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COVID-19 has spread among many college students this fall. Boston Globe / Getty Images
  • Bethany Nesbitt, 20, a student at Grace College in Indiana, was found dead in her dorm room after testing positive for COVID-19.
  • Health officials said she had a pulmonary embolism (blood clot) in her lungs.
  • Blood clots are a known complication of COVID-19.

A 20-year-old college student in Indiana with COVID-19 died of an undetected pulmonary embolism (PE), thrusting the topic of blood clots and COVID-19 into the spotlight.

Bethany Nesbitt, 20, a student at Grace College in Indiana, was found dead in her dorm room on Oct. 30, the school said in a statement.

“After a complete investigation and autopsy, the cause of death has been ruled natural due to a pulmonary embolism that had not been previously detected. While COVID did play a role in contributing to the death, it was not caused by COVID,” the statement said, citing a report from Kosciusko County Coroner, Tony Ciriello.

A pulmonary embolism occurs as a result of a blood clot in the deep veins, which is known as deep vein thrombosis (DVT).

If a part of that clot breaks off and travels to the lungs and causes a blockage, that’s known as pulmonary embolism (PE.) If the clot is small enough and treated, most people can recover.

According to her brother Stephen Nesbitt’s Twitter account, she started experiencing symptoms the week of Oct. 20. She got a test on Oct. 22, but never got the results due to an “unknown” clerical error.

A few days before her death, she went to the emergency room because of a drop in her oxygen level.

“An emergency room doctor determined that Bethany very likely had COVID-19, but it was not a severe case, and she seemed to be recovering,” a statement from the family said. She then returned to her dorm to quarantine.

“On Oct. 28, she told her family that she had been fever-free for 24 hours and her oxygen levels were normalizing. She was encouraged,” the statement said.

She had been tested again on Oct. 29 and was found dead the next day.

“Please don’t assume that young people will not be impacted by this virus,” the family said. “Bethany was careful. She wore her mask. She socially distanced.”

Dr. Sharon E. Fox, the associate director of research and development in the Department of Pathology at the LSU Health Sciences Center, said not having seen Nesbitt’s records or medical history, it’s not clear if the pulmonary embolism would have occurred without her also having developed COVID-19.

“If COVID-19 is listed as a contributing factor, it is likely that the pathologist performing the autopsy believes there is reason to suspect it as the cause of the blood clots, but we don’t have a method of saying with certainty that this is due directly to COVID-19,” Fox told Healthline.

PE can be difficult to diagnose because it depends on clinical signs and symptoms, in combination with imaging tests such as CT pulmonary angiography, said Dr. Edwin J.R. van Beek, a physician at Queen’s Medical Research Institute in Edinburgh.

A blood test, plasma D-dimer, can determine the presence of clot remnants in the bloodstream. That can help stratify potential risk.

A normal test more or less excludes thrombosis/pulmonary embolism, while a high level would indicate the presence of abnormal clotting and should lead to diagnostic testing and therapeutic intervention, he said.

COVID-19 is known to cause both small and large vessel blood clots, and in some cases this can be in the form of large vessel PE that leads to death.

It’s also possible that COVID-19 was a factor in this woman’s death for other reasons, but Fox couldn’t say without more information.

“Since the information that we have on blood clots in COVID-19 is based upon group data, where we see a higher incidence, and we do not have a test to say that COVID-19 definitively caused an individual blood clot, the coroner may list COVID-19 as a factor rather than a definitive primary cause of death,” Fox explained.

Fox said there’s evidence to support the presence of blood clots related to COVID-19 in young people, including a higher rate of pulmonary thrombi, as well as stroke.

It’s an effect now widely described in autopsies, typically in middle-aged to older adults around the world.

In her experience reviewing autopsies, they see a high rate of blood clots in the lungs of patients who die from COVID-19.

She also said that these patients have blood test results that suggest they’re in a hypercoagulable state or at higher risk of forming dangerous blood clots.

Fox hasn’t seen as many severely affected young adults, but they have seen MIS-A (Multisystem Inflammatory Syndrome in Adults), which tends to occur after recovery from the initial infection with SARS-CoV-2.

Those patients can have pulmonary thrombi, and often have severe inflammation in multiple organs.

COVID-19 affects many organs, mostly through a pathway where we see inflammation of tissues and small blood vessels, known as “thrombo-inflammation.” That leads to clotting-related complications, said van Beek, who has studied COVID-19 and thromboembolic disease.

“In susceptible patients, this can occur early in the disease process. PE is a later complication, usually occurring after at least one week,” van Beek said.

“In hospitalized patients, there have been more cases of thrombosis… overt, so these have symptoms and were diagnosed… in patients with COVID-19, so this connection is most certainly present. There are many reports now that have shown this high occurrence,” van Beek said.

“What is not clear, however, is whether patients in the out-of-hospital situation equally have this increased risk of thrombosis. These are likely patients with less severe COVID symptoms,” he stated.

Van Beek said it’s possible that even if she had been hospitalized, it may not have saved her life.

“Had she been hospitalized, additional testing may have been performed with blood tests and possibly a CT pulmonary angiogram, but equally, these could have been normal,” van Beek said.

It can be difficult for patients, and even doctors, to initially detect a PE, Fox said.

A blood oxygen test can indicate a mismatch between air breathed in and the ability of the lungs to circulate blood for oxygenation.

A type of blood test can also help indicate if a person is likely to develop a blood clot, but it doesn’t indicate that a clot has actually formed in the lungs.

Doctors will perform a CT scan if they suspect it, but a large PE can also be rapidly lethal, she added.

“As a pathologist, I don’t like to give clinical recommendations on this topic, but there are a few things that people can do,” Fox said.

Track oxygen saturation at home and seek help if it’s persistently low or you experience sudden changes in shortness of breath, or the sensation of chest pain.

Anticoagulant therapies are available, as well as immediate therapies such as taking aspirin if you have COVID-19.

“The pros and cons of anticoagulation must always be weighed within an individual, as the risk of bleeding may be higher than the risk of blood clots in some patients, but it would be worth asking a treating physician if any of these would be appropriate,” Fox said.

Fox added that we still need more data on whether certain treatments will actually help people with these symptoms.

“At this time, we are still awaiting full results of the efficacy of many of these therapies, and this is an evolving topic in clinical medicine,” Fox said.

Even though young adults can have a milder course of COVID-19, they should “take the disease seriously,” Fox emphasized.

“Blood clots and vascular damage are complications that can occur at any age, and MIS-A is more frequently seen after the initial course of the disease, and in a younger adult population,” she said.

“In addition to some deaths, young adults have been left with significant cardiac disease, cognitive dysfunction, or persistent shortness of breath after COVID-19, and this age group should take precautions to avoid contracting the disease, and not hesitate to seek help if they do develop serious symptoms,” Fox continued.

This news comes as researchers report in Science Translational Medicine that an autoimmune antibody in the blood of COVID-19 patients may be responsible for their blood clots.

The antibody circulates in the blood and attacks cells and causes clots in veins, arteries, and microscopic vessels.

In patients with COVID-19, those tiny clots may restrict blood flow in the lungs, which impairs oxygen exchange, the researchers said.

The antibodies are normal in people with the autoimmune disease antiphospholipid syndrome. Seeing them in COVID-19 patients without the syndrome surprised the researchers.

“Now we’re learning that autoantibodies could be a culprit in this loop of clotting and inflammation that makes people who were already struggling even sicker,” Dr. Yogendra Kanthi, an assistant professor at the Michigan Medicine Frankel Cardiovascular Center, said in a statement.