Letter to the Editor: “Pandemic novel coronavirus 2019-nCoV pneumonia and acute pulmonary embolism: are we underestimating the problem?”

by Lorenzo Monfardini, Paolo Botti, Mauro Morassi, Claudio Sallemi, Stefania Pezzotti and Claudio Bnà (lorenzo.monfardini@poliambulanza.it)

Dear Editor,

The COVID-19 outbreak that is currently ongoing in Northern Italy is intensely stressing the health machine. ICU departments are under a great deal of pressure because of the number of critically ill patients. As many other radiologists in the Lombardia region, we have tried to learn as much as possible from the literature based on the experience of the Chinese. However, a problem we are still trying to face is the high mortality rate with pulmonary embolism (PE). So far, such condition has only been described as pictorial issue [1] but in our clinical practice, it does not seem to be so rare. Out of 296 CT scans in patients with positive COVID-19 nasopharyngeal swabs (Novel Coronavirus PCR Fluorescence Diagnostic Kit, BioGerm Medical Biotechnology), 14 (4%) were positive for PE and one patient died in the emergency room with a multiple organ embolism condition (cerebral and renal). At the time of writing, we are not fully aware of how many CT scans were performed with contrast media in the clinical doubt of PE; this would require a considerable time-consuming effort that we cannot afford, but it will be one of our priorities as soon as the situation is under control.

Our intent with this letter is to draw radiologists’ attention to PE; such a condition is not easy to suspect in a respiratory failure clinical setting, but the thrombofilic risk in such a scenario has been already postulated only by means of “ex adiuvantibus” treatment decisions [2]. Maybe, in addition to the previously described study [3], some additional findings we should pay attention to in a non-contrast enhanced CT scan, are pulmonary artery and right heart measures; pulmonary infarction could be challenging to distinguish from interstitial pneumonia. Another situation to consider for the high risk of PE is the sudden worsening of respiratory function already compromised: five out of our 14 cases already performed a non-enhanced CT as in-patients but no relevant changes were observed in vasculature metrics.

To conclude, even if these are only speculations, waiting for precise data in the next few months, please be aware of PE.