COVID-19 associated with extensive pulmonary arterial, intra
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COVID-19 is the clinical syndrome associated with SARS-CoV-2 infection. Although respiratory failure is the most apparent feature of the disease, venous and arterial thrombosis are well-recognised sequalae.

Expert guidance currently recommends higher than standard doses of prophylactic anticoagulation for patients with COVID-19 requiring critical care. This is the first case of COVID-19 associated with simultaneous pulmonary, intracardiac and peripheral arterial thrombosis.

A 58-year-old man, without major comorbidity, was admitted with a 14-day history of breathlessness. SARS-CoV-2 infection was confirmed by laboratory testing. Initial imaging revealed COVID-19 pneumonia but no pulmonary thromboembolism (PTE) on CT pulmonary angiography (CTPA). The patient subsequently developed respiratory failure and left foot ischaemia associated with a rising D-dimer.

Repeat CTPA and lower limb CT angiography revealed simultaneous bilateral PTE, biventricular cardiac thrombi and bilateral lower limb arterial occlusions. This case highlights a broad range of vascular sequalae associated with COVID-19 and the fact that these can occur despite a combination of prophylactic and treatment dose anticoagulation.

Learning points:
- COVID-19 is associated with high thrombotic risk.
- Current prophylactic anticoagulation strategies may not confer sufficient protection.
- Clinicians should be wary of false reassurance of prophylactic anticoagulation in this patient group.
- There is an urgent need for randomised control trials to test novel prophylactic strategies.

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