Asymptomatic COVID-19 Patient with a Subtle Hypercoagulable State and Fluctuating D-dimer Level


Background: COVID-19 can infect an asymptomatic person silently without any overt symptoms despite diffuse blood clots throughout the body. Clot formation is induced by COVID-19 associated coagulopathy that can cause a high mortality rate. D-dimer, a fairly decisive marker for the coagulopathy event, is physiologically a marker of the fibrinolysis process. The increase of D-dimers in COVID-19 cases must be followed up because it relates to the initiation of a cytokine storm.

Case presentation: We report an asymptomatic patient with sudden D-dimer elevation who received anticoagulant therapy. After three days of heparin administration, D-dimer results became normal and anticoagulant therapy was stopped. However, on the 12th day, the D-dimer level rebounded back and was followed by an increase of hs-C-reactive protein, erythrocyte sedimentation rate, IL-6, although SARS-CoV-2 PCR result became negative. A hyperglycaemic reaction and a sudden increase of HbA1C was observed in the patient. After three weeks D-dimer had returned to normal levels, and so did the other markers. The patient recovered fully and still no symptoms were obvious.

Conclusion: COVID-19 patients without symptoms may be at risk of an asymptomatic coagulopathy process. The decreasing level of D-dimer erroneously cannot ensure that the coagulopathy process stops.

Keywords: COVID-19, Coagulopathy, Asymptomatic, D-dimer, Anticoagulant Therapy



Coronavirus Disease 2019 (COVID-19), following SARS-Cov-2 infection, silently attacks various organs in the human body including the lung. Silent hypoxia and blood clots throughout the body are sometimes not followed by any symptoms. COVID-19 associated coagulopathy leading to massive thrombosis is the cause of high mortality rates and adds complexity in treating the disease. It has been shown to be present in up to 31% of critically ill intensive care unit (ICU) patients. COVID-19 associated coagulopathy has a fairly-decisive marker, namely D-dimer, which is a physiological marker of the fibrinolysis process. D-dimer elevation in Disseminated Intravascular Coagulation (DIC) generally shows a highly active fibrinolysis process to oppose clot formation. However, the fibrinolysis process in COVID-19 is very minimal when compared to the clot formation.This imbalance has the potential to increase mortality.

Therefore, the increase in D-dimer in COVID-19 cases must be monitored more seriously because it is related to the initiation of a cytokine storm, which causes worsening conditions in COVID-19. D-dimer monitoring is necessary because subclinical thrombosis tends to be missed in asymptomatic cases.7,8 Here we present an asymptomatic case in which the elevation of D-dimer was present before the cytokine-storm.

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