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Diamond MS, Kanneganti TD. Innate immunity: the first line of defense against SARS-CoV-2. Nat Immunol 2022; 23:165-176. [PMID: 35105981 PMCID: PMC8935980 DOI: 10.1038/s41590-021-01091-0] [Citation(s) in RCA: 292] [Impact Index Per Article: 146.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/03/2021] [Indexed: 02/03/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus (SARS-CoV)-2, continues to cause substantial morbidity and mortality. While most infections are mild, some patients experience severe and potentially fatal systemic inflammation, tissue damage, cytokine storm and acute respiratory distress syndrome. The innate immune system acts as the first line of defense, sensing the virus through pattern recognition receptors and activating inflammatory pathways that promote viral clearance. Here, we discuss innate immune processes involved in SARS-CoV-2 recognition and the resultant inflammation. Improved understanding of how the innate immune system detects and responds to SARS-CoV-2 will help identify targeted therapeutic modalities that mitigate severe disease and improve patient outcomes.
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Affiliation(s)
- Michael S Diamond
- Department of Medicine, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
- The Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
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102
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Pathogenesis of Two Faces of DVT: New Identity of Venous Thromboembolism as Combined Micro-Macrothrombosis via Unifying Mechanism Based on “Two-Path Unifying Theory” of Hemostasis and “Two-Activation Theory of the Endothelium”. Life (Basel) 2022; 12:life12020220. [PMID: 35207507 PMCID: PMC8874373 DOI: 10.3390/life12020220] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary DVT is an intravascular blood clotting disorder that can be a life-threatening disease, particularly if it occurs in critically ill patients. Typically, distal DVT develops following a vascular injury associated with incidental trauma commonly involving lower extremities, which is transient and benign condition localized in the lower legs as solitary lesion. However, proximal/central DVT (i.e., venous thromboembolism) typically occurs in association with critical illnesses such as sepsis, diabetes, hypertension, cancer, autoimmune disease and others in the hospitalized patient, especially in the ICU. Recognition of different pathogenesis between distal DVT and proximal/central DVT is critically important because the prognosis is poorer in VTE. Its therapeutic approach should be different from distal DVT. The aim of this review is to identify the pathogenesis of two different types of DVT based on in vivo hemostatic mechanisms, which can explain their distinct phenotypes by clinical characteristics, laboratory data and imaging findings. An appropriate preventive measure can be put into the practice to avoid the onset of VTE. Additionally, should VTE be developed, proper and rational therapeutic regimen based on its pathogenesis can be designed for clinical trials to improve the outcome. Abstract Venous thrombosis includes deep venous thrombosis (DVT), venous thromboembolism (VTE), venous microthrombosis and others. Still, the pathogenesis of each venous thrombosis is not clearly established. Currently, isolated distal DVT and multiple proximal/central DVT are considered to be the same macrothrombotic disease affecting the venous system but with varying degree of clinical expression related to its localization and severity. The genesis of two phenotypes of DVT differing in clinical features and prognostic outcome can be identified by their unique hemostatic mechanisms. Two recently proposed hemostatic theories in vivo have clearly defined the character between “microthrombi” and “macrothrombus” in the vascular system. Phenotypic expression of thrombosis depends upon two major variables: (1) depth of vascular wall damage and (2) extent of the injury affecting the vascular tree system. Vascular wall injury limited to endothelial cells (ECs) in sepsis produces “disseminated” microthrombi, but intravascular injury due to trauma extending from ECs to subendothelial tissue (SET) produces “local” macrothrombus. Pathogen-induced sepsis activates the complement system leading to generalized endotheliopathy, which releases ultra large von Willebrand factor (ULVWF) multimers from ECs and promotes ULVWF path of hemostasis. In the venous system, the activated ULVWF path initiates microthrombogenesis to form platelet-ULVWF complexes, which become “microthrombi strings” that produce venous endotheliopathy-associated vascular microthrombotic disease (vEA-VMTD) and immune thrombocytopenic purpura (ITP)-like syndrome. In the arterial system, endotheliopathy produces arterial EA-VMTD (aEA-VMTD) with “life-threatening” thrombotic thrombocytopenic purpura (TTP)-like syndrome. Typically, vEA-VMTD is “silent” unless complicated by additional local venous vascular injury. A local venous vessel trauma without sepsis produces localized macrothrombosis due to activated ULVWF and tissue factor (TF) paths from damaged ECs and SET, which causes distal DVT with good prognosis. However, if a septic patient with “silent” vEA-VMTD is complicated by additional vascular injury from in-hospital vascular accesses, “venous combined micro-macrothrombosis” may develop as VTE via the unifying mechanism of the “two-path unifying theory” of hemostasis. This paradigm shifting pathogenetic difference between distal DVT and proximal/central DVT calls for a reassessment of current therapeutic approaches.
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103
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Zitek T, Weber L, Pinzon D, Warren N. Assessment and Management of Immune Thrombocytopenia (ITP) in the Emergency Department: Current Perspectives. Open Access Emerg Med 2022; 14:25-34. [PMID: 35125895 PMCID: PMC8809484 DOI: 10.2147/oaem.s331675] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/20/2022] [Indexed: 12/04/2022] Open
Abstract
Immune thrombocytopenia (ITP) is characterized by a platelet count less than 100 × 10^9/L without anemia or leukopenia. Patients with ITP may be asymptomatic, or they may have mild bleeding like petechiae, purpura, or epistaxis. In rare cases, they may present to the emergency department (ED) with life-threatening bleeding as a result of their thrombocytopenia. The emergency physician should thus be prepared to diagnose ITP and treat the bleeding that can result from it. The diagnosis of ITP requires excluding secondary causes of thrombocytopenia, and in the ED, the bare minimum workup for ITP includes a complete blood count and a peripheral blood smear. The peripheral blood smear should show a small number of large platelets with normal morphology, and there should not be an increased number of schistocytes. Many patients with ITP require no emergent treatment. However, if a patient with suspected ITP presents to the ED with critical hemorrhage, the emergency physician should initiate treatment with a platelet transfusion, corticosteroids, and intravenous immune globulin (IVIG) as soon as possible. For less severe bleeding, platelet transfusions are not recommended, and the treatment consists of corticosteroids by themselves or in conjunction with IVIG.
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Affiliation(s)
- Tony Zitek
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
- Department of Emergency Medicine, Herbert Wertheim College of Medicine at Florida International University, Miami, FL, USA
| | - Luke Weber
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Dominique Pinzon
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Nicole Warren
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
- Department of Emergency Medicine, Herbert Wertheim College of Medicine at Florida International University, Miami, FL, USA
- Department of Medical Education, University of Miami School of Medicine, Miami, FL, USA
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104
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Ryan FJ, Hope CM, Masavuli MG, Lynn MA, Mekonnen ZA, Yeow AEL, Garcia-Valtanen P, Al-Delfi Z, Gummow J, Ferguson C, O'Connor S, Reddi BAJ, Hissaria P, Shaw D, Kok-Lim C, Gleadle JM, Beard MR, Barry SC, Grubor-Bauk B, Lynn DJ. Long-term perturbation of the peripheral immune system months after SARS-CoV-2 infection. BMC Med 2022; 20:26. [PMID: 35027067 PMCID: PMC8758383 DOI: 10.1186/s12916-021-02228-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 64.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious respiratory virus which is responsible for the coronavirus disease 2019 (COVID-19) pandemic. It is increasingly clear that recovered individuals, even those who had mild COVID-19, can suffer from persistent symptoms for many months after infection, a condition referred to as "long COVID", post-acute sequelae of COVID-19 (PASC), post-acute COVID-19 syndrome, or post COVID-19 condition. However, despite the plethora of research on COVID-19, relatively little is known about the molecular underpinnings of these long-term effects. METHODS We have undertaken an integrated analysis of immune responses in blood at a transcriptional, cellular, and serological level at 12, 16, and 24 weeks post-infection (wpi) in 69 patients recovering from mild, moderate, severe, or critical COVID-19 in comparison to healthy uninfected controls. Twenty-one of these patients were referred to a long COVID clinic and > 50% reported ongoing symptoms more than 6 months post-infection. RESULTS Anti-Spike and anti-RBD IgG responses were largely stable up to 24 wpi and correlated with disease severity. Deep immunophenotyping revealed significant differences in multiple innate (NK cells, LD neutrophils, CXCR3+ monocytes) and adaptive immune populations (T helper, T follicular helper, and regulatory T cells) in convalescent individuals compared to healthy controls, which were most strongly evident at 12 and 16 wpi. RNA sequencing revealed significant perturbations to gene expression in COVID-19 convalescents until at least 6 months post-infection. We also uncovered significant differences in the transcriptome at 24 wpi of convalescents who were referred to a long COVID clinic compared to those who were not. CONCLUSIONS Variation in the rate of recovery from infection at a cellular and transcriptional level may explain the persistence of symptoms associated with long COVID in some individuals.
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Affiliation(s)
- Feargal J Ryan
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, 5001, Australia
| | - Christopher M Hope
- Women's and Children's Health Network, North Adelaide, SA, Australia.,Molecular Immunology, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Makutiro G Masavuli
- Viral Immunology Group, Adelaide Medical School, University of Adelaide and Basil Hetzel Institute for Translational Health Research, Adelaide, SA, Australia
| | - Miriam A Lynn
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, 5001, Australia
| | - Zelalem A Mekonnen
- Viral Immunology Group, Adelaide Medical School, University of Adelaide and Basil Hetzel Institute for Translational Health Research, Adelaide, SA, Australia
| | - Arthur Eng Lip Yeow
- Viral Immunology Group, Adelaide Medical School, University of Adelaide and Basil Hetzel Institute for Translational Health Research, Adelaide, SA, Australia
| | - Pablo Garcia-Valtanen
- Viral Immunology Group, Adelaide Medical School, University of Adelaide and Basil Hetzel Institute for Translational Health Research, Adelaide, SA, Australia
| | - Zahraa Al-Delfi
- Viral Immunology Group, Adelaide Medical School, University of Adelaide and Basil Hetzel Institute for Translational Health Research, Adelaide, SA, Australia
| | - Jason Gummow
- Gene Silencing and Expression Core Facility, Adelaide Health and Medical Sciences, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Catherine Ferguson
- Infectious Diseases Department, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Stephanie O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Central Adelaide Local Health Network and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Benjamin A J Reddi
- Intensive Care Unit, Royal Adelaide Hospital, Central Adelaide Local Health Network and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Pravin Hissaria
- Infectious Diseases Department, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - David Shaw
- Infectious Diseases Department, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Chuan Kok-Lim
- Infectious Diseases Department, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia.,Microbiology and Infectious Diseases Department, SA Pathology, Adelaide, SA, Australia
| | - Jonathan M Gleadle
- Department of Renal Medicine, Flinders Medical Centre, Flinders University, Bedford Park, SA, 5042, Australia.,Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, 5042, Australia
| | - Michael R Beard
- Research Centre for Infectious Diseases, School of Biological Sciences, University of Adelaide, Adelaide, SA, 5005, Australia
| | - Simon C Barry
- Women's and Children's Health Network, North Adelaide, SA, Australia. .,Molecular Immunology, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia.
| | - Branka Grubor-Bauk
- Viral Immunology Group, Adelaide Medical School, University of Adelaide and Basil Hetzel Institute for Translational Health Research, Adelaide, SA, Australia.
| | - David J Lynn
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, 5001, Australia. .,Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, 5042, Australia.
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105
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Bobircă A, Bobircă F, Ancuța I, Florescu A, Bojincă M, Muscă A, Florescu DN, Florescu LM, Sima RM, Florescu A, Mușetescu AE. COVID-19-A Trigger Factor for Severe Immune-Mediated Thrombocytopenia in Active Rheumatoid Arthritis. LIFE (BASEL, SWITZERLAND) 2022; 12:life12010077. [PMID: 35054471 PMCID: PMC8780601 DOI: 10.3390/life12010077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 12/13/2022]
Abstract
Thrombocytopenia is defined as a platelet count below 150,000/mm3 for adults. There is still controversy about whether individuals with platelet counts of 100,000/mm3 to 150,000/mm3 should be classified as having genuine thrombocytopenia or borderline thrombocytopenia. Thrombocytopenia is considered mild when the platelet count is between 70,000 and 150,000/mm3 and severe if the count is less than 20,000/mm3. Thrombocytopenia in rheumatoid arthritis is a rare complication, with an incidence estimated between 3 and 10%. The main etiological aspects include drug-induced thrombocytopenia and immune thrombocytopenic purpura. The most common hematological abnormalities in SARS-CoV-2 infection are lymphopenia and thrombocytopenia. It has been observed that the severity of thrombocytopenia correlates with the severity of the infection, being a poor prognosis indicator and a risk factor for mortality. COVID-19 can stimulate the immune system to destroy platelets by increasing the production of autoantibodies and immune complexes. Autoimmunity induced by viral infections can be related to molecular mimicry, cryptic antigen expression and also spreading of the epitope. During the COVID-19 pandemic, it is of great importance to include the SARS-CoV-2 infection in differential diagnoses, due to the increased variability in forms of presentation of this pathology. In this review, our aim is to present one of the most recently discovered causes of thrombocytopenia, which is the SARS-CoV-2 infection and the therapeutic challenges it poses in association with an autoimmune disease such as rheumatoid arthritis.
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Affiliation(s)
- Anca Bobircă
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Florin Bobircă
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Dr I. Cantacuzino Clinical Hospital, 050474 Bucharest, Romania;
| | - Ioan Ancuța
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Anca Florescu
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Mihai Bojincă
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Alice Muscă
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Dan Nicolae Florescu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Lucian Mihai Florescu
- Department of Radiology and Medical Imaging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Romina Marina Sima
- Department of Obstetrics and Gynecology, “Bucur” Maternity, “Saint John” Clinical Emergency Hospital, 077160 Bucharest, Romania;
| | - Alesandra Florescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
- Correspondence:
| | - Anca Emanuela Mușetescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
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106
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Lassandro G, Carriero F, Palladino V, Vecchio GCD, Giordano P. Quick drop of platelet counts in children with chronic immune thrombocytopenia after COVID-19 mRNA vaccination: case reports. Clin Exp Vaccine Res 2022; 11:290-293. [DOI: 10.7774/cevr.2022.11.3.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 04/30/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Giuseppe Lassandro
- Department Interdisciplinary of Medicine, Pediatric Unit “B. Trambusti”, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesco Carriero
- Department Interdisciplinary of Medicine, Pediatric Unit “B. Trambusti”, University of Bari “Aldo Moro”, Bari, Italy
| | - Valentina Palladino
- Department Interdisciplinary of Medicine, Pediatric Unit “B. Trambusti”, University of Bari “Aldo Moro”, Bari, Italy
| | - Giovanni Carlo Del Vecchio
- Department Interdisciplinary of Medicine, Pediatric Unit “B. Trambusti”, University of Bari “Aldo Moro”, Bari, Italy
| | - Paola Giordano
- Department Interdisciplinary of Medicine, Pediatric Unit “B. Trambusti”, University of Bari “Aldo Moro”, Bari, Italy
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107
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Ceglie G, De Ioris MA, Mercadante S, Olivini N, Del Bufalo F, Marchesani S, Cocca F, Monteferrario E, Boccieri E, Pianese J, Palumbo G. Immune thrombocytopenia in a child with COVID-19: Is it the calm after the (cytokine) storm? Pediatr Blood Cancer 2022; 69:e29326. [PMID: 34490996 PMCID: PMC8661709 DOI: 10.1002/pbc.29326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/19/2021] [Accepted: 08/21/2021] [Indexed: 01/16/2023]
Affiliation(s)
- Giulia Ceglie
- Department of Pediatric Hematology/OncologyCell and Gene Therapy, IRCCS Bambino Gesù Children's HospitalRomeItaly,PhD Program in Immunology, Molecular Medicine and Applied BiotechnologyUniversity of Rome Tor VergataRomeItaly
| | - Maria Antonietta De Ioris
- Department of Pediatric Hematology/OncologyCell and Gene Therapy, IRCCS Bambino Gesù Children's HospitalRomeItaly
| | - Stefania Mercadante
- University Department of PediatricsBambino Gesù Children's Hospital, IRCCSRomeItaly,Department of Systems MedicineUniversity of Rome Tor VergataRomeItaly
| | - Nicole Olivini
- University Department of PediatricsBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Francesca Del Bufalo
- Department of Pediatric Hematology/OncologyCell and Gene Therapy, IRCCS Bambino Gesù Children's HospitalRomeItaly
| | - Silvio Marchesani
- University Department of PediatricsBambino Gesù Children's Hospital, IRCCSRomeItaly,Department of Systems MedicineUniversity of Rome Tor VergataRomeItaly
| | - Francesca Cocca
- Department of Pediatric Hematology/OncologyCell and Gene Therapy, IRCCS Bambino Gesù Children's HospitalRomeItaly
| | - Emanuela Monteferrario
- Department of Pediatric Hematology/OncologyCell and Gene Therapy, IRCCS Bambino Gesù Children's HospitalRomeItaly
| | - Emilia Boccieri
- Department of Pediatric Hematology/OncologyCell and Gene Therapy, IRCCS Bambino Gesù Children's HospitalRomeItaly
| | - Jolanda Pianese
- Department of Pediatric Hematology/OncologyCell and Gene Therapy, IRCCS Bambino Gesù Children's HospitalRomeItaly
| | - Giuseppe Palumbo
- Department of Pediatric Hematology/OncologyCell and Gene Therapy, IRCCS Bambino Gesù Children's HospitalRomeItaly,Department of Systems MedicineUniversity of Rome Tor VergataRomeItaly
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108
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Korompoki E, Gavriatopoulou M, Fotiou D, Ntanasis‐Stathopoulos I, Dimopoulos MA, Terpos E. Late-onset hematological complications post COVID-19: An emerging medical problem for the hematologist. Am J Hematol 2022; 97:119-128. [PMID: 34687462 PMCID: PMC8646944 DOI: 10.1002/ajh.26384] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/28/2021] [Accepted: 10/20/2021] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 19 (COVID‐19) is considered a multisystemic disease. Several studies have reported persistent symptoms or late‐onset complications after acute COVID‐19, including post‐COVID‐19 hematological disorders. COVID‐19‐induced coagulopathy, an immunothrombotic state, has been linked to thromboembolic and hemorrhagic events. Late‐onset thrombocytopenia related to immune system dysregulation has also been reported as a rare manifestation post COVID‐19. Close monitoring of laboratory dynamics is considered essential to identify timely abnormal values that need further investigation, providing supportive care whenever indicated. The role of hematologists is essential in terms of the multidisciplinary approach of long COVID‐19. This review summarizes all the available evidence on post‐acute COVID‐19 hematological complications.
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Affiliation(s)
- Eleni Korompoki
- Department of Clinical Therapeutics, School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - Ioannis Ntanasis‐Stathopoulos
- Department of Clinical Therapeutics, School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine National and Kapodistrian University of Athens Athens Greece
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109
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Calcaterra G, Bassareo PP, De Gregorio C, Barilla F, Romeo F, Mehta JL. COVID-19 Vaccine-Induced Pro-thrombotic Immune Thrombocytopenia (VIPIT): State of the Art. Curr Cardiol Rev 2022; 18:11-17. [PMID: 35319381 PMCID: PMC9896421 DOI: 10.2174/1573403x18666220321105909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/03/2021] [Accepted: 01/07/2022] [Indexed: 11/22/2022] Open
Abstract
In 2020, as the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic spread rapidly throughout the world, scientists worked relentlessly to develop and test the safety and effectiveness of potential vaccines. Usually, the vaccine development process involves years of investigation and testing prior to gaining approval for use in practice. A pathogenic PF4-dependent syndrome, unrelated to the use of heparin therapy, may be manifested following the administration of viral vector vaccines. It leads to severe clot formation at unusual sites approximately in 1 out of 110.000 vaccinated persons. This side effect, although rare, represents a newly devastating clotting phenomenon manifested in otherwise healthy young adults, who are often female. An in-depth description of the specific biological mechanisms implicated in the syndrome is here summarized.
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Affiliation(s)
| | - Pier Paolo Bassareo
- Address correspondence to this author at the University College of Dublin, School of Medicine, Mater Misericordiae University Hospital, Dublin, Republic of Ireland; E-mail:
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110
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Kim CS, Choi DR, Lee JH. Immune thrombocytopenic purpura worsened by COVID-19. Blood Res 2021; 56:347-349. [PMID: 34880143 PMCID: PMC8721462 DOI: 10.5045/br.2021.2021147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/27/2021] [Accepted: 11/12/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Chul Soo Kim
- Hematology/Oncology Service, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
| | - Dae Ro Choi
- Hematology/Oncology Service, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
| | - Jong Hwa Lee
- Hematology/Oncology Service, Department of Internal Medicine, Sahmyook Medical Center, Seoul, Korea
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111
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Davoodian A, Umeh C, Novatcheva E, Sassi GP, Ahaneku H, Kundu A. Severe Immune Thrombocytopenia Post-COVID-19: A Case Report. Cureus 2021; 13:e19544. [PMID: 34934562 PMCID: PMC8668258 DOI: 10.7759/cureus.19544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2021] [Indexed: 11/17/2022] Open
Abstract
Immune thrombocytopenia, also called idiopathic thrombocytopenic purpura, is a common cause of thrombocytopenia after viral infections. Even in the second year of the coronavirus disease 2019 (COVID-19) pandemic, our body of knowledge regarding the diverse symptoms and complications of the virus continues to grow and evolve. We present a case of a 48-year-old African American male who came into the emergency department with severe left foot pain. A platelet count of 7x103/mL was incidentally found on complete blood count (CBC) during the patient's initial workup. The patient had previously been hospitalized for COVID-19 five weeks prior. Further workup did not support any etiology of his thrombocytopenia. Therefore, we gave a presumed diagnosis of idiopathic thrombocytopenic purpura secondary to COVID-19. The patient was treated with corticosteroid resulting in improvement in his platelet count.
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Affiliation(s)
| | | | | | | | | | - Ankur Kundu
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
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112
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Santosa D, Sofro MAU, Farida, Nindita N, Pangarsa EA, Setiawan B, Rizky D, Suharti C. A full-term pregnant woman with secondary Evans syndrome caused by severe coronavirus disease 2019: a case report. J Med Case Rep 2021; 15:606. [PMID: 34903274 PMCID: PMC8667974 DOI: 10.1186/s13256-021-03205-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In this report, we describe a very challenging case of a patient with secondary Evans syndrome caused by severe coronavirus disease 2019 infection in a pregnant full-term woman. CASE PRESENTATION A 29-year-old full-term pregnant Indonesian woman presented with gross hematuria, dry cough, fever, dyspnea, nausea, anosmia, and fatigue 5 days after confirmation of coronavirus disease 2019 infection. Laboratory examinations showed very severe thrombocytopenia, increased indirect bilirubin, and a positive direct Coombs' test. From peripheral blood, there was an increased number of spherocytes, which indicated an autoimmune hemolytic process. Antinuclear antibody and anti-double-stranded DNA test results were negative, and her virology serological markers are also negative for human immunodeficiency virus, cytomegalovirus, and hepatitis B and C. Despite aggressive treatment with platelet transfusion, high-dose steroid, and thrombopoietin receptor agonists, the platelet count did not recover, and a speculative cesarean delivery had to be done with a very low platelet count.
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Affiliation(s)
- Damai Santosa
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Muchlis A U Sofro
- Department of Tropical-Infection, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Farida
- Department of Pulmonology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Nurvita Nindita
- Department of Obstetrics and Gynecology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Eko A Pangarsa
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Budi Setiawan
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Daniel Rizky
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia.
| | - Catharina Suharti
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia
- Faculty of Medicine, Diponegoro University, Semarang, Indonesia
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113
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Putilina MV, Teplova NV, Bairova KI, Petrikeeva AE, Shabalina NI. [The result of prospective randomized study CITADEL - the efficacy and safety of drug cytoflavin in postcovid rehabilitation]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:45-51. [PMID: 34874654 DOI: 10.17116/jnevro202112110145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate the structure of postcovid syndrome, age and gender characteristics of its course, and to assess the effect of Cytoflavin on the clinical course of neurological disorders in patients who have undergone COVID-19. MATERIAL AND METHODS The study included 100 patients, the average age was 40.4±11.7 years, there were statistically more men than women. The duration of the transferred SARS-CoV-2 days is from 30 to 90 days from the date of recovery). By random sampling, the patients were divided into two groups, the main group, received Cytoflavin tablets, a course of 25 days, 2 tablets 2 times a day. Comparison group - other drugs (vitamins, nootropic drugs). All patients were examined on the day of treatment and 25-30 days after the end of therapy. The status was assessed using Asthenia Assessment Scale (MFI-20), Brief Mental Status Assessment Scale (MMSE), Quality-of-Life Questionnaire (EQ-5D), General Health Assessment Scale, and Pittsburgh Sleep Quality Index (PSQI). The analysis of laboratory parameters was carried out retrospectively. RESULTS AND CONCLUSION Postcovid syndrome was more common in men, among comorbid conditions arterial hypertension and atherosclerosis prevailed, neurocognitive and autonomic disorders predominated. Appointment of Cytoflavin made it possible to achieve a pronounced anti-asthenic effect with the correction of cognitive impairments, which was reflected in a significantly more significant positive dynamics of indicators of all scales. An additional effect of Cytoflavin was revealed - a decrease in the severity of thrombocytopenia. During the observation period, no patient had any serious adverse events or side effects associated with taking the drug. Prescription of the drug does not require age-related dose adjustment and is well combined with basic therapy for concomitant pathology.
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Affiliation(s)
- M V Putilina
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - N V Teplova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - K I Bairova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - N I Shabalina
- Central Polyclinic of Russian Railways, Moscow, Russia
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114
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Turgutkaya A, Bolaman AZ, Yavaşoğlu İ. COVID-19-associated Evans syndrome: A case report and review of the literature. Transfus Apher Sci 2021; 61:103339. [PMID: 34896007 PMCID: PMC8655821 DOI: 10.1016/j.transci.2021.103339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/16/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022]
Abstract
Evans syndrome is a rare condition characterized by simultaneous or sequential development of autoimmune hemolytic anemia and immune thrombocytopenia (and/or immune neutropenia). Coronavirus disease 2019 (COVID-19) may cause various hematologic conditions, such as coagulation abnormalities (e.g., bleeding or thrombosis) or cell count alterations (e.g., lymphopenia and neutrophilia). COVID-19 may also induce Evans syndrome via immune mechanisms. Here, we describe the case of a patient developing Evans syndrome shortly after COVID-19 infection. Immune thrombocytopenia and warm-type autoimmune hemolytic anemia developed simultaneously, and intravenous immunoglobulin and methylprednisolone were initially administered. Additionally, we intend to review all COVID-19-induced Evans syndrome cases currently present in the literature and emphasize the differences as well as the similarities regarding patient characteristics, relationship to COVID-19 infection, and treatment approach. Since autoimmune cytopenias are frequent in COVID-19 patients, clinicians should pay particular attention to profound and abrupt-onset cytopenias. In these circumstances, hemolysis markers such as lactate dehydrogenase, haptoglobulin, Coombs tests, etc. should be investigated, and the possibility of Evans syndrome should always be considered to ensure prompt and appropriate treatment. These factors are essential to ensure hematologic recovery and prevent complications such as thrombosis.
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Affiliation(s)
- Atakan Turgutkaya
- Adnan Menderes University Hematology Department, Aytepe Mevki, Efeler, PC: 09010, Aydın, Turkey.
| | - Ali Zahit Bolaman
- Adnan Menderes University Hematology Department, Aytepe Mevki, Efeler, PC: 09010, Aydın, Turkey.
| | - İrfan Yavaşoğlu
- Adnan Menderes University Hematology Department, Aytepe Mevki, Efeler, PC: 09010, Aydın, Turkey.
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115
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Marfe G, Perna S, Shukla AK. Effectiveness of COVID-19 vaccines and their challenges (Review). Exp Ther Med 2021; 22:1407. [PMID: 34676000 PMCID: PMC8524740 DOI: 10.3892/etm.2021.10843] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/24/2021] [Indexed: 12/13/2022] Open
Abstract
At the end of 2019, a new disease recognized such as severe acute respiratory syndrome (SARS), was reported in Wuhan, China. This disease was caused by an unknown SARS coronavirus 2 (SARS-CoV-2); a virus is characterized by high infectivity among humans. In some cases, this disease can be asymptomatic, while in other cases can induce flu-like symptoms or acute respiratory distress syndrome, pneumonia and death. For this reason, the World Health Organization and Public Health Emergency of International Concern declared a pandemic status in January 2020. Currently, numerous countries have been involved in the development of effective vaccines to protect humans against SARS-CoV-2 infection. The present review will discuss the four vaccines, AZD1222 (AstraZeneca or Vaxzevria), Janssen (Ad26.COV2.S), Moderna/mRNA-1273 and BioNTech/Fosun/Pfizer BNT162b1, that are currently in use worldwide to understand their efficacy, but also evaluate the difficulties and challenges of vaccine development. Although several questions should be addressed regarding these vaccines, the current review will examine the viral elements used in the coronavirus-19 vaccine that can play a crucial role in inducing a strong immune response, as well as the different adverse effects that they can cause to individuals.
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Affiliation(s)
- Gabriella Marfe
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, University of Campania ‘Luigi Vanvitelli’, 81100 Caserta, Italy
| | - Stefania Perna
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, University of Campania ‘Luigi Vanvitelli’, 81100 Caserta, Italy
| | - Arvind Kumar Shukla
- School of Biomedical Convergence Engineering, Pusan National University, Yangsan, Gyeongsangnam-do 50612, Republic of Korea
- Inventra Medclin Biomedical Healthcare and Research Center, Katemanivli, Kalyan, Thane, Maharashtra 421306, India
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116
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Root‐Bernstein R. COVID-19 coagulopathies: Human blood proteins mimic SARS-CoV-2 virus, vaccine proteins and bacterial co-infections inducing autoimmunity: Combinations of bacteria and SARS-CoV-2 synergize to induce autoantibodies targeting cardiolipin, cardiolipin-binding proteins, platelet factor 4, prothrombin, and coagulation factors. Bioessays 2021; 43:e2100158. [PMID: 34677872 PMCID: PMC8646673 DOI: 10.1002/bies.202100158] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/15/2022]
Abstract
Severe COVID-19 is often accompanied by coagulopathies such as thrombocytopenia and abnormal clotting. Rarely, such complications follow SARS-CoV-2 vaccination. The cause of these coagulopathies is unknown. It is hypothesized that coagulopathies accompanying SARS-CoV-2 infections and vaccinations result from bacterial co-infections that synergize with virus-induced autoimmunity due to antigenic mimicry of blood proteins by both bacterial and viral antigens. Coagulopathies occur mainly in severe COVID-19 characterized by bacterial co-infections with Streptococci, Staphylococci, Klebsiella, Escherichia coli, and Acinetobacter baumannii. These bacteria express unusually large numbers of antigens mimicking human blood antigens, as do both SARS-CoV-2 and adenoviruses. Bacteria mimic cardiolipin, prothrombin, albumin, and platelet factor 4 (PF4). SARS-CoV-2 mimics complement factors, Rh antigens, platelet phosphodiesterases, Factors IX and X, von Willebrand Factor (VWF), and VWF protease ADAMTS13. Adenoviruses mimic prothrombin and platelet factor 4. Bacterial prophylaxis, avoidance of vaccinating bacterially infected individuals, and antigen deletion for vaccines may reduce coagulopathy risk. Also see the video abstract here: https://youtu.be/zWDOsghrPg8.
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117
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A rare case of absolute thrombocytopaenia in a COVID-19 patient: Case report. Ann Med Surg (Lond) 2021; 72:103097. [PMID: 34840780 PMCID: PMC8607684 DOI: 10.1016/j.amsu.2021.103097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Thrombocytopaenia, one of the most common haematological disorders worldwide, is characterised by platelet counts <150,000/mm3. Patients with coronavirus disease (COVID-19) were found to commonly exhibit haematological abnormalities, often with mild forms of thrombocytopaenia. Absolute thrombocytopaenia tends to be rare among these patients and is believed to be secondary to immune-induced thrombocytopaenia. Case presentation A 53-y-old man presented with fever and generalised body ache that persisted for a few days. His polymerase chain reaction test was positive for COVID-19, for which he was treated with acetaminophen, levofloxacin, and favipiravir. On the third day of treatment, he noticed bruising and bleeding, mainly in the oral cavity, with clot formation. A complete blood picture (CBP) revealed severe thrombocytopaenia with an almost-zero count. Prednisone 1 mg/kg/d and frequent doses of intravenous platelet transfusion were administered as rescue therapy to prevent fatal bleeding. The patient was able to recover. Clinical discussion Immune thrombocytopaenia should be considered in patients presenting with bleeding tendencies after severe acute respiratory syndrome coronavirus 2 infection. Serial CBP is recommended for vulnerable patients, especially during the second and third weeks of hospitalisation, for the early detection and prevention of life-threatening COVID-19 complications. Conclusions Absolute thrombocytopaenia is a rare condition. Such a condition should be considered in patients presenting with bleeding tendencies with severe Covid-19 infection. With early diagnosis and appropriate treatment, patients’ lives can be saved. Absolute thrombocytopaenia is a rare condition. Such a condition should be considered in patients presenting with bleeding tendencies with severe Covid-19 infection. Prednisone 1 mg/kg/d and intravenous platelet transfusion should be considered as rescue therapy to prevent fatal bleeding.
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118
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Immune thrombocytopenia following immunisation with Vaxzevria ChadOx1-S (AstraZeneca) vaccine, Victoria, Australia. Vaccine 2021; 39:7052-7057. [PMID: 34756770 PMCID: PMC8556135 DOI: 10.1016/j.vaccine.2021.10.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 12/04/2022]
Abstract
Emerging evidence suggest a possible association between immune thrombocytopenia (ITP) and some formulations of COVID-19 vaccine. We conducted a retrospective case series of ITP following vaccination with Vaxzevria ChadOx1-S (AstraZeneca) and mRNA Comirnaty BNT162b2 COVID-19 (Pfizer-BioNTech) vaccines and compare the incidence to expected background rates for Victoria during the first six months of the Australian COVID-19 vaccination roll-out in 2021. Cases were identified by reports to the Victorian state vaccine safety service, SAEFVIC, of individuals aged 18 years or older presenting with thrombocytopenia following COVID-19 vaccination without evidence of thrombosis. Twenty-one confirmed or probable cases of ITP were identified following receipt of AstraZeneca (n = 17) or Pfizer-BioNTech (n = 4) vaccines. This translates to an observed incidence of 8 per million doses for AstraZeneca vaccine, twice the expected background rate of 4.1 per million. The observed rate for Pfizer-BioNTech was consistent with the expected background rate. The median time to onset for the cases post AstraZeneca vaccination was 10 days (range 1–78) and median platelet nadir 5 × 109/L (range 0–67 × 109/L). Hospital presentations or admissions for management of symptoms such as bleeding occurred in 18 (86%) of the cases. The majority of cases (n = 11) required intervention with at least 2 therapy modalities. In conclusion, we observed a substantially higher than expected rate of ITP following AstraZeneca vaccination. ITP is the second haematological adverse event, distinct from that of thrombosis with thrombocytopenia syndrome (TTS), observed following AstraZeneca vaccination.
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119
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Immune thrombocytopenia relapse post covid-19 vaccine in young male patient. IDCases 2021; 26:e01344. [PMID: 34804803 PMCID: PMC8595970 DOI: 10.1016/j.idcr.2021.e01344] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/16/2021] [Accepted: 11/16/2021] [Indexed: 12/18/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is a blood disorder in which antibodies coating platelets cause platelets destruction in the spleen with resultant low platelets count and an increased tendency for bleeding. Coronavirus disease 2019 (COVID-19) is an illness caused by SARS-COV2; it was first identified in December/2019; though it mainly affects the respiratory system, multisystemic complications are identified. Several ITP cases post mRNA SARS-CoV-2 vaccines were reported, and different pathophysiology theories about the underlying pathophysiology were discussed, but only a few ITP relapse cases have been reported so far. We present a 28-year-old Asian male, a known patient of ITP and in partial remission for eighteen months, who presented to the emergency department with ITP relapse (platelets count of 1 × 10^3 /µL), four days after receiving the second dose of Pfizer SARS-CoV-2 vaccine, which required treatment with intravenous immunoglobulins and dexamethasone. We further discuss the preferred approach in ITP patients who are willing to receive the COVID-19 vaccine.
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120
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Kim G, Choi EJ, Park HS, Lee JH, Lee JH, Lee KH. A Case Report of Immune Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination. J Korean Med Sci 2021; 36:e306. [PMID: 34751013 PMCID: PMC8575766 DOI: 10.3346/jkms.2021.36.e306] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/20/2021] [Indexed: 11/20/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune condition characterized by platelet destruction through antibody-mediated mechanism. ITP is one of the manifestations of a coronavirus disease, as well as an adverse event occurring after vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Several cases of ITP have been described after vaccination with two mRNA-based vaccines-BTN162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna)-against SARS-CoV-2. Herein, we report a case of ITP occurring after vaccination with ChAdOx1 adenovirus vector nCoV-19 (AstraZeneca) vaccine in Korea. A 66-year-old woman presented with multiple ecchymoses on both upper and lower extremities and gingival bleeding, appearing 3 days after receiving the first dose of ChAdOx1 nCoV-19. Her laboratory results showed isolated severe thrombocytopenia without evidence of combined coagulopathy. She was diagnosed with ITP and successfully treated with high-dose dexamethasone and intravenous immunoglobulin. Clinical suspicion to identify vaccine-related ITP is important to promptly initiate appropriate treatment.
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Affiliation(s)
- Gyungah Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Ji Choi
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Han-Seung Park
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Hee Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoo-Hyung Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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121
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Dongre A, Jameel PZ, Deshmukh M, Bhandarkar S. Immune thrombocytopenic purpura secondary to SARS-CoV-2 infection in a child with acute lymphoblastic leukaemia: a case report and review of literature. BMJ Case Rep 2021; 14:14/11/e245869. [PMID: 34740909 PMCID: PMC8573630 DOI: 10.1136/bcr-2021-245869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is characterised by isolated thrombocytopenia which may be idiopathic or due to a secondary aetiology. ITP is being increasingly recognised secondary to SARS-CoV-2 infection in the current pandemic. Here, we report a case of a five-and-a-half-year-old female child on maintenance chemotherapy for acute lymphoblastic leukaemia who subsequently developed ITP secondary to SARS-CoV-2 infection. Our patient had prolonged thrombocytopenia secondary to ITP, requiring the use of second-line agents including romiplostim and eltrombopag. This is a unique case where ITP was recognised secondary to SARS-CoV-2. In such cases of thrombocytopenia, ITP should be considered as an important differential in addition to relapse of leukaemia or thrombocytopenia due to chemotherapy drugs.
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Affiliation(s)
- Amol Dongre
- Department of Medical Oncology, Alexis Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Patel Zeeshan Jameel
- Department of Paediatrics, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
| | - Mahesh Deshmukh
- Department of Pathology, Alexis Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Shweta Bhandarkar
- Department of Paediatrics and Neonatology, Alexis Multispeciality Hospital, Nagpur, Maharashtra, India
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122
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Briquez PS, Rouhani SJ, Yu J, Pyzer AR, Trujillo J, Dugan HL, Stamper CT, Changrob S, Sperling AI, Wilson PC, Gajewski TF, Hubbell JA, Swartz MA. SARS-CoV-2 infection induces cross-reactive autoantibodies against angiotensin II. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.11.02.21265789. [PMID: 34751272 PMCID: PMC8575143 DOI: 10.1101/2021.11.02.21265789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Patients infected with the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) can experience life-threatening respiratory distress, blood pressure dysregulation and thrombosis. This is thought to be associated with an impaired activity of angiotensin-converting enzyme-2 (ACE-2), which is the main entry receptor of SARS-CoV-2 and which also tightly regulates blood pressure by converting the vasoconstrictive peptide angiotensin II (AngII) to a vasopressor peptide. Here, we show that a significant proportion of hospitalized COVID-19 patients developed autoantibodies against AngII, whose presence correlates with lower blood oxygenation, blood pressure dysregulation, and overall higher disease severity. Anti-AngII antibodies can develop upon specific immune reaction to the SARS-CoV-2 proteins Spike or RBD, to which they can cross-bind, suggesting some epitope mimicry between AngII and Spike/RBD. These results provide important insights on how an immune reaction against SARS-CoV-2 can impair blood pressure regulation.
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Affiliation(s)
- Priscilla S Briquez
- Pritzker School for Molecular Engineering, University of Chicago, Chicago, Illinois, USA
| | - Sherin J Rouhani
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| | - Jovian Yu
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| | - Athalia R Pyzer
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| | - Jonathan Trujillo
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| | - Haley L Dugan
- Department of Medicine, Section of Rheumatology, University of Chicago, Chicago, Illinois, USA
- Committee on Immunology, University of Chicago, Chicago, Illinois, USA
| | - Christopher T Stamper
- Department of Medicine, Section of Rheumatology, University of Chicago, Chicago, Illinois, USA
- Committee on Immunology, University of Chicago, Chicago, Illinois, USA
| | - Siriruk Changrob
- Department of Medicine, Section of Rheumatology, University of Chicago, Chicago, Illinois, USA
| | - Anne I Sperling
- Committee on Immunology, University of Chicago, Chicago, Illinois, USA
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois, USA
| | - Patrick C Wilson
- Department of Medicine, Section of Rheumatology, University of Chicago, Chicago, Illinois, USA
- Committee on Immunology, University of Chicago, Chicago, Illinois, USA
| | - Thomas F Gajewski
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
- Committee on Immunology, University of Chicago, Chicago, Illinois, USA
- Ben May Department of Cancer Research, University of Chicago, Chicago, Illinois, USA
- Committee on Cancer Biology, University of Chicago, Chicago, Illinois, USA
| | - Jeffrey A Hubbell
- Pritzker School for Molecular Engineering, University of Chicago, Chicago, Illinois, USA
- Committee on Immunology, University of Chicago, Chicago, Illinois, USA
- Committee on Cancer Biology, University of Chicago, Chicago, Illinois, USA
| | - Melody A Swartz
- Pritzker School for Molecular Engineering, University of Chicago, Chicago, Illinois, USA
- Committee on Immunology, University of Chicago, Chicago, Illinois, USA
- Ben May Department of Cancer Research, University of Chicago, Chicago, Illinois, USA
- Committee on Cancer Biology, University of Chicago, Chicago, Illinois, USA
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123
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Hayashi K, Wada H, Shiraki K, Makino K. Immune Thrombocytopenia and Cerebral Hemorrhaging Associated with COVID-19. Intern Med 2021; 60:3513. [PMID: 34471017 PMCID: PMC8627808 DOI: 10.2169/internalmedicine.7541-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Koken Hayashi
- Department of Cardiology, Mie Prefectural General Medical Center, Japan
| | - Hideo Wada
- Department of Hematology, Mie Prefectural General Medical Center, Japan
| | - Katsuya Shiraki
- Department of Gastroenterology, Mie Prefectural General Medical Center, Japan
| | - Katsutoshi Makino
- Department of Cardiology, Mie Prefectural General Medical Center, Japan
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Danieli MG, Piga MA, Paladini A, Longhi E, Mezzanotte C, Moroncini G, Shoenfeld Y. Intravenous immunoglobulin as an important adjunct in the prevention and therapy of coronavirus 2019 disease. Scand J Immunol 2021; 94:e13101. [PMID: 34940980 PMCID: PMC8646640 DOI: 10.1111/sji.13101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/31/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
The coronavirus disease-19 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) challenged globally with its morbidity and mortality. A small percentage of affected patients (20%) progress into the second stage of the disease clinically presenting with severe or fatal involvement of lung, heart and vascular system, all contributing to multiple-organ failure. The so-called 'cytokines storm' is considered the pathogenic basis of severe disease and it is a target for treatment with corticosteroids, immunotherapies and intravenous immunoglobulin (IVIg). We provide an overview of the role of IVIg in the therapy of adult patients with COVID-19 disease. After discussing the possible underlying mechanisms of IVIg immunomodulation in COVID-19 disease, we review the studies in which IVIg was employed. Considering the latest evidence that show a link between new coronavirus and autoimmunity, we also discuss the use of IVIg in COVID-19 and anti-SARS-CoV-2 vaccination related autoimmune diseases and the post-COVID-19 syndrome. The benefit of high-dose IVIg is evident in almost all studies with a rapid response, a reduction in mortality and improved pulmonary function in critically ill COVID-19 patients. It seems that an early administration of IVIg is crucial for a successful outcome. Studies' limitations are represented by the small number of patients, the lack of control groups in some and the heterogeneity of included patients. IVIg treatment can reduce the stay in ICU and the demand for mechanical ventilation, thus contributing to attenuate the burden of the disease.
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Affiliation(s)
- Maria Giovanna Danieli
- Clinica Medica, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di Ancona and DISCLIMOUniversità Politecnica delle Marche, Clinica MedicaAnconaItaly
- School of Specialisation in Allergology and Clinical Immunology, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Mario Andrea Piga
- School of Specialisation in Allergology and Clinical Immunology, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Alberto Paladini
- School of Specialisation in Internal Medicine, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Eleonora Longhi
- Scuola di Medicina e ChirurgiaAlma Mater StudiorumUniversità degli Studi di BolognaBolognaItaly
| | - Cristina Mezzanotte
- School of Specialisation in Internal Medicine, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Gianluca Moroncini
- Clinica Medica, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di Ancona and DISCLIMOUniversità Politecnica delle Marche, Clinica MedicaAnconaItaly
- School of Specialisation in Internal Medicine, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Yehuda Shoenfeld
- Ariel UniversityArielIsrael
- The Zabludowicz Center for Autoimmune DiseasesSheba Medical CenterRamat GanIsrael
- Saint Petersburg State UniversitySt. PetersburgRussia
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University)MoscowRussia
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125
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Bahadorizadeh L, Emamikhah M, Pour Mohammad A, Gholizadeh Mesgarha M. Simultaneous Occurrence of Cerebral Venous Sinus Thrombosis and Immune Thrombocytopenic Purpura in a Patient with a History of COVID-19 Infection. Neurol Ther 2021; 11:491-497. [PMID: 34714517 PMCID: PMC8554500 DOI: 10.1007/s40120-021-00294-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
Since the emergence of the coronavirus disease 2019 (COVID-19) pandemic, multiple but rare complications of this infection have been described, comprising cerebral venous sinus thrombosis (CVST) and immune thrombocytopenic purpura (ITP). Although these two complications have been reported as separate entities, to the best of our knowledge, their concurrent presentation has not been reported. In this case report, we present a middle-aged man with a history of COVID-19 infection who developed a sudden-onset severe occipital headache followed by right-sided blindness (right homonymous hemianopia). Upon his diagnostic workup, brain computed tomography scan with and without contrast was indicative of thrombosis of the left transverse venous sinus and hemorrhagic venous infarction. In addition, laboratory data revealed thrombocytopenia, which upon investigation confirmed a diagnosis of ITP. We postulate three pathophysiological mechanisms for this circumstance: either COVID-19 infection caused ITP and then ITP gave rise to CVST, or COVID-19 complications themselves resulted in ITP and CVST independently and simultaneously, or another plausible mechanism is immune-mediated thrombocytopenia caused by the anti-platelet 4-factor antibody, which is the proposed mechanism for CVST after the COVID-19 vaccine.
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Affiliation(s)
- Leyla Bahadorizadeh
- Antimicrobial Resistance Research Center, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Maziar Emamikhah
- Department of Neurology, Rasool-E Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Arash Pour Mohammad
- Faculty of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
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126
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Brazel D, Eid T, Harding C. Warm and Cold Autoimmune Hemolytic Anemia in the Setting of COVID-19 Disease. Cureus 2021; 13:e18127. [PMID: 34692337 PMCID: PMC8528168 DOI: 10.7759/cureus.18127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 12/03/2022] Open
Abstract
Known associations with autoimmune hemolytic anemia (AIHA) include lymphoproliferative neoplasms, autoimmune conditions, and viral infections. There are a few case reports that implicate a potential relationship between COVID-19 and either warm or cold AIHA. We present the case of combined warm and cold AIHA in the setting of COVID-19. A 51-year-old male with no known past medical history presented with weakness and jaundice. Initial workup revealed white blood cells 41.4, hemoglobin 3.1, platelets 343, total bilirubin 5.3, direct bilirubin 1.6, and COVID-19 positive. Direct antiglobulin test (DAT) found IgG and C3 antibodies and pathology revealed cold agglutinins, consistent with both warm and cold AIHA. He received a total of five blood transfusions and was started on prednisone 1 mg/kg daily with a gradual taper over months. Hemolysis labs normalized within two weeks after discharge although antibodies remained positive 70 days after admission. Our patient presented with IgG and C3 antibodies as well as cold agglutinins, consistent with both warm and cold AIHA. To our knowledge, this is the first case of both warm and cold AIHA presenting simultaneously in COVID-19 infection. Unlike most cases in the existing literature, this patient had no history of underlying hematologic malignancy and both warm and cold AIHA.
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Affiliation(s)
- Danielle Brazel
- Medicine, University of California Irvine Medical Center, Orange, USA
| | - Tarek Eid
- Medicine, University of California Irvine Medical Center, Orange, USA
| | - Cameron Harding
- Internal Medicine, University of California, Irvine, Orange, USA
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127
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Peramo-Álvarez FP, López-Zúñiga MÁ, López-Ruz MÁ. Medical sequels of COVID-19. ACTA ACUST UNITED AC 2021; 157:388-394. [PMID: 34632064 PMCID: PMC8491931 DOI: 10.1016/j.medcle.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/29/2021] [Indexed: 12/13/2022]
Abstract
COVID-19 pandemic has impacted the world population, with a high rate of morbidity and mortality. While the evidence to date has attempted to describe clinical feature of acute illness, recent reports have also begun to describe persistent symptoms that extend beyond the initial period of illness. Adverse outcomes, in addition to respiratory, have been found to occur at different levels: cardiovascular, neurological, or immunological; skin, gastrointestinal or renal manifestations. The detrimental effect on mental health has also been described, not only in COVID-19 patients. The burden of disease secondary to this pandemic is likely to be enormous and not limited to acute disease alone, thus epidemiological studies are needed to further investigate the long-term impact of this disease. This review summarizes the current evidence on short-term effects and describes the possible long-term sequelae of COVID-19.
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128
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Peramo-Álvarez FP, López-Zúñiga MÁ, López-Ruz MÁ. Medical sequels of COVID-19. Med Clin (Barc) 2021; 157:388-394. [PMID: 34140166 PMCID: PMC8157124 DOI: 10.1016/j.medcli.2021.04.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 12/16/2022]
Abstract
COVID-19 pandemic has impacted the world population, with a high rate of morbidity and mortality. While the evidence to date has attempted to describe clinical feature of acute illness, recent reports have also begun to describe persistent symptoms that extend beyond the initial period of illness. Adverse outcomes, in addition to respiratory, have been found to occur at different levels: cardiovascular, neurological, or immunological; skin, gastrointestinal or renal manifestations. The detrimental effect on mental health has also been described, not only in COVID-19 patients. The burden of disease secondary to this pandemic is likely to be enormous and not limited to acute disease alone, thus epidemiological studies are needed to further investigate the long-term impact of this disease. This review summarizes the current evidence on short-term effects and describes the possible long-term sequelae of COVID-19.
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Affiliation(s)
| | - Miguel Ángel López-Zúñiga
- Infectious Diseases Unit, Hospital Universitario Virgen de las Nieves, Granada, España,Autor para correspondencia
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129
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A review of ischemic stroke in COVID-19: currently known pathophysiological mechanisms. Neurol Sci 2021; 43:67-79. [PMID: 34671854 PMCID: PMC8528653 DOI: 10.1007/s10072-021-05679-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/15/2021] [Indexed: 02/08/2023]
Abstract
Coronavirus disease 2019 (COVID-19), the third type of coronavirus pneumonia after severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), is spreading widely worldwide now. This pneumonia causes not only respiratory symptoms but also multiple organ dysfunction, including thrombotic diseases such as ischemic stroke. The purpose of this review is to explore whether COVID-19 is a risk factor for ischemic stroke and its related pathophysiological mechanisms. Based on the high thrombosis rate and frequent strokes of COVID-19 patients, combined with related laboratory indicators and pathological results, the discussion is mainly from two aspects: nerve invasion and endothelial dysfunction. SARS-CoV-2 can directly invade the CNS through blood-borne and neuronal retrograde pathways, causing cerebrovascular diseases. In addition, the endothelial dysfunction in COVID-19 is almost certain. Cytokine storm causes thromboinflammation, and downregulation of ACE2 leads to RAS imbalance, which eventually lead to ischemic stroke.
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130
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Behlivani E, Tragiannidis A, Hatzipantelis E, Panagopoulou P. Immune thrombocytopenia secondary to COVID-19 infection: Report of two cases. Pediatr Blood Cancer 2021; 68:e29175. [PMID: 34061445 PMCID: PMC8209819 DOI: 10.1002/pbc.29175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 01/16/2023]
Affiliation(s)
- Evangelia Behlivani
- 4th Department of Pediatrics, School of Medicine, Aristotle University of ThessalonikiPapageorgiou General HospitalThessalonikiGreece
| | - Athanasios Tragiannidis
- Children & Adolescent Hematology‐Oncology Unit, 2nd Department of Pediatrics, School of Medicine, Aristotle University of ThessalonikiAHEPA HospitalThessalonikiGreece
| | - Emmanuel Hatzipantelis
- Children & Adolescent Hematology‐Oncology Unit, 2nd Department of Pediatrics, School of Medicine, Aristotle University of ThessalonikiAHEPA HospitalThessalonikiGreece
| | - Paraskevi Panagopoulou
- 4th Department of Pediatrics, School of Medicine, Aristotle University of ThessalonikiPapageorgiou General HospitalThessalonikiGreece
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131
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Kumar R, Paul SS, Meena VP, Tiwari P, Bhatnagar S, Mohan A. Fifty Shades of COVID-19 - Immune Thrombocytopenic Purpura in HIV-TB-COVID Co-Infection. J Family Med Prim Care 2021; 10:2703-2705. [PMID: 34568158 PMCID: PMC8415644 DOI: 10.4103/jfmpc.jfmpc_1939_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/02/2020] [Accepted: 01/12/2021] [Indexed: 11/09/2022] Open
Abstract
SARS CoV-2 infection is associated with various hematological manifestations, including leucopenia, thrombocytopenia, thrombocytopenia. Severe thrombocytopenia is, however, rare and is associated with severe COVID-19. ITP remains an important differential among other causes. We report a case of HIV-TB-COVID-19 co-infection, without any feature of severe COVID, presenting with severe thrombocytopenia which resolved on its own; cause was attributed to immune-mediated effect of SARS CoV-2 virus.
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Affiliation(s)
- Rohit Kumar
- Department of Medicine, AIIMS, New Delhi, India
| | | | | | - Pavan Tiwari
- Department of Pulmonary Medicine and Sleep Disorders, AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Department of Oncoanesthesia and Palliative Medicine, AIIMS, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary Medicine and Sleep Disorders, AIIMS, New Delhi, India
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132
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Jasaraj RB, Shrestha DB, Gaire S, Kassem M. Immune Thrombocytopenic Purpura Following Pfizer-BioNTech COVID-19 Vaccine in an Elderly Female. Cureus 2021; 13:e16871. [PMID: 34513446 PMCID: PMC8414938 DOI: 10.7759/cureus.16871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 11/05/2022] Open
Abstract
Mass vaccination campaigns are being run all over the globe to combat the ongoing COVID-19 pandemic. There have been several reports of immune thrombocytopenic purpura (ITP) occurrence following COVID-19 vaccination. However, ITP due to the Pfizer-BioNTech vaccine has been rarely reported, and a causal link has not been identified. The pathophysiology behind immune thrombocytopenia is similar to heparin-induced thrombocytopenia. The management is also similar to other secondary immune thrombocytopenia. We present a case of a 67-year old female diagnosed with immune thrombocytopenia following Pfizer-BioNTech vaccination. The treatment was resistant to high-dose steroids, intravenous immunoglobulin (IVIG), and rituximab and eventually responded to a thrombopoietin-stimulating agent.
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Affiliation(s)
- Ranjit B Jasaraj
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Dhan B Shrestha
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Suman Gaire
- Department of Emergency Medicine, Palpa Hospital, Palpa, NPL
| | - Mohammed Kassem
- Department of Hematology and Oncology, Mount Sinai Hospital, Chicago, USA
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133
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Rampotas A, Watson E, Burton K, Hill QA, Pavord S. A real-world study of immune thrombocytopenia management during the COVID-19 pandemic in the UK. Br J Haematol 2021; 196:351-355. [PMID: 34448203 PMCID: PMC8652653 DOI: 10.1111/bjh.17804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 01/13/2023]
Abstract
The COVID‐19 pandemic has created many challenges in the management of immune thrombocytopenic purpura (ITP). The recommendation for avoidance of steroids by WHO led to the off‐licence use, supported by NHS England, of thrombopoietin mimetics (TPO‐RA) for newly diagnosed or relapsed ITP. This is a real‐world prospective study which investigated the treatment patterns and outcomes in this setting. Twenty‐four hospitals across the UK submitted 343 cases. Corticosteroids remain the mainstay of ITP treatment, but TPO‐RAs were more effective. Incidental COVID‐19 infection was identified in a significant number of patients (9·5%), while 14 cases were thought to be secondary to COVID‐19 vaccination.
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Affiliation(s)
- Alexandros Rampotas
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford University Graduate Academic School, Oxford, UK
| | - Edmund Watson
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kieran Burton
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Sue Pavord
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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134
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Petcu AE, Dumitru IM, Cernat RC, Șerban CI, Hangan A, Ghiță E, Vlad ND, Dumitrașcu M, Câmpeanu AT, Rugină S. Immune thrombocytopenic purpura secondary to COVID-19 - case report. Germs 2021; 11:319-323. [PMID: 34422703 DOI: 10.18683/germs.2021.1268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 01/18/2023]
Abstract
Introduction Thrombocytopenia is common in SARS-COV-2 infection, and about a quarter of cases have moderate thrombocytopenia. Severe thrombocytopenia is less common and is associated with severe forms of COVID-19. The pathogenesis of this thrombocytopenia appears to be complex, the immune mechanism being incriminated. Immune thrombocytopenic purpura (ITP) is one of the severe complications of COVID-19 and has an increased risk of mucosal or cutaneous bleeding. Case report We present the case of a 72-year-old woman admitted to the hospital with moderate COVID-19 who developed severe thrombocytopenia 13 days after the onset of COVID symptoms. Nine days after admission, her platelets decreased from 149×109/L to 3×109/L and numerous patches appeared on the skin and mucous membranes. She was responsive to corticosteroids and platelet transfusion, after five days, the platelet level returned to normal. Conclusions Close hematological monitoring of patients with COVID is necessary to prevent severe complications. Even if this patient did not receive immunoglobulins, corticosteroid therapy and platelet administration led to a favorable outcome.
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Affiliation(s)
- Andra Elena Petcu
- MD, Clinical Infectious Diseases Hospital, Constanța, Doctoral School, Ovidius University of Constanța, 124 Mamaia boulevard, Constanţa, Romania
| | - Irina Magdalena Dumitru
- MD, PhD, Associate Professor, Faculty of Medicine, Ovidius University of Constanța, 124 Mamaia boulevard, Constanţa, Clinical Infectious Diseases Hospital, Constanța, Romania
| | - Roxana Carmen Cernat
- MD, PhD, Assistant Professor, Faculty of Medicine, Ovidius University of Constanța, 124 Mamaia boulevard, Constanţa, Clinical Infectious Diseases Hospital, Constanța, Romania
| | - Carmen Ilie Șerban
- MD, Clinical Infectious Diseases Hospital, 100 Ferdinand boulevard, Constanța, 900178, Romania
| | - Aurelia Hangan
- MD, Clinical Infectious Diseases Hospital, Constanța, Doctoral School, Ovidius University of Constanța, 124 Mamaia boulevard, Constanţa, Romania
| | - Elena Ghiță
- MD, County Hospital Mangalia, 3 Carol Davila street, Mangalia, Romania
| | - Nicoleta Dorina Vlad
- MD, Clinical Infectious Diseases Hospital, Constanța, Romania, Doctoral School, Ovidius University of Constanța, 124 Mamaia boulevard, Constanţa, Romania
| | - Mirela Dumitrașcu
- MD, Clinical Infectious Diseases Hospital, 100 Ferdinand boulevard, Constanța, 900178, Romania
| | | | - Sorin Rugină
- MD, PhD, Professor, Faculty of Medicine, Ovidius University of Constanța, 124 Mamaia boulevard, Constanţa, Clinical Infectious Diseases Hospital, Constanța, Romanian Academy of Scientists, Romanian Academy of Medical Sciences, Romania
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135
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Which ones, when and why should renin-angiotensin system inhibitors work against COVID-19? Adv Biol Regul 2021; 81:100820. [PMID: 34419773 PMCID: PMC8359569 DOI: 10.1016/j.jbior.2021.100820] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 12/15/2022]
Abstract
The article describes the possible pathophysiological origin of COVID-19 and the crucial role of renin-angiotensin system (RAS), providing several “converging” evidence in support of this hypothesis. SARS-CoV-2 has been shown to initially upregulate ACE2 systemic activity (early phase), which can subsequently induce compensatory responses leading to upregulation of both arms of the RAS (late phase) and consequently to critical, advanced and untreatable stages of COVID-19 disease. The main and initial actors of the process are ACE2 and ADAM17 zinc-metalloproteases, which, initially triggered by SARS-CoV-2 spike proteins, work together in increasing circulating Ang 1–7 and Ang 1–9 peptides and downstream (Mas and Angiotensin type 2 receptors) pathways with anti-inflammatory, hypotensive and antithrombotic activities. During the late phase of severe COVID-19, compensatory secretion of renin and ACE enzymes are subsequently upregulated, leading to inflammation, hypertension and thrombosis, which further sustain ACE2 and ADAM17 upregulation. Based on this hypothesis, COVID-19-phase-specific inhibition of different RAS enzymes is proposed as a pharmacological strategy against COVID-19 and vaccine-induced adverse effects. The aim is to prevent the establishment of positive feedback-loops, which can sustain hyperactivity of both arms of the RAS independently of viral trigger and, in some cases, may lead to Long-COVID syndrome.
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136
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Immune Thrombocytopenic Purpura in a Child with COVID-19: A Case Report. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2021. [DOI: 10.5812/pedinfect.110428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Introduction: Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It may have many undescribed clinical manifestations. Case Presentation: In this study, we report a 7-year-old male COVID-19 patient with low platelet count who presented with gingival bleeding and ecchymosis and had a good response to corticosteroid therapy. Conclusions: This case highlights the need to be vigilant for atypical presentations or complications of COVID-19, one of which is SARS-CoV-2-induced immune thrombocytopenic purpura (ITP). It is necessary to pay attention to platelet count in addition to typical clinical features and radiographic findings. On the other hand, viral testing in thrombocytopenic patients should be considered for timely diagnosis of COVID-19 and taking necessary measurements for patient isolation in order to prevent the spread of disease and healthcare workers’ infection during this pandemic.
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137
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Moody R, Wilson K, Flanagan KL, Jaworowski A, Plebanski M. Adaptive Immunity and the Risk of Autoreactivity in COVID-19. Int J Mol Sci 2021; 22:ijms22168965. [PMID: 34445670 PMCID: PMC8396528 DOI: 10.3390/ijms22168965] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/03/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022] Open
Abstract
While first and foremost considered a respiratory infection, COVID-19 can result in complications affecting multiple organs. Immune responses in COVID-19 can both protect against the disease as well as drive it. Insights into these responses, and specifically the targets being recognised by the immune system, are of vital importance in understanding the side effects of COVID-19 and associated pathologies. The body's adaptive immunity recognises and responds against specific targets (antigens) expressed by foreign pathogens, but not usually to target self-antigens. However, if the immune system becomes dysfunctional, adaptive immune cells can react to self-antigens, which can result in autoimmune disease. Viral infections are well reported to be associated with, or exacerbate, autoimmune diseases such as multiple sclerosis (MS) and systemic lupus erythematosus (SLE). In COVID-19 patients, both new onset MS and SLE, as well as the occurrence of other autoimmune-like pathologies, have been reported. Additionally, the presence of autoantibodies, both with and without known associations to autoimmune diseases, have been found. Herein we describe the mechanisms of virally induced autoimmunity and summarise some of the emerging reports on the autoimmune-like diseases and autoreactivity that is reported to be associated with SARS-CoV-2 infection.
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Affiliation(s)
- Rhiane Moody
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
| | - Kirsty Wilson
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
| | - Katie L. Flanagan
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
- Tasmanian Vaccine Trial Centre, Clifford Craig Foundation, Launceston General Hospital, Launceston, TAS 7250, Australia
- School of Medicine, University of Tasmania, Launceston, TAS 7250, Australia
- Department of Immunology and Pathology, Monash University, Melbourne, VIC 3004, Australia
| | - Anthony Jaworowski
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
| | - Magdalena Plebanski
- School of Health and Biomedical Science, RMIT University, Bundoora, VIC 3083, Australia; (R.M.); (K.W.); (K.L.F.); (A.J.)
- Correspondence:
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138
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Islam A, Bashir MS, Joyce K, Rashid H, Laher I, Elshazly S. An Update on COVID-19 Vaccine Induced Thrombotic Thrombocytopenia Syndrome and Some Management Recommendations. Molecules 2021; 26:5004. [PMID: 34443589 PMCID: PMC8400504 DOI: 10.3390/molecules26165004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/08/2021] [Accepted: 08/13/2021] [Indexed: 12/25/2022] Open
Abstract
The thrombotic thrombocytopenia syndrome (TTS), a complication of COVID-19 vaccines, involves thrombosis (often cerebral venous sinus thrombosis) and thrombocytopenia with occasional pulmonary embolism and arterial ischemia. TTS appears to mostly affect females aged between 20 and 50 years old, with no predisposing risk factors conclusively identified so far. Cases are characterized by thrombocytopenia, higher levels of D-dimers than commonly observed in venous thromboembolic events, inexplicably low fibrinogen levels and worsening thrombosis. Hyper fibrinolysis associated with bleeding can also occur. Antibodies that bind platelet factor 4, similar to those associated with heparin-induced thrombocytopenia, have also been identified but in the absence of patient exposure to heparin treatment. A number of countries have now suspended the use of adenovirus-vectored vaccines for younger individuals. The prevailing opinion of most experts is that the risk of developing COVID-19 disease, including thrombosis, far exceeds the extremely low risk of TTS associated with highly efficacious vaccines. Mass vaccination should continue but with caution. Vaccines that are more likely to cause TTS (e.g., Vaxzevria manufactured by AstraZeneca) should be avoided in younger patients for whom an alternative vaccine is available.
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Affiliation(s)
- Amin Islam
- Department of Haematology, Mid & South Essex University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea SS0 0RY, UK; (M.S.B.); (K.J.); (S.E.)
- Department of Haematology, Queen Mary University of London, Mile End Road, London E1 3NS, UK
| | - Mohammed Sheraz Bashir
- Department of Haematology, Mid & South Essex University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea SS0 0RY, UK; (M.S.B.); (K.J.); (S.E.)
| | - Kevin Joyce
- Department of Haematology, Mid & South Essex University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea SS0 0RY, UK; (M.S.B.); (K.J.); (S.E.)
| | - Harunor Rashid
- National Centre for Immunisation Research and Surveillance(NCIRS) Kids Research, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia;
- The Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2145, Australia
| | - Ismail Laher
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Colombia, Vancouver, BC V6T 1Z3, Canada;
| | - Shereen Elshazly
- Department of Haematology, Mid & South Essex University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea SS0 0RY, UK; (M.S.B.); (K.J.); (S.E.)
- Adult Haemato-Oncology Unit, Faculty of Medicne, Ainshams University, Cairo 11566, Egypt
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139
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mRNA COVID-19 Vaccines and Potential Autoimmunity. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2021. [DOI: 10.5812/pedinfect.117372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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140
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Farley S, Ousley R, Van Wagoner N, Bril F. Autoimmunity After Coronavirus Disease 2019 (COVID-19) Vaccine: A Case of Acquired Hemophilia A. Thromb Haemost 2021; 121:1674-1676. [PMID: 34352911 DOI: 10.1055/a-1579-5396] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
No Abstract.
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Affiliation(s)
- Scott Farley
- Gastroenterology & Hepatology, The University of Alabama at Birmingham School of Medicine, Birmingham, United States
| | - Robert Ousley
- Gastroenterology & Hepatology, The University of Alabama at Birmingham School of Medicine, Birmingham, United States
| | - Nicholas Van Wagoner
- Gastroenterology & Hepatology, The University of Alabama at Birmingham School of Medicine, Birmingham, United States
| | - Fernando Bril
- The University of Alabama at Birmingham School of Medicine, Birmingham, United States
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141
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Antigen Presentation of mRNA-Based and Virus-Vectored SARS-CoV-2 Vaccines. Vaccines (Basel) 2021; 9:vaccines9080848. [PMID: 34451973 PMCID: PMC8402319 DOI: 10.3390/vaccines9080848] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
Infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causes Coronavirus Disease 2019 (COVID-19), which has reached pandemic proportions. A number of effective vaccines have been produced, including mRNA vaccines and viral vector vaccines, which are now being implemented on a large scale in order to control the pandemic. The mRNA vaccines are composed of viral Spike S1 protein encoding mRNA incorporated in a lipid nanoparticle and stabilized by polyethylene glycol (PEG). The mRNA vaccines are novel in many respects, including cellular uptake and the intracellular routing, processing, and secretion of the viral protein. Viral vector vaccines have incorporated DNA sequences, encoding the SARS-CoV-2 Spike protein into (attenuated) adenoviruses. The antigen presentation routes in MHC class I and class II, in relation to the induction of virus-neutralizing antibodies and cytotoxic T-lymphocytes, will be reviewed. In rare cases, mRNA vaccines induce unwanted immune mediated side effects. The mRNA-based vaccines may lead to an anaphylactic reaction. This reaction may be triggered by PEG. The intracellular routing of PEG and potential presentation in the context of CD1 will be discussed. Adenovirus vector-based vaccines have been associated with thrombocytopenic thrombosis events. The anti-platelet factor 4 antibodies found in these patients could be generated due to conformational changes of relevant epitopes presented to the immune system.
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142
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Kenney A, Adhikari A. Immune thrombocytopenia in a 68-year-old woman after COVID-19 vaccination. Clin Case Rep 2021; 9:e04689. [PMID: 34466248 PMCID: PMC8385179 DOI: 10.1002/ccr3.4689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/03/2021] [Accepted: 07/23/2021] [Indexed: 12/02/2022] Open
Abstract
This case discusses a patient who presented with immune thrombocytopenia purpura (ITP) one week after COVID-19 vaccination, introducing ITP as a consideration for a potential, but rare, adverse reaction to COVID-19 vaccination.
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Affiliation(s)
- Ashley Kenney
- Ascension Columbia St. Mary’s Milwaukee HospitalMilwaukeeWIUSA
| | - Anju Adhikari
- Ascension Columbia St. Mary’s Milwaukee HospitalMilwaukeeWIUSA
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143
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Stepman G, Daley I, Bralts D, Patel JB, Frunzi J. A Case of Immune Thrombocytopenia After COVID-19 Infection. Cureus 2021; 13:e15843. [PMID: 34322335 PMCID: PMC8298207 DOI: 10.7759/cureus.15843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 11/22/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a hematological condition that is characterized by a low platelet count. ITP can be primary or secondary. Secondary causes are diverse and include viral infections. The novel coronavirus has rarely been recognized as cause of ITP. This is a case of an 82-year-old Caucasian male who was infected by the novel coronavirus four weeks prior. His platelet count on admission was 1,000/mm3. He was diagnosed with ITP caused by the novel coronavirus as there were no other causes for his thrombocytopenia. The patient was treated with platelet infusions, high-dose corticosteroids, and intravenous immunoglobulin infusions.
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Affiliation(s)
| | - Ivy Daley
- Internal Medicine, Medical Center of Trinity, Trinity, USA
| | - Duncan Bralts
- Internal Medicine, Medical Center of Trinity, Trinity, USA
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144
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Koch M, Fuld S, Middeke JM, Fantana J, von Bonin S, Beyer-Westendorf J. Secondary Immune Thrombocytopenia (ITP) Associated with ChAdOx1 Covid-19 Vaccination - A Case Report. TH OPEN 2021; 5:e315-e318. [PMID: 34377889 PMCID: PMC8324423 DOI: 10.1055/s-0041-1731774] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/08/2021] [Indexed: 11/06/2022] Open
Abstract
Novel mRNA and vector-based covid-19 vaccinations have shown high efficacy in preventing symptomatic COVID-19 infections. Compared with the number of performed vaccinations, rates of severe side effects seem low. Rare prothrombotic coagulation disorders with suspected association to ChAdOx1 nCoV-19 (AstraZeneca) have been reported. These cases have gathered considerable media attention and caused a temporary pause of usage of the AstraZeneca vaccine in Europe and several other countries and are currently discussed as vaccine-induced immune thrombotic thrombocytopenia (VITT). However, hemorrhagic complications from ChAdOx1 nCoV-19 vaccination have also been reported but, so far, received less public attention despite considerable potential for life-threatening complications. Here we present a case of severe immune thrombocytopenia after ChAdOx1 covid-19 vaccination and its successful primary management.
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Affiliation(s)
- Martin Koch
- Department of Medicine, Hematology Division, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Sybille Fuld
- Department of Medicine, Nephrology Division, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan M Middeke
- Department of Medicine, Hematology Division, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Julia Fantana
- Department of Medicine, Emergency and Intensive Medicine Division, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Simone von Bonin
- Department of Medicine, Emergency and Intensive Medicine Division, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan Beyer-Westendorf
- Department of Medicine, Hematology Division, University Hospital Carl Gustav Carus, Dresden, Germany
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145
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King ER, Towner E. A Case of Immune Thrombocytopenia After BNT162b2 mRNA COVID-19 Vaccination. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931478. [PMID: 34285180 PMCID: PMC8311388 DOI: 10.12659/ajcr.931478] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Immune thrombocytopenic purpura (ITP) is an immune response that destroys platelets and increases the risk of bleeding, which can range from bruising to intracranial hemorrhage. ITP is a known complication of coronavirus disease 2019 (COVID-19). In the first studies of the BNT162b2 messenger RNA (mRNA) COVID-19 vaccine, there were no reports of ITP and the incidence of serious adverse events (AEs) was low overall. Here, we present a case of ITP as a complication of the BNT162b2 mRNA COVID-19 vaccine. CASE REPORT Three days after receiving a second dose of the BNT162b2 mRNA COVID-19 vaccine, a 39-year-old woman presented with a petechial rash on her trunk, legs, and arms, and fatigue and muscle aches. At the time of her hospital admission, her platelet count was 1000/µL. A peripheral smear showed profound thrombocytopenia. During the course of the patient's hospitalization, she was treated with 2 units of platelets, 2 infusions of i.v. immunoglobulin, and i.v. methylprednisolone. Her platelet count increased to 92 000/µL on the day of discharge and she was prescribed a tapered dose of oral prednisone. One day later, her rash had resolved and her platelet count was 243 000/µL. The patient recovered completely with no complications. CONCLUSIONS ITP should be considered a severe AE of the BNT162b2 mRNA COVID-19 vaccine. Knowing the early signs and symptoms of ITP will become increasingly important as more of the population receives this vaccine. Quick diagnosis and management are essential to avoid life-threatening bleeding.
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Affiliation(s)
- Eleanor R King
- Department of Family Medicine, Ascension Providence Rochester Hospital, Rochester, MI, USA
| | - Elizabeth Towner
- Department of Family Medicine and Public Health Sciences, Wayne State University, Detroit, MI, USA
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146
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Delshad M, Safaroghli-Azar A, Pourbagheri-Sigaroodi A, Poopak B, Shokouhi S, Bashash D. Platelets in the perspective of COVID-19; pathophysiology of thrombocytopenia and its implication as prognostic and therapeutic opportunity. Int Immunopharmacol 2021; 99:107995. [PMID: 34304001 PMCID: PMC8295197 DOI: 10.1016/j.intimp.2021.107995] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023]
Abstract
Despite endorsed and exponential research to improve diagnostic and therapeutic strategies, efforts have not yet converted into a better prospect for patients infected with the novel coronavirus (2019nCoV), and still, the name of SARS-CoV-2 is coupled with numerous unanswered questions. One of these questions is concerning how this respiratory virus reduces the number of platelets (PLTs)? The results of laboratory examinations showed that about a quarter of COVID-19 cases experience thrombocytopenia, and more remarkably, about half of these patients succumb to the infection due to coagulopathy. These findings have positioned PLTs as a pillar in the management as well as stratifying COVID-19 patients; however, not all the physicians came into a consensus about the prognostic value of these cells. The current review aims to unravel the contributory role of PLTs s in COVID-19; and also to summarize the original data obtained from international research laboratories on the association between COVID-19 and PLT production, activation, and clearance. In addition, we provide a special focus on the prognostic value of PLTs and their related parameters in COVID-19. Questions on how SARS-CoV-2 induces thrombocytopenia are also responded to. The last section provides a general overview of the most recent PLT- or thrombocytopenia-related therapeutic approaches. In conclusion, since SARS-CoV-2 reduces the number of PLTs by eliciting different mechanisms, treatment of thrombocytopenia in COVID-19 patients is not as simple as it appears and serious cautions should be considered to deal with the problem through scrutiny awareness of the causal mechanisms.
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Affiliation(s)
- Mahda Delshad
- Department of Laboratory Sciences, School of Allied Medical Sciences, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Ava Safaroghli-Azar
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atieh Pourbagheri-Sigaroodi
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behzad Poopak
- Department of Hematology, Faculty of Paramedical Sciences, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Shervin Shokouhi
- Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Davood Bashash
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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147
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Badulescu OV, Popescu D, Ciocoiu M, Rezus C. Immune thrombocytopenia, severe hematological consequence in a patient with COVID-19: A case report. Exp Ther Med 2021; 22:1043. [PMID: 34373729 DOI: 10.3892/etm.2021.10475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/29/2021] [Indexed: 01/08/2023] Open
Abstract
Since the first appearance of coronavirus disease 2019 (COVID-19), multiple studies have focused on this novel coronavirus. Within a few months, the clinical and paraclinical manifestations and the mechanisms by which these changes are induced were elaborated. Clinically, the virus mainly causes the common cold, but can also result in severe or fatal pneumonia/acute respiratory syndrome. Regarding the biological changes, similar to any other virus, it can lead to a reduced lymphocyte count. The second most common change is represented by a reduced thrombocyte count. Furthermore, most patients have blood clotting abnormalities, inflammatory syndrome, raised D-dimer and lactate dehydrogenase levels. Detection of immune thrombocytopenia in asymptomatic patients who tested positive for COVID-19 justifies the need to perform differential diagnosis and testing for COVID-19. Typically, patients with severe forms of COVID-19 develop mild thrombocytopenia, while severe thrombocytopenia is rarely reported. The aim of this case report was to present the situation in which one asymptomatic patient who tested positive for COVID-19 developed severe immune thrombocytopenia.
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Affiliation(s)
- Oana-Viola Badulescu
- Department of Pathophysiology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Diana Popescu
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
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148
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Bucke D, Alizadeh K, Hallam S. COVID-19 complicated by immune thrombocytopaenic purpura and internal jugular vein thrombosis. BMJ Case Rep 2021; 14:e243680. [PMID: 34285032 PMCID: PMC8292802 DOI: 10.1136/bcr-2021-243680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 12/13/2022] Open
Abstract
A 61-year-old woman who had tested positive for COVID-19 in the community 5 days prior to admission presented with new onset severe headache and mild shortness of breath. She had an acute reduction in her platelet counts from 153×10⁹/L to 5×10⁹/L. She was diagnosed with immune thrombocytopenia purpura and after treatment with intravenous immunoglobulin, her platelet count increased to 15×10⁹/L. Due to nonresolving headache, she had a magnetic resonance venogram, which showed bilateral internal jugular vein thrombosis. She was discharged from hospital and followed up in Haematology and Neurology clinics. Her platelet count returned to normal range 7 days later. She was commenced on anticoagulation for thrombosis.
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Affiliation(s)
- Danielle Bucke
- Medicine, Chelsea and Westminster Healthcare NHS Trust, London, UK
| | - Katrin Alizadeh
- Haematology, Chelsea and Westminster Healthcare NHS Trust, London, UK
| | - Simon Hallam
- Haemato-Oncology, Barts Health NHS Trust, London, UK
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149
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150
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Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with a variety of clinical manifestations related to viral tissue damage, as well as a virally induced immune response. Hyperstimulation of the immune system can serve as a trigger for autoimmunity. Several immune-mediated manifestations have been described in the course of SARS-CoV-2 infection. Immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia (AIHA) are the most common hematologic autoimmune disorders seen in the course of SARS-CoV-2 infection. Vaccine-induced thrombocytopenia is a unique autoimmune hematologic cytopenia associated with SARS-CoV-2 vaccination. This paper will review the current literature on the association of SARS-CoV-2 infection and vaccination with autoimmune cytopenias and the clinical course of autoimmune cytopenias in patients with COVID-19.
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