVT anticoagulation is indicated anyway. However the absence of DVT can not exclude PE. In most patients the absence of DVT does reduce the probability of PE. However, need more data to establish whether this is true in COVID-19.

He needs anticoagulant, anti viral according to his investigations

First, i think there should be a knowlegde of prior history. Is this the first bout with covid19 or it is a reinfection? then we need knowledge of if he has had history of thrombosis.. however, there is a definite indication of Theurapetic Anticoagulants. This appears to be a fairly less complicated case.

Diognostic Interpretation - https://www.researchgate.net/post/What_are_the_Complete_Diognostic_Tests_to_Screen_Covid19_Pateints

Antiviral Therapy -https://www.researchgate.net/post/Broad_Spectrum_Synthetic_Antiviral_Compounds_Including_covid19-A_Short_Review

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Think out of the the box!

I would recommend giving your patient therapeutic doses of weight adjusted subcutaneous Enoxaparin whether or not a chest CT-angiography shows pulmonary embolism:

This is because:

Patients with pulmonary embolism have no detectable thrombosis in the lower limb veins (1).

Furthermore, the thrombosis in patients with COVID-19 can be a part of inflammation and endothelitis (2).

1. Article Pulmonary Embolism Without Deep Venous Thrombosis

2. Article Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogen...

Muhammad Yousuf seemingly there is a misunderstanding.

PE without DVT is very unlikely as backed by the paper you cited:

230 patients with PE and 131 with source of PE in either lower or upper extremities. The rest was not checked!

Ultimately 15 patients were found without source of PE, but ten of them had mailignancy which is a well known thrombogenic promotor.

This narrows your statement: " Patients with pulmonary embolism have no detectable thrombosis in the lower limb veins (1). " down to five patients with PE without origin vs 131 patients with DVT in 230 PE patients....very clear.

I agree to give anticoagulant as a prophylactic measure and continue for 2 moths after recovery for those patients had increased D- dimmer and Serum Ferritin.

I agree to give anticoagulant as a prophylactic measure and continue for 2 moths after recovery for those patients had increased D- dimmer and Serum Ferritin.

S2k guideline recommendations for the inpatient treatment of patients with COVID-19 released 23rd november 2020 in Germany

Part of critical ill patient treatment:

In the absence of a confirmed VTE or ECMO therapy, therapeutically dosed anticoagulation cannot be routinely recommended at present; however, it appears justifiable in individual cases, e.g., when rapid increases in D-dimers and/or acute deterioration of gas exchange do not allow for timely diagnostic imaging. Since the formation of microthrombi in the pulmonary endothelial tract is considered

characteristic findings of COVID-19-associated ARDS (1), therapeutic anticoagulation is also a possible therapy option in ventilated intensive care patients under individual consideration of benefit and risk (e.g. pulmonary hemorrhages) (2;3)

Conclusion: in your setting secondary preventive NOAC use is a justifiable way to go as you did

Following Answer !!

Message from Astrobiology: first global foci are linked geographically.

We have answer why.

I do agree with Ban N.

Any kind of flew effect person suffers from lung function problem. So it is immediate to be ensure the breathing and blood should be enrich of Oxygen properly. Then notice on other factors. In case COVID also that steps should be taken early, then think about prescribe dose or others. Because lack of Oxygen makes versatile organal malfunctions. So supply of glucose in cell and Oxygen supply is the must.

Vaccines are currently the only way to limit the infection. But there are too many negative opinions against vaccines. Even people without primary education express opinions (negative), people who do not understand anything but are "against". False "facts" are written. This prevents all of humanity from solving this serious problem.

Kindly see the attached article.

Article The “Quarantine Dry Eye”: The Lockdown for Coronavirus Disea...

New Model for the COVID-19 Reported Cases and Deaths of Ghana in Accelerated Spread and Prediction of the Delayed Phase

https://www.researchgate.net/publication/356970930_New_Model_for_the_COVID-19_Reported_Cases_and_Deaths_of_Ghana_in_Accelerated_Spread_and_Prediction_of_the_Delayed_Phase