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eConsult Clinical Question

A 35-year-old female who presents to establish care, recently moved from California, and complains of long haul COVID symptoms. She had COVID previously. Her pulmonary specific complaints are shortness of breath and chest tightness. She feels like something is in her chest. She has had an extensive work up in California and will be getting her records. She states her previous physician was concerned about chronic thromboembolic disease and she was placed on Eliquis. However, she never started the medication.

Computed tomography (CT) scans from California have not shown a pulmonary embolism. She has also had a normal cardiac catheterization and a normal chest CT without evidence of pulmonary embolus. I am going to obtain PFTs. Would a ventilation/perfusion (V/Q) scan be of use to rule out chronic thromboembolic disease?

eConsult Response

Individuals with prolonged symptoms after COVID can be challenging because often there is no clear abnormality on imaging or other diagnostics to explain symptoms. I agree that getting prior work up and records from California is important to make sure there is nothing we are missing.  

As outlined, your current plan is: (1) obtain records; (2) perform PFTs. I would add on a six-minute walk test to her PFTs if you did not order one. This will give us a better idea of physical endurance and aerobic capacity and heart rate, O2 saturation, and blood pressure with exercise; (3) nocturnal oximetry.

Regarding the question of V/Q imaging, given that her prior treating physician had ordered Eliquis, I would be inclined to go forward with V/Q as this would be better test to assess for chronic thromboembolic disease. Her ECHO does not show any significant pulmonary hypertension.

Overall, given that she has a normal echocardiogram, I do think she will be unlikely to have chronic thromboembolic pulmonary hypertension. Finally, I would consider physical therapy or other structured rehabilitation program. 

These real-life examples have some limitations. Given the evolving recommendations and guidance on COVID-19 care, these cases should not be considered complete or definitive and may not reflect the most up-to-date guidance.