Thrombolysis in severe COVID-19 pneumonia with massive pulmonary embolism

Am J Emerg Med. 2021 Mar;41:261.e1-261.e3. doi: 10.1016/j.ajem.2020.07.068. Epub 2020 Jul 30.


Objective: No guidelines exist for the management of massive pulmonary embolism (PE) in COVID-19. We present a COVID-19 patient with refractory acute respiratory syndrome (ARDS), and life-threatening PE who underwent successful thrombolysis.

Case presentation: A previously healthy 47 year old male was admitted to our hospital due to severe COVID-19 pneumonia [confirmed by Real-Time-Polymerase-Chain-Reaction (RT-PCR)]. He had rapidly evolving ARDS [partial arterial pressure of oxygen to fractional inspired concentration of oxygen ratio: 175], and sepsis. Laboratory results showed lymphocytopenia, and increased D-dimer levels (7.7 μg/ml; normal: 0-0.5 μg/ml). The patient was treated in the intensive care unit. On day-1, ARDS-net/prone positioning ventilation, and empiric anti-COVID treatment integrating prophylactic anticoagulation was administered. On hospital day-2, the patient developed shock with worsening oxygenation. Point-of-care-ultrasound depicted a large thrombus migrating from the right atrium to the pulmonary circulation. Intravenous alteplase (100 mg over 2 h) was administered as rescue therapy. The patient made an uneventful recovery, and was discharged to home isolation (day-20) on oral rivaroxaban.

Conclusion: Thrombolysis may have a critical therapeutic role for massive PE in COVID-19; however the risk of potential bleeding should not be underestimated. Point-of-care ultrasound has a pivotal role in the management of refractory ARDS in COVID-19.

Keywords: Acute respiratory distress syndrome; COVID-19; Massive pulmonary embolism; Point-of-care ultrasound; Thrombolysis.

Publication types

  • Case Reports

MeSH terms

  • COVID-19 / complications*
  • Critical Care
  • Fibrinolytic Agents / adverse effects
  • Fibrinolytic Agents / therapeutic use*
  • Hemorrhage / chemically induced
  • Hemorrhage / prevention & control
  • Humans
  • Male
  • Middle Aged
  • Point-of-Care Testing
  • Pulmonary Embolism / diagnostic imaging
  • Pulmonary Embolism / drug therapy*
  • Pulmonary Embolism / etiology*
  • SARS-CoV-2
  • Thrombolytic Therapy*
  • Tissue Plasminogen Activator / adverse effects
  • Tissue Plasminogen Activator / therapeutic use*
  • Ultrasonography


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator