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TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 (Coronavirus Disease of 2019) is a global pandemic caused by the rapidly spreading SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2). Although COVID-19 primarily affects the respiratory system, evidence suggests a strong predisposition for pro-thrombotic states with COVID-19 infection, manifesting as both venous and arterial thromboembolism. COVID-19 associated coagulopathy and its varying complications contribute to a significant portion or morbidity and mortality in addition to respiratory failure. CASE PRESENTATION: A 75-year-old woman with stage IV colorectal carcinoma, rheumatic mitral valve stenosis status-post recent balloon valvulotomy, and atrial fibrillation on warfarin presented with fever, cough, anosmia, ageusia, dyspnea, generalized weakness, and anorexia. She was admitted for neutropenic fever, acute hypoxic respiratory failure, and sepsis in the context of COVID-19 pneumonia. Computed tomography angiogram (CTA) of the chest showed bilateral infiltrates consistent with COVID-19 pneumonia, as well as a more unusual finding of a large 7 x 4 x 7 cm left atrial mass (Figure 1), consistent in appearance with a thrombus. Comparison with CTA chest one month prior confirmed that the thrombus was acute. On admission, the patient also had a supratherapeutic INR of 4. Echocardiography confirmed the suspicion for thrombus and redemonstrated restricted mitral valve leaflets consistent with rheumatic valvular stenosis. The patient was treated with supplemental oxygen, remdesivir, vancomycin, cefepime and filgrastim. She responded well and had resolution of her neutropenia, sepsis, and hypoxia. Because she formed the thrombus while on warfarin, decision was made to discontinue warfarin and transition to enoxaparin for anticoagulation. She was subsequently discharged home on hospice. DISCUSSION: Although venous thromboembolism is commonly encountered with COVID-19 patients, to our knowledge this case represents the first report of COVID-19 associated left atrial thrombus. Rheumatic mitral valve disease is a known risk factor for left atrial thrombus formation and colorectal carcinoma may have also contributed to hypercoagulability. However, the patient in our vignette had a supratherapeutic INR at the time of thrombus formation. Furthermore, the absence of thrombus on imaging one month prior confirms a temporal association with COVID-19 infection. As such, evidence suggests that hypercoagulability secondary to COVID-19 contributed to the formation of her left atrial thrombus. CONCLUSIONS: This case adds to the growing body of literature surrounding the profound hypercoagulability provoked by SARS-CoV-2 infection and reiterates the role of anticoagulation in the management of COVID-19 patients during the ongoing pandemic. REFERENCE #1: Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun. 2020;109:102433. REFERENCE #2: Incidence of thrombotic complications in critically ill ICU patients with COVID-19. lok FA, Kruip MJHA, van der Meer NJM, et al. Thromb Res. 2020;191:145–147. REFERENCE #3: Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844–847. DISCLOSURES: No relevant relationships by Nikhila Janakiram, source=Web Response No relevant relationships by Eva Ma, source=Web Response No relevant relationships by Andreas Mauer, source=Web Response