A 79-year-old woman presented to our hospital with complaints of weakness, loss of appetite, and shortness of breath. The patient had a history of falling from the tractor one month before and had been operated on for fractures in the humerus and femur. She had been discharged from the hospital 12 days before readmission. Her family history was unremarkable and she had no history of smoking and alcohol use.

The patient had mild dyspnea and rales in the left lung base on auscultation. She had a temperature of 36°C, a heart rate of 78 beats/min, and blood pressure of 108/78 mmHg. The oxygen saturation measured by a pulse oximeter was 92%.

The laboratory analyses were noteworthy due to elevated levels of D-dimer, C-reactive protein (CRP), troponin-T, and ferritin. There was also mild hypoxemia on arterial blood gas analysis ( Table 1 ). The patient’s ECG was normal ( Figure 1 ). Computed tomography pulmonary angiography (CTPA) scan showed embolism at the peripheral segmental branches of both lower pulmonary lobes ( Figure 1 ), with bilateral pleural effusions ( Figure 2 ), and fibrotic changes and infiltrations as sequelae ( Figure 3 ). Although there was no ground glass opacity in the parenchyma (atypical findings for COVID-19), a polymerase chain reaction (PCR) test for COVID-19 was performed on the nasopharyngeal smear and was found positive at hospitalization.

Table 1

Parameters	On hospital admission	After treatment	Reference range
CRP (mg/dL)	64	17	0-5
Sedimentation (mm/h)	35	27	3-55 (>70 years old)
Procalcitonin (ng/mL)	0.177	0.054	<0.5
WBCs (x103cells/mm3)	5.2	2.9	5.2-12.4
Neutrophils (x103cells/microL)	4.1	1.8	2.1-6.1
Lymphocytes (x103/microL)	0.6	0.6	1.3-3.5
Platelets (x103/microL)	180	257	156-373
Hemoglobin (g/dL)	10.3	10.9	13.6-17.2
Hematocrit (%)	30.9	33.2	39.5-50.3
D-dimer (ng/L)	2454	858	69-243
PT (sec)	16.7	17.7	9.4-12.5
aPTT (sec)	27.5	32	25.4-38.4
TT (sec)	23.7	-	15.8-24.9
INR INR	1.42	1.51	0.8-1.1
Fibrinogen (mg/dL)	301	419	200-393
Ferritin (ng/dL)	1057	1022	4.63-204
Troponin T (ng/mL)	0.065	0.024	0-0.014
LDH (U/L)	321	349	0-247
ALT (U/L)	6	11	0-34
AST (U/L)	18	29	0-31
Creatine (mg/dL)	0.31	0.28	0.66-1.29
Protein (g/dL)	5.45	5.64	6.6-8.3
Albumin (g/dL)	2.8	2.9	3.5-5.2
Na (mmol/L)	130	138	136-146
K (mmol/L)	3.77	3.97	3.3-5.1
Ca (mg/dL)	7.67	8.37	8.8-10.6
Corrected Ca (mg/dL)	8.63	9.17	9.2-9.64

CRP: C-reactive protein; WBCs: White blood cells; PT: Prothrombin time; aPTT: Activated partial thromboplastin time; TT: Thrombin time; INR: International normalized ratio; LDH: Lactate dehydrogenase; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; Na: Sodium; K: Potassium; Ca: Calcium.

Figure 1

Figure 2

Figure 3

The final diagnosis of the patient was COVID-19 infection with PE and bilateral pleural effusions. The patient was transferred to the COVID-positive service and treated with favipiravir (2x1600 mg/day on the first day and 2x600 mg/day for the next four days), moxifloxacin 1x400 mg/day and 2x0.6 IU low-molecular-weight heparin (LMWH). Ten days later she was discharged from the hospital without the need for oxygen supplementation. The patient was prescribed low molecular weight heparin for one month and the treatment was subsequently continued with oral anticoagulants.