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Background Coronavirus disease 19 (COVID-19) reinfection has been a topic of discussion with data still emerging. Viral antibodies are known to develop upon initial infection; however, it is unclear the amount of protection this confers against reinfection. Additionally, COVID-19-associated coagulopathy (CAC) is a well-documented phenomenon; however, there are no high-quality studies to support the treatment of outpatients beyond standard indications of venous thromboembolism (VTE) prophylaxis. This case describes a patient with either COVID-19 reinfection or prolonged course of CAC resulting in pulmonary embolism (PE). Case summary A 40-year-old healthy man presented with fever and cough. He tested positive for COVID-19 and was sent home to self-quarantine. His symptoms resolved and repeat COVID-19 testing returned negative. Two months later, he developed dyspnoea on exertion and syncope. Computed tomography with PE protocol demonstrated acute bilateral PE, and repeat COVID-19 testing returned positive. He was escalated to catheter-directed thrombolysis, but prior to the procedure went into cardiopulmonary arrest. Cardiopulmonary resuscitation was initiated and full-dose systemic alteplase was administered. Cardiothoracic surgery was consulted for consideration of veno-arterial extracorporeal membrane oxygenation; however, return of spontaneous circulation was unable to be achieved. Discussion This case raises the question of COVID-19 reinfection and prolonged risk of VTE due to CAC. We believe the patient was reinfected with COVID-19 provoking his PE; however, a single COVID-19 infection causing a prolonged course of CAC is possible. Until better data exists, decisions regarding outpatient prophylaxis must be individualized to weigh the risks of bleeding against the risk of thrombosis.

Acute submassive pulmonary embolism after SARS-CoV-2 infection: a case report of reinfection or prolonged hypercoagulable state