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Karcher DS. From HIV to Coronavirus Disease 2019 (COVID-19): Hematologic Complications in Viral Pandemics. Arch Pathol Lab Med 2021; 146:433-439. [PMID: 33946099 DOI: 10.5858/arpa.2021-0097-ra] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— From the onset of the human immunodeficiency virus (HIV) pandemic in the 1980s to the recent coronavirus disease 2019 (COVID-19) pandemic, multiple viral pandemics have occurred and all have been associated with hematologic complications of varying severity. OBJECTIVE.— To review the hematologic complications associated with the HIV and other viral pandemics, the current theories regarding their causation, and the incidence and clinical impact of these complications on infected patients. DATA SOURCES.— Peer-reviewed medical literature and the author's personal experience. CONCLUSIONS.— The HIV and other viral pandemics have been associated with a variety of hematologic complications that often cause significant morbidity and mortality in affected patients. HIV infection is associated with multiple hematologic disorders, many of which have a lower incidence in the era of highly active antiretroviral therapy but still represent a major clinical problem for HIV-infected patients. Our understanding of the pathogenesis of HIV-related hematologic complications, including HIV-associated lymphoproliferative disorders, has evolved in recent years. Other viral pandemics, including H1N1 influenza, severe acute respiratory syndrome (SARS) coronavirus, Middle East respiratory syndrome (MERS) coronavirus, and COVID-19, have also been associated with hematologic complications of varying severity. Our emerging understanding of the pathogenesis of the hematologic complications of HIV, COVID-19, and other viral pandemics may help in prevention, correct diagnosis, and treatment of these complications in current and future pandemics.
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Affiliation(s)
- Donald S Karcher
- From the Department of Pathology, George Washington University Medical Center, Washington, District of Columbia
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102
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Anilkumar A, Tan E, Cleaver J, Morrison HD. Isolated abducens nerve palsy in a patient with asymptomatic SARS-CoV-2 infection. J Clin Neurosci 2021; 89:65-67. [PMID: 34119296 PMCID: PMC8055164 DOI: 10.1016/j.jocn.2021.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/03/2021] [Accepted: 04/14/2021] [Indexed: 11/30/2022]
Abstract
The neuro-ophthalmological complications of SARS-CoV-2 infection are emerging but the spectrum of presentations and pathophysiological mechanism underpinning the association remains to be fully determined. We describe the case of a 44-year-old female who presented with a 12-hour history of diplopia preceded by a mild headache and found to have an isolated right abducens nerve palsy. Initial vital signs were normal but she developed a fever and nasopharyngeal swab confirmed SARS-CoV-2 infection by RT-PCR. All other investigations returned normal including blood tests, chest X-ray, MRI brain and cerebrospinal fluid analysis. She remained systemically well, and there was complete resolution of the abducens palsy and diplopia at two week follow up. In the absence of an alternative underlying cause or risk factors identified, the aetiology was presumed to be microvascular and potentially related to the viral infection. We add to the evolving literature of neuro-ophthalmological associations of SARS-CoV-2, discuss possible causal mechanisms and suggest considering asymptomatic SARS-CoV-2 infection in cases of isolated abducens palsy without clear risk factors.
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Affiliation(s)
| | - Elizabeth Tan
- Department of Neurology, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - Jonathan Cleaver
- Department of Neurology, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - Hamish D Morrison
- Department of Neurology, North Bristol NHS Trust, Bristol BS10 5NB, UK; Population Health Sciences, University of Bristol, Bristol BS8 2PL, UK.
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103
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Sweeney JM, Barouqa M, Krause GJ, Gonzalez-Lugo JD, Rahman S, Gil MR. Low ADAMTS13 Activity Correlates with Increased Mortality in COVID-19 Patients. TH OPEN 2021; 5:e89-e103. [PMID: 33709050 PMCID: PMC7943318 DOI: 10.1055/s-0041-1723784] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
The causes of coagulopathy associated with coronavirus disease 2019 (COVID-19) are poorly understood. We aimed to investigate the relationship between von Willebrand factor (VWF) biomarkers, intravascular hemolysis, coagulation, and organ damage in COVID-19 patients and study their association with disease severity and mortality. We conducted a retrospective study of 181 hospitalized COVID-19 patients randomly selected with balanced distribution of survivors and nonsurvivors. Patients who died had significantly lower ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity, significantly elevated lactate dehydrogenase levels, significantly increased shistocyte/RBC fragment counts, and significantly elevated VWF antigen and activity levels compared with patients discharged alive. These biomarkers correlate with markedly elevated D-dimers. Additionally, only 30% of patients who had an ADAMTS13 activity level of less than 43% on admission survived, yet 60% of patients survived who had an ADAMTS13 activity level of greater than 43% on admission. In conclusion, COVID-19 may present with low ADAMTS13 activity in a subset of hospitalized patients. Presence of schistocytes/RBC fragment and elevated D-dimer on admission may warrant a work-up for ADAMTS13 activity and VWF antigen and activity levels. These findings indicate the need for future investigation to study the relationship between endothelial and coagulation activation and the efficacy of treatments aimed at prevention and/or amelioration of microangiopathy in COVID-19.
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Affiliation(s)
- Joseph M Sweeney
- Department Physiology and Biophysics, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Mohammad Barouqa
- Department of Pathology Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Gregory J Krause
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, New York, United States.,Institute of Aging Studies, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Jesus D Gonzalez-Lugo
- Division of Hematology, Department of Medical Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Shafia Rahman
- Division of Hematology, Department of Medical Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Morayma Reyes Gil
- Department of Pathology Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
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104
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Verhoef PA, Kannan S, Sturgill JL, Tucker EW, Morris PE, Miller AC, Sexton TR, Koyner JL, Hejal R, Brakenridge SC, Moldawer LL, Hotchkiss RS, Blood TM, Mazer MB, Bolesta S, Alexander SA, Armaignac DL, Shein SL, Jones C, Hoemann CD, Doctor A, Friess SH, Parker RI, Rotta AT, Remy KE. Severe Acute Respiratory Syndrome-Associated Coronavirus 2 Infection and Organ Dysfunction in the ICU: Opportunities for Translational Research. Crit Care Explor 2021; 3:e0374. [PMID: 33786450 PMCID: PMC7994036 DOI: 10.1097/cce.0000000000000374] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Since the beginning of the coronavirus disease 2019 pandemic, hundreds of thousands of patients have been treated in ICUs across the globe. The severe acute respiratory syndrome-associated coronavirus 2 virus enters cells via the angiotensin-converting enzyme 2 receptor and activates several distinct inflammatory pathways, resulting in hematologic abnormalities and dysfunction in respiratory, cardiac, gastrointestinal renal, endocrine, dermatologic, and neurologic systems. This review summarizes the current state of research in coronavirus disease 2019 pathophysiology within the context of potential organ-based disease mechanisms and opportunities for translational research. DATA SOURCES Investigators from the Research Section of the Society of Critical Care Medicine were selected based on expertise in specific organ systems and research focus. Data were obtained from searches conducted in Medline via the PubMed portal, Directory of Open Access Journals, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, and Web of Science from an initial search from December 2019 to October 15, 2020, with a revised search to February 3, 2021. The medRxiv, Research Square, and clinical trial registries preprint servers also were searched to limit publication bias. STUDY SELECTION Content experts selected studies that included mechanism-based relevance to the severe acute respiratory syndrome-associated coronavirus 2 virus or coronavirus disease 2019 disease. DATA EXTRACTION Not applicable. DATA SYNTHESIS Not applicable. CONCLUSIONS Efforts to improve the care of critically ill coronavirus disease 2019 patients should be centered on understanding how severe acute respiratory syndrome-associated coronavirus 2 infection affects organ function. This review articulates specific targets for further research.
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Affiliation(s)
- Philip A Verhoef
- Department of Medicine, University of Hawaii-Manoa, Honolulu, HI
- Kaiser Permanente Hawaii, Honolulu, HI
| | - Sujatha Kannan
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jamie L Sturgill
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, KY
| | - Elizabeth W Tucker
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter E Morris
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, KY
| | - Andrew C Miller
- Department of Emergency Medicine, Nazareth Hospital, Philadelphia, PA
| | - Travis R Sexton
- Department of Internal Medicine, The University of Kentucky-Lexington School of Medicine, The Gill Heart and Vascular Institute, Lexington, KY
| | - Jay L Koyner
- Section of Nephrology, University of Chicago, Chicago, IL
| | - Rana Hejal
- Department of Internal Medicine, Division of Pulmonary Critical Care, Case Western School of Medicine, Cleveland, OH
| | - Scott C Brakenridge
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL
| | - Lyle L Moldawer
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL
| | - Richard S Hotchkiss
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Surgery, St. Louis, Washington University School of Medicine, MO
| | - Teresa M Blood
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Monty B Mazer
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Scott Bolesta
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | | | | | - Steven L Shein
- Department of Pediatrics, Division of Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Christopher Jones
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Allan Doctor
- Department of Pediatrics, Division of Critical Care Medicine, The University of Maryland School of Medicine, Baltimore, MD
| | - Stuart H Friess
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Robert I Parker
- Department of Pediatrics, Hematology Hematology/Oncology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Alexandre T Rotta
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Kenneth E Remy
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
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105
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Franchini M, Glingani C, Liumbruno GM. Potential mechanisms of action of convalescent plasma in COVID-19. ACTA ACUST UNITED AC 2021; 8:413-420. [PMID: 33652503 DOI: 10.1515/dx-2020-0161] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/03/2021] [Indexed: 12/13/2022]
Abstract
The COVID-19 pandemic will be remembered as one of the worst catastrophic events in human history. Unfortunately, no universally recognized effective therapeutic agents are currently available for the treatment of severe SARS-CoV-2 infection. In this context, the use of convalescent plasma from recovered COVID-19 patients has gained increasing interest thanks to the initially positive clinical reports. A number of mechanisms of action have been proposed for convalescent plasma, including direct neutralization and suppression of viremia, anti-inflammatory and immunomodulation effects and mitigation of the COVID-19-associated hypercoagulable state. These immune and non-immune mechanisms will be critically discussed in this narrative review.
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Affiliation(s)
- Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
| | - Claudia Glingani
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
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106
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Abstract
Platelets play an essential role in maintaining vascular integrity after injury. In addition, platelets contribute to the immune response to pathogens. For instance, they express receptors that mediate binding of viruses, and toll-like receptors that activate the cell in response to pathogen-associated molecular patterns. Platelets can be beneficial and/or detrimental during viral infections. They reduce blood-borne viruses by engulfing the free virus and presenting the virus to neutrophils. However, platelets can also enhance inflammation and tissue injury during viral infections. Here, we discuss the roles of platelets in viral infection.
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Affiliation(s)
- Silvio Antoniak
- UNC Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel Mackman
- UNC Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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107
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Lipcsey M, Persson B, Eriksson O, Blom AM, Fromell K, Hultström M, Huber-Lang M, Ekdahl KN, Frithiof R, Nilsson B. The Outcome of Critically Ill COVID-19 Patients Is Linked to Thromboinflammation Dominated by the Kallikrein/Kinin System. Front Immunol 2021; 12:627579. [PMID: 33692801 PMCID: PMC7937878 DOI: 10.3389/fimmu.2021.627579] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023] Open
Abstract
An important manifestation of severe COVID-19 is the ARDS-like lung injury that is associated with vascular endothelialitis, thrombosis, and angiogenesis. The intravascular innate immune system (IIIS), including the complement, contact, coagulation, and fibrinolysis systems, which is crucial for recognizing and eliminating microorganisms and debris in the body, is likely to be involved in the pathogenesis of COVID-19 ARDS. Biomarkers for IIIS activation were studied in the first 66 patients with COVID-19 admitted to the ICU in Uppsala University Hospital, both cross-sectionally on day 1 and in 19 patients longitudinally for up to a month, in a prospective study. IIIS analyses were compared with biochemical parameters and clinical outcome and survival. Blood cascade systems activation leading to an overreactive conjunct thromboinflammation was demonstrated, reflected in consumption of individual cascade system components, e.g., FXII, prekallikrein, and high molecular weight kininogen and in increased levels of activation products, e.g., C4d, C3a, C3d,g, sC5b-9, TAT, and D-dimer. Strong associations were found between the blood cascade systems and organ damage, illness severity scores, and survival. We show that critically ill COVID-19 patients display a conjunct activation of the IIIS that is linked to organ damage of the lung, heart, kidneys, and death. We present evidence that the complement and in particular the kallikrein/kinin system is strongly activated and that both systems are prognostic markers of the outcome of the patients suggesting their role in driving the inflammation. Already licensed kallikrein/kinin inhibitors are potential drugs for treatment of critically ill patients with COVID-19.
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Affiliation(s)
- Miklós Lipcsey
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
- Hedenstierna Laboratory, Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Barbro Persson
- Department of Immunology Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Oskar Eriksson
- Department of Immunology Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Anna M. Blom
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Karin Fromell
- Department of Immunology Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Michael Hultström
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
- Unit for Integrative Physiology, Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Markus Huber-Lang
- Institute for Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Kristina N. Ekdahl
- Department of Immunology Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Linnaeus Centre for Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
| | - Robert Frithiof
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Bo Nilsson
- Department of Immunology Genetics and Pathology, Uppsala University, Uppsala, Sweden
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108
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Sustained prothrombotic changes in COVID-19 patients 4 months after hospital discharge. Blood Adv 2021; 5:756-759. [PMID: 33560386 PMCID: PMC7857699 DOI: 10.1182/bloodadvances.2020003968] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/04/2021] [Indexed: 01/03/2023] Open
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109
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Jiang T, Lv B, Liu H, He S, Zhang G, Li C, Li W, Li W, He Y, Zhang T, Wang Y, Mo W, Yi N, Peng L, Li Y, Ruan C, Li C, Liu Y, Luo P, Jiang H, Xue Z, Liu L, Wang W. Autopsy and statistical evidence of disturbed hemostasis progress in COVID-19: medical records from 407 patients. Thromb J 2021; 19:8. [PMID: 33568153 PMCID: PMC7873516 DOI: 10.1186/s12959-020-00256-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The progression of coagulation in COVID-19 patients with confirmed discharge status and the combination of autopsy with complete hemostasis parameters have not been well studied. OBJECTIVE To clarify the thrombotic phenomena and hemostasis state in COVID-19 patients based on epidemiological statistics combining autopsy and statistical analysis. METHODS Using autopsy results from 9 patients with COVID-19 pneumonia and the medical records of 407 patients, including 39 deceased patients whose discharge status was certain, time-sequential changes in 11 relevant indices within mild, severe and critical infection throughout hospitalization according to the Chinese National Health Commission (NHC) guidelines were evaluated. Statistical tools were applied to calculate the importance of 11 indices and the correlation between those indices and the severity of COVID-19. RESULTS At the beginning of hospitalization, platelet (PLT) counts were significantly reduced in critically ill patients compared with severely or mildly ill patients. Blood glucose (GLU), prothrombin time (PT), activated partial thromboplastin time (APTT), and D-dimer levels in critical patients were increased compared with mild and severe patients during the entire admission period. The International Society on Thrombosis and Haemostasis (ISTH) disseminated intravascular coagulation (DIC) score was also high in critical patients. In the relatively late stage of nonsurvivors, the temporal changes in PLT count, PT, and D-dimer levels were significantly different from those in survivors. A random forest model indicated that the most important feature was PT followed by D-dimer, indicating their positive associations with disease severity. Autopsy of deceased patients fulfilling diagnostic criteria for DIC revealed microthromboses in multiple organs. CONCLUSIONS Combining autopsy data, time-sequential changes and statistical methods to explore hemostasis-relevant indices among the different severities of the disease helps guide therapy and detect prognosis in COVID-19 infection.
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Affiliation(s)
- Tiebin Jiang
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Bo Lv
- Department of Regenerative Medicine, School of Medicine, Tongji University, 1239 Siping Road, Shanghai, 200092, China
| | - Hongxia Liu
- Scientometrics and Evaluation Center for Rule of Law, China University of Political Science and Law, Beijing, 100088, China
| | - Shiwen He
- School of Computer Science and Engineering, Central South University, Changsha, 410083, China
| | - Guogang Zhang
- Department of Cardiovascular, The Third Xiangya Hospital, The Central South University, Changsha, 410013, Hunan, China
| | - Chanyi Li
- Department of Regenerative Medicine, School of Medicine, Tongji University, 1239 Siping Road, Shanghai, 200092, China
| | - Wanqiong Li
- Reproductive Medicine Center, Tongji Hospital, Tongji University, Shanghai, 200065, China
| | - Weilin Li
- Stem Cell and Regenerative Medicine Engineering Research Center of Hunan Province, Hunan Yuanpin Cell Technology Co. Ltd, 102 Dongwu Road, Changsha City, 410100, Hunan Province, China
| | - Yaqi He
- School of Computer Science and Engineering, Central South University, Changsha, 410083, China
| | - Tong Zhang
- School of Computer Science and Engineering, Central South University, Changsha, 410083, China
| | - Yunyun Wang
- Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan City, 430030, Hubei Province, China
| | - Wu Mo
- Stem Cell and Regenerative Medicine Engineering Research Center of Hunan Province, Hunan Yuanpin Cell Technology Co. Ltd, 102 Dongwu Road, Changsha City, 410100, Hunan Province, China
| | - Ning Yi
- Stem Cell and Regenerative Medicine Engineering Research Center of Hunan Province, Hunan Yuanpin Cell Technology Co. Ltd, 102 Dongwu Road, Changsha City, 410100, Hunan Province, China
| | - Luying Peng
- Department of Regenerative Medicine, School of Medicine, Tongji University, 1239 Siping Road, Shanghai, 200092, China
| | - Ying Li
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Chunhong Ruan
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Chengyuan Li
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Yaqi Liu
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Peipei Luo
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Huan Jiang
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Zhigang Xue
- Department of Regenerative Medicine, School of Medicine, Tongji University, 1239 Siping Road, Shanghai, 200092, China.
- Reproductive Medicine Center, Tongji Hospital, Tongji University, Shanghai, 200065, China.
- Stem Cell and Regenerative Medicine Engineering Research Center of Hunan Province, Hunan Yuanpin Cell Technology Co. Ltd, 102 Dongwu Road, Changsha City, 410100, Hunan Province, China.
| | - Liang Liu
- Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan City, 430030, Hubei Province, China.
| | - Wenjun Wang
- Stem Cell and Regenerative Medicine Engineering Research Center of Hunan Province, Hunan Yuanpin Cell Technology Co. Ltd, 102 Dongwu Road, Changsha City, 410100, Hunan Province, China.
- Department of Spinal Surgery, The First Affiliated Hospital of University of South China, Hengyang, 421002, Hunan, China.
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110
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Large Cerebellar Stroke in a Young COVID-19-Positive Patient: Case Report. J Emerg Med 2021; 61:29-36. [PMID: 33863570 PMCID: PMC7871887 DOI: 10.1016/j.jemermed.2021.02.004] [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: 09/09/2020] [Revised: 11/26/2020] [Accepted: 02/06/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), most frequently presents with respiratory symptoms, such as fever, dyspnea, shortness of breath, cough, or myalgias. There is now a growing body of evidence that demonstrates that severe SARS-CoV-2 infections can develop clinically significant coagulopathy, inflammation, and cardiomyopathy, which have been implicated in COVID-19-associated cerebrovascular accidents (CVAs). CASE REPORT We report an uncommon presentation of a 32-year-old man who sustained a large vessel cerebellar stroke associated with a severe COVID-19 infection. He presented with a headache, worse than his usual migraine, dizziness, rotary nystagmus, and dysmetria on examination, but had no respiratory symptoms initially. He was not a candidate for thrombolytic therapy or endovascular therapy and was managed with clopidogrel, aspirin, and atorvastatin. During hospital admission he developed COVID-19-related hypoxia and pneumonia, but ultimately he was discharged to home rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the growing number of reports of neurologic and vascular complications, such as ischemic CVAs, in otherwise healthy individuals who are diagnosed with SARS-CoV-2 infection. A brief review of the current literature will help elucidate possible mechanisms, risk factors, and current treatments for CVA associated with SARS-CoV-2.
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111
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Ng H, Havervall S, Rosell A, Aguilera K, Parv K, von Meijenfeldt FA, Lisman T, Mackman N, Thålin C, Phillipson M. Circulating Markers of Neutrophil Extracellular Traps Are of Prognostic Value in Patients With COVID-19. Arterioscler Thromb Vasc Biol 2021; 41:988-994. [PMID: 33267662 PMCID: PMC7837697 DOI: 10.1161/atvbaha.120.315267] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/09/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The full spectrum of coronavirus disease 2019 (COVID-19) infection ranges from asymptomatic to acute respiratory distress syndrome, characterized by hyperinflammation and thrombotic microangiopathy. The pathogenic mechanisms are poorly understood, but emerging evidence suggest that excessive neutrophil extracellular trap (NET) formation plays a key role in COVID-19 disease progression. Here, we evaluate if circulating markers of NETs are associated with COVID-19 disease severity and clinical outcome, as well as to markers of inflammation and in vivo coagulation and fibrinolysis. Approach and Results: One hundred six patients with COVID-19 with moderate to severe disease were enrolled shortly after hospital admission and followed for 4 months. Acute and convalescent plasma samples as well as plasma samples from 30 healthy individuals were assessed for markers of NET formation: citrullinated histone H3, cell-free DNA, NE (neutrophil elastase). We found that all plasma levels of NET markers were elevated in patients with COVID-19 relative to healthy controls, that they were associated with respiratory support requirement and short-term mortality, and declined to those found in healthy individuals 4 months post-infection. The levels of the NET markers also correlated with white blood cells, neutrophils, inflammatory cytokines, and C-reactive protein, as well as to markers of in vivo coagulation, fibrinolysis, and endothelial damage. CONCLUSIONS Our findings suggest a role of NETs in COVID-19 disease progression, implicating their contribution to an immunothrombotic state. Further, we observed an association between circulating markers of NET formation and clinical outcome, demonstrating a potential role of NET markers in clinical decision-making, as well as for NETs as targets for novel therapeutic interventions in COVID-19.
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Affiliation(s)
- Henry Ng
- Department of Medical Cell Biology, Uppsala University, SciLifeLab, Sweden (H.N., K.P., M.P.)
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (H.N., S.H., A.R., K.A., C.T.)
| | - Sebastian Havervall
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (H.N., S.H., A.R., K.A., C.T.)
| | - Axel Rosell
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (H.N., S.H., A.R., K.A., C.T.)
| | - Katherina Aguilera
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (H.N., S.H., A.R., K.A., C.T.)
| | - Kristel Parv
- Department of Medical Cell Biology, Uppsala University, SciLifeLab, Sweden (H.N., K.P., M.P.)
| | - Fien A. von Meijenfeldt
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands (F.A.v.M., T.L.)
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands (F.A.v.M., T.L.)
| | - Nigel Mackman
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, UNC Blood Research Center (N.M.)
| | - Charlotte Thålin
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (H.N., S.H., A.R., K.A., C.T.)
| | - Mia Phillipson
- Department of Medical Cell Biology, Uppsala University, SciLifeLab, Sweden (H.N., K.P., M.P.)
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Affiliation(s)
- Robert D McBane
- Vascular Division, Department of Cardiology, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
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113
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Rosell A, Havervall S, von Meijenfeldt F, Hisada Y, Aguilera K, Grover SP, Lisman T, Mackman N, Thålin C. Patients With COVID-19 Have Elevated Levels of Circulating Extracellular Vesicle Tissue Factor Activity That Is Associated With Severity and Mortality-Brief Report. Arterioscler Thromb Vasc Biol 2021; 41:878-882. [PMID: 33267656 PMCID: PMC7837685 DOI: 10.1161/atvbaha.120.315547] [Citation(s) in RCA: 154] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/15/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Patients with coronavirus disease 2019 (COVID-19) have a high rate of thrombosis. We hypothesized that severe acute respiratory syndrome coronavirus 2 infection leads to induction of TF (tissue factor) expression and increased levels of circulating TF-positive extracellular vesicles (EV) that may drive thrombosis. Approach and Results: We measured levels of plasma EV TF activity in 100 patients with COVID-19 with moderate and severe disease and 28 healthy controls. Levels of EV TF activity were significantly higher in patients with COVID-19 compared with controls. In addition, levels of EV TF activity were associated with disease severity and mortality. Finally, levels of EV TF activity correlated with several plasma markers, including D-dimer, which has been shown to be associated with thrombosis in patients with COVID-19. CONCLUSIONS Our results indicate that severe acute respiratory syndrome coronavirus 2 infection induces the release of TF-positive EVs into the circulation that are likely to contribute to thrombosis in patients with COVID-19. EV TF activity was also associated with severity and mortality.
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Affiliation(s)
- Axel Rosell
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (A.R., S.H., K.A., C.T.)
| | - Sebastian Havervall
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (A.R., S.H., K.A., C.T.)
| | - Fien von Meijenfeldt
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands (F.v.M., T.L.)
| | - Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill (Y.H., S.P.G., N.M.)
| | - Katherina Aguilera
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (A.R., S.H., K.A., C.T.)
| | - Steven P. Grover
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill (Y.H., S.P.G., N.M.)
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands (F.v.M., T.L.)
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill (Y.H., S.P.G., N.M.)
| | - Charlotte Thålin
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (A.R., S.H., K.A., C.T.)
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114
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Roy D, Ramasamy R, Schmidt AM. Journey to a Receptor for Advanced Glycation End Products Connection in Severe Acute Respiratory Syndrome Coronavirus 2 Infection: With Stops Along the Way in the Lung, Heart, Blood Vessels, and Adipose Tissue. Arterioscler Thromb Vasc Biol 2021; 41:614-627. [PMID: 33327744 PMCID: PMC7837689 DOI: 10.1161/atvbaha.120.315527] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 11/30/2020] [Indexed: 01/08/2023]
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected millions of people worldwide and the pandemic has yet to wane. Despite its associated significant morbidity and mortality, there are no definitive cures and no fully preventative measures to combat SARS-CoV-2. Hence, the urgency to identify the pathobiological mechanisms underlying increased risk for and the severity of SARS-CoV-2 infection is mounting. One contributing factor, the accumulation of damage-associated molecular pattern molecules, is a leading trigger for the activation of nuclear factor-kB and the IRF (interferon regulatory factors), such as IRF7. Activation of these pathways, particularly in the lung and other organs, such as the heart, contributes to a burst of cytokine release, which predisposes to significant tissue damage, loss of function, and mortality. The receptor for advanced glycation end products (RAGE) binds damage-associated molecular patterns is expressed in the lung and heart, and in priming organs, such as the blood vessels (in diabetes) and adipose tissue (in obesity), and transduces the pathological signals emitted by damage-associated molecular patterns. It is proposed that damage-associated molecular pattern-RAGE enrichment in these priming tissues, and in the lungs and heart during active infection, contributes to the widespread tissue damage induced by SARS-CoV-2. Accordingly, the RAGE axis might play seminal roles in and be a target for therapeutic intervention in SARS-CoV-2 infection.
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Affiliation(s)
- Divya Roy
- Diabetes Research Program, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, NYU Grossman School of Medicine (D.R., R.R., A.M.S.)
- New York Institute of Technology College of Osteopathic Medicine, Glen Head (D.R.)
| | - Ravichandran Ramasamy
- Diabetes Research Program, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, NYU Grossman School of Medicine (D.R., R.R., A.M.S.)
| | - Ann Marie Schmidt
- Diabetes Research Program, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, NYU Grossman School of Medicine (D.R., R.R., A.M.S.)
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115
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Ondracek AS, Lang IM. Neutrophil Extracellular Traps as Prognostic Markers in COVID-19: A Welcome Piece to the Puzzle. Arterioscler Thromb Vasc Biol 2021; 41:995-998. [PMID: 33955780 PMCID: PMC7837687 DOI: 10.1161/atvbaha.120.315633] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Anna S Ondracek
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria
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116
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Harenberg J, Violi F. Waves of SARS-CoV-2 Infection and Blood Coagulation-A Link and Beyond. Thromb Haemost 2021; 121:4-6. [PMID: 33477197 DOI: 10.1055/s-0040-1721778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Job Harenberg
- Medical Faculty Mannheim, Ruprecht-Karls-University, Heidelberg, Germany.,DOASENSE GmbH, Heidelberg, Germany
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117
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Chen W, Pan JY. Anatomical and Pathological Observation and Analysis of SARS and COVID-19: Microthrombosis Is the Main Cause of Death. Biol Proced Online 2021; 23:4. [PMID: 33472576 PMCID: PMC7816139 DOI: 10.1186/s12575-021-00142-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/11/2021] [Indexed: 12/22/2022] Open
Abstract
The spread of the coronavirus (SARS-CoV-2, COVID-19 for short) has caused a large number of deaths around the world. We summarized the data reported in the past few months and emphasized that the main causes of death of COVID-19 patients are DAD (Diffuse Alveolar Damage) and DIC (Disseminated intravascular coagulation). Microthrombosis is a prominent clinical feature of COVID-19, and 91.3% of dead patients had microthrombosis.Endothelial damage caused by SARS-CoV-2 cell invasion and subsequent host response disorders involving inflammation and coagulation pathways play a key role in the progression of severe COVID-19. Microvascular thrombosis may lead to microcirculation disorders and multiple organ failure lead to death.The characteristic pathological changes of DAD include alveolar epithelial and vascular endothelial injury, increased alveolar membrane permeability, large numbers of neutrophil infiltration, alveolar hyaline membrane formation, and hypoxemia and respiratory distress as the main clinical manifestations. DAD leads to ARDS in COVID-19 patients. DIC is a syndrome characterized by the activation of systemic intravascular coagulation, which leads to extensive fibrin deposition in the blood. Its occurrence and development begin with the expression of tissue factor and interact with physiological anticoagulation pathways. The down-regulation of fibrin and the impaired fibrinolysis together lead to extensive fibrin deposition.DIC is described as a decrease in the number of platelets and an increase in fibrin degradation products, such as D-dimer and low fibrinogen. The formation of microthrombus leads to the disturbance of microcirculation, which in turn leads to the death of the patient. However, the best prevention and treatment of COVID-19 microthrombosis is still uncertain.This review discusses the latest findings of basic and clinical research on COVID-19-related microthrombosis, and then we proposed the theory of microcirculation perfusion bundle therapy to explore effective methods for preventing and treating COVID-19-related microthrombosis. Further research is urgently needed to clarify how SARS-CoV-2 infection causes thrombotic complications, and how it affects the course and severity of the disease. To cultivate a more comprehensive understanding of the underlying mechanism of this disease. Raise awareness of the importance of preventing and treating microthrombosis in patients with COVID-19.
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Affiliation(s)
- Wenjing Chen
- School of the First Clinical Medical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Jing Ye Pan
- School of the First Clinical Medical Sciences, Wenzhou Medical University, Wenzhou, China
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou, China
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118
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Biological and Clinical Consequences of Integrin Binding via a Rogue RGD Motif in the SARS CoV-2 Spike Protein. Viruses 2021; 13:v13020146. [PMID: 33498225 PMCID: PMC7909284 DOI: 10.3390/v13020146] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 12/12/2022] Open
Abstract
Although ACE2 (angiotensin converting enzyme 2) is considered the primary receptor for CoV-2 cell entry, recent reports suggest that alternative pathways may contribute. This paper considers the hypothesis that viral binding to cell-surface integrins may contribute to the high infectivity and widespread extra-pulmonary impacts of the SARS-CoV-2 virus. This potential is suggested on the basis of the emergence of an RGD (arginine-glycine-aspartate) sequence in the receptor-binding domain of the spike protein. RGD is a motif commonly used by viruses to bind cell-surface integrins. Numerous signaling pathways are mediated by integrins and virion binding could lead to dysregulation of these pathways, with consequent tissue damage. Integrins on the surfaces of pneumocytes, endothelial cells and platelets may be vulnerable to CoV-2 virion binding. For instance, binding of intact virions to integrins on alveolar cells could enhance viral entry. Binding of virions to integrins on endothelial cells could activate angiogenic cell signaling pathways; dysregulate integrin-mediated signaling pathways controlling developmental processes; and precipitate endothelial activation to initiate blood clotting. Such a procoagulant state, perhaps together with enhancement of platelet aggregation through virions binding to integrins on platelets, could amplify the production of microthrombi that pose the threat of pulmonary thrombosis and embolism, strokes and other thrombotic consequences. The susceptibility of different tissues to virion–integrin interactions may be modulated by a host of factors, including the conformation of relevant integrins and the impact of the tissue microenvironment on spike protein conformation. Patient-specific differences in these factors may contribute to the high variability of clinical presentation. There is danger that the emergence of receptor-binding domain mutations that increase infectivity may also enhance access of the RGD motif for integrin binding, resulting in viral strains with ACE2 independent routes of cell entry and novel integrin-mediated biological and clinical impacts. The highly infectious variant, B.1.1.7 (or VUI 202012/01), includes a receptor-binding domain amino acid replacement, N501Y, that could potentially provide the RGD motif with enhanced access to cell-surface integrins, with consequent clinical impacts.
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119
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Cañas CA, Cañas F, Bautista-Vargas M, Bonilla-Abadía F. Role of Tissue Factor in the Pathogenesis of COVID-19 and the Possible Ways to Inhibit It. Clin Appl Thromb Hemost 2021; 27:10760296211003983. [PMID: 33784877 PMCID: PMC8020089 DOI: 10.1177/10760296211003983] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023] Open
Abstract
COVID-19 (Coronavirus Disease 2019) is a highly contagious infection and associated with high mortality rates, primarily in elderly; patients with heart failure; high blood pressure; diabetes mellitus; and those who are smokers. These conditions are associated to increase in the level of the pulmonary epithelium expression of angiotensin-converting enzyme 2 (ACE-2), which is a recognized receptor of the S protein of the causative agent SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2). Severe cases are manifested by parenchymal lung involvement with a significant inflammatory response and the development of microvascular thrombosis. Several factors have been involved in developing this prothrombotic state, including the inflammatory reaction itself with the participation of proinflammatory cytokines, endothelial dysfunction/endotheliitis, the presence of antiphospholipid antibodies, and possibly the tissue factor (TF) overexpression. ARS-Cov-19 ACE-2 down-regulation has been associated with an increase in angiotensin 2 (AT2). The action of proinflammatory cytokines, the increase in AT2 and the presence of antiphospholipid antibodies are known factors for TF activation and overexpression. It is very likely that the overexpression of TF in COVID-19 may be related to the pathogenesis of the disease, hence the importance of knowing the aspects related to this protein and the therapeutic strategies that can be derived. Different therapeutic strategies are being built to curb the expression of TF as a therapeutic target for various prothrombotic events; therefore, analyzing this treatment strategy for COVID-19-associated coagulopathy is rational. Medications such as celecoxib, cyclosporine or colchicine can impact on COVID-19, in addition to its anti-inflammatory effect, through inhibition of TF.
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Affiliation(s)
- Carlos A. Cañas
- Unit of Rheumatology, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Felipe Cañas
- Unit of Cardiology, Clínica Medellín, Medellín, Colombia
| | | | - Fabio Bonilla-Abadía
- Unit of Rheumatology, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
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Chen Y, Klein SL, Garibaldi BT, Li H, Wu C, Osevala NM, Li T, Margolick JB, Pawelec G, Leng SX. Aging in COVID-19: Vulnerability, immunity and intervention. Ageing Res Rev 2021; 65:101205. [PMID: 33137510 PMCID: PMC7604159 DOI: 10.1016/j.arr.2020.101205] [Citation(s) in RCA: 508] [Impact Index Per Article: 169.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/20/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023]
Abstract
The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic was first reported in Wuhan, China in December 2019, moved across the globe at an unprecedented speed, and is having a profound and yet still unfolding health and socioeconomic impacts. SARS-CoV-2, a β-coronavirus, is a highly contagious respiratory pathogen that causes a disease that has been termed the 2019 coronavirus disease (COVID-19). Clinical experience thus far indicates that COVID-19 is highly heterogeneous, ranging from being asymptomatic and mild to severe and causing death. Host factors including age, sex, and comorbid conditions are key determinants of disease severity and progression. Aging itself is a prominent risk factor for severe disease and death from COVID-19. We hypothesize that age-related decline and dysregulation of immune function, i.e., immunosenescence and inflammaging play a major role in contributing to heightened vulnerability to severe COVID-19 outcomes in older adults. Much remains to be learned about the immune responses to SARS-CoV-2 infection. We need to begin partitioning all immunological outcome data by age to better understand disease heterogeneity and aging. Such knowledge is critical not only for understanding of COVID-19 pathogenesis but also for COVID-19 vaccine development.
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Affiliation(s)
- Yiyin Chen
- Guangdong Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Brian T Garibaldi
- Division of Pulmonary and Critical Care Medicine and Johns Hopkins Biocontainment Unit, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Huifen Li
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Cunjin Wu
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Geriatrics, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Nicole M Osevala
- Division of Geriatrics, Department of Medicine, Pennsylvania State University School of Medicine, Hershey, PA, United States
| | - Taisheng Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Joseph B Margolick
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Graham Pawelec
- Department of Immunology, University of Tübingen, Tübingen, Germany; Health Sciences North Research Institute, Sudbury, ON, Canada
| | - Sean X Leng
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States; Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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121
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von Meijenfeldt FA, Havervall S, Adelmeijer J, Lundström A, Rudberg A, Magnusson M, Mackman N, Thalin C, Lisman T. Prothrombotic changes in patients with COVID-19 are associated with disease severity and mortality. Res Pract Thromb Haemost 2021; 5:132-141. [PMID: 33537537 PMCID: PMC7845083 DOI: 10.1002/rth2.12462] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Patients with severe coronavirus disease 2019 (COVID-19) are at significant risk of thrombotic complications. However, their prothrombotic state is incompletely understood. Therefore, we measured in vivo activation markers of hemostasis, plasma levels of hemostatic proteins, and functional assays of coagulation and fibrinolysis in plasma from patients with COVID-19 and determined their association with disease severity and 30-day mortality. METHODS We included 102 patients with COVID-19 receiving various levels of respiratory support admitted to general wards, intermediate units, or intensive care units and collected plasma samples shortly after hospital admission. RESULTS Patients with COVID-19 with higher respiratory support had increased in vivo activation of coagulation and fibrinolysis, as reflected by higher plasma levels of d-dimer, thrombin-antithrombin, and plasmin-antiplasmin complexes as compared to patients with no to minimal respiratory support and healthy controls. Moreover, the patients with COVID-19 with higher respiratory support exhibited substantial ex vivo thrombin generation and lower ex vivo fibrinolytic capacity, despite higher doses of anticoagulant therapy compared to less severely ill patients. Fibrinogen, factor VIII, and von Willebrand factor levels increased, and ADAMTS13 levels decreased with increasing respiratory support in patients with COVID-19. Low platelet count; low levels of prothrombin, antithrombin, and ADAMTS13; and high levels of von Willebrand factor were associated with short-term mortality. CONCLUSIONS Severe COVID-19 is associated with prothrombotic changes with increased in vivo activation of coagulation and fibrinolysis, despite anticoagulant therapy.
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Affiliation(s)
- Fien A. von Meijenfeldt
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Sebastian Havervall
- Division of Internal MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyd HospitalStockholmSweden
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Annika Lundström
- Division of Internal MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyd HospitalStockholmSweden
| | - Ann‐Sofie Rudberg
- Department of NeurologyDanderyd HospitalStockholmSweden
- Department of Clinical NeurosciencesKarolinska InstitutetStockholmSweden
| | - Maria Magnusson
- Clinical Chemistry and Blood Coagulation ResearchMMKDepartment of PediatricsDepartment of HematologyCLINTECKarolinska InstitutetKarolinska University HospitalStockholmSweden
| | - Nigel Mackman
- UNC Blood Research CenterDivision of HematologyDepartment of MedicineUniversity of North Carolina at Chapel HillNCUSA
| | - Charlotte Thalin
- Division of Internal MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyd HospitalStockholmSweden
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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122
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Birocchi S, Manzoni M, Podda GM, Casazza G, Cattaneo M. High rates of pulmonary artery occlusions in COVID-19. A meta-analysis. Eur J Clin Invest 2021; 51:e13433. [PMID: 33053206 PMCID: PMC7646003 DOI: 10.1111/eci.13433] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND COVID-19 patients are considered at high risk of venous thromboembolism (VTE). The real nature of pulmonary artery occlusions (PAO) in COVID-19 has been questioned, suggesting that it is caused also by in situ thrombi, rather than only by emboli (PE) from peripheral thrombi. METHODS We searched MEDLINE for studies published until 6 June 2020 that included COVID-19 patients or non-COVID-19 medical patients at VTE risk, treated with heparins, in whom VTE (PE and deep vein thrombosis, DVT) had been reported. Systematic review and results reporting were conducted in accordance with PRISMA guidelines. Data were independently extracted by two observers, and estimates were pooled using random-effects meta-analysis. RESULTS We identified 17 studies including 3224 COVID-19 patients and 7 including 11 985 non-COVID-19 patients. Two analyses were performed: in all COVID-19 patients and only in those (n = 515) who, like non-COVID-19 patients, were screened systematically for DVT. The latter analysis revealed that the prevalence of DVT was 15.43% (95%CI, 4.08-31.77) in COVID-19 and 4.21% (2.27-6.68) in non-COVID-19 patients (P = .0482). The prevalence of PE was 4.85% (40.33-13.01) in COVID-19 patients and 0.22% (0.03-0.55) in non-COVID-19 patients (P = .0128). The percentage of PE among VTE events was 22.15% (5.31-44.60) in COVID-19 and 6.39% (3.17-10.41) in non-COVID-19 patients (P = .0482). Differences were even more marked when all COVID-19 patients were analysed. CONCLUSIONS The results of our meta-analysis highlight a disproportion in the prevalence of PE among all VTE events in COVID 19 patients, likely reflecting PAO by pulmonary thrombi, rather than emboli from peripheral vein thrombi.
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Affiliation(s)
- Simone Birocchi
- Unità di Medicina II, ASST Santi Paolo e Carlo - Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
| | - Marco Manzoni
- Unità di Medicina II, ASST Santi Paolo e Carlo - Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
| | - Gian Marco Podda
- Unità di Medicina II, ASST Santi Paolo e Carlo - Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche L. Sacco, Università degli Studi di Milano, Milano, Italy
| | - Marco Cattaneo
- Unità di Medicina II, ASST Santi Paolo e Carlo - Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
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123
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Bouck EG, Denorme F, Holle LA, Middelton EA, Blair A, de Laat B, Schiffman JD, Yost CC, Rondina MT, Wolberg AS, Campbell RA. COVID-19 and Sepsis Are Associated With Different Abnormalities in Plasma Procoagulant and Fibrinolytic Activity. Arterioscler Thromb Vasc Biol 2021; 41:401-414. [PMID: 33196292 PMCID: PMC7942774 DOI: 10.1161/atvbaha.120.315338] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Coronavirus disease 2019 (COVID-19) is associated with derangement in biomarkers of coagulation and endothelial function and has been likened to the coagulopathy of sepsis. However, clinical laboratory metrics suggest key differences in these pathologies. We sought to determine whether plasma coagulation and fibrinolytic potential in patients with COVID-19 differ compared with healthy donors and critically ill patients with sepsis. Approach and Results: We performed comparative studies on plasmas from a single-center, cross-sectional observational study of 99 hospitalized patients (46 with COVID-19 and 53 with sepsis) and 18 healthy donors. We measured biomarkers of endogenous coagulation and fibrinolytic activity by immunoassays, thrombin, and plasmin generation potential by fluorescence and fibrin formation and lysis by turbidity. Compared with healthy donors, patients with COVID-19 or sepsis both had elevated fibrinogen, d-dimer, soluble TM (thrombomodulin), and plasmin-antiplasmin complexes. Patients with COVID-19 had increased thrombin generation potential despite prophylactic anticoagulation, whereas patients with sepsis did not. Plasma from patients with COVID-19 also had increased endogenous plasmin potential, whereas patients with sepsis showed delayed plasmin generation. The collective perturbations in plasma thrombin and plasmin generation permitted enhanced fibrin formation in both COVID-19 and sepsis. Unexpectedly, the lag times to thrombin, plasmin, and fibrin formation were prolonged with increased disease severity in COVID-19, suggesting a loss of coagulation-initiating mechanisms accompanies severe COVID-19. CONCLUSIONS Both COVID-19 and sepsis are associated with endogenous activation of coagulation and fibrinolysis, but these diseases differently impact plasma procoagulant and fibrinolytic potential. Dysregulation of procoagulant and fibrinolytic pathways may uniquely contribute to the pathophysiology of COVID-19 and sepsis.
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Affiliation(s)
- Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Frederik Denorme
- University of Utah Molecular Medicine Program, Salt Lake City, Utah
| | - Lori A. Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Antoinette Blair
- University of Utah Molecular Medicine Program, Salt Lake City, Utah
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Joshua D. Schiffman
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84112,PEEL Therapeutics, Inc., Salt Lake City, UT 84112
| | | | - Matthew T. Rondina
- University of Utah Molecular Medicine Program, Salt Lake City, Utah,Department of Internal Medicine & Pathology, University of Utah, Salt Lake City, Utah,George E. Wahlen VAMC Department of Internal Medicine and GRECC, Salt Lake City, Utah, 84148
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Robert A. Campbell
- University of Utah Molecular Medicine Program, Salt Lake City, Utah,Department of Internal Medicine & Pathology, University of Utah, Salt Lake City, Utah
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Burlacu A, Crisan-Dabija R, Popa IV, Covic A. The Second Wave of COVID-19 Pandemic Strikes during the Flu Season: An Awareness Perspective. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E707. [PMID: 33352889 PMCID: PMC7766640 DOI: 10.3390/medicina56120707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/02/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022]
Abstract
Coinfection with both SARS-CoV-2 and influenza viruses seems to be a real and severe problem. However, coinfection is far from a simple matter, and cannot be considered having more unfavorable outcomes as a direct consequence. In reality, the aftermath is powerfully nuanced by the presence of risk factors and specific molecular mechanisms. Our objective was to raise awareness around the unpredictable association between COVID-19 pandemics and the upcoming flu season, and make arguments about the need to develop new routine testing protocols for both viruses, at least during the period with an expected high incidence. Our reasoning is built around the various impacts that the whole range of risk groups, common immunological mechanisms, and complex interactions, such as influenza vaccination, will have on patients' prognosis. We show that the more flawed clinical course is due to managing only one of the infections (and, subsequently, neglecting the other condition).
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Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology—Cardiovascular Diseases Institute, 700503 Iasi, Romania;
- Department of Internal Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania; (R.C.-D.); (A.C.)
| | - Radu Crisan-Dabija
- Department of Internal Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania; (R.C.-D.); (A.C.)
- Pulmonology Department, Clinic of Pulmonary Diseases, 700115 Iasi, Romania
| | - Iolanda Valentina Popa
- Department of Internal Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania; (R.C.-D.); (A.C.)
| | - Adrian Covic
- Department of Internal Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania; (R.C.-D.); (A.C.)
- Nephrology Clinic, Dialysis, and Renal Transplant Center—‘C.I. Parhon’ University Hospital, 700503 Iasi, Romania
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125
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Affiliation(s)
- Pamela K Woodard
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
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126
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Zakeri A, Jadhav AP, Sullenger BA, Nimjee SM. Ischemic stroke in COVID-19-positive patients: an overview of SARS-CoV-2 and thrombotic mechanisms for the neurointerventionalist. J Neurointerv Surg 2020; 13:202-206. [PMID: 33298508 DOI: 10.1136/neurintsurg-2020-016794] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/17/2020] [Accepted: 11/21/2020] [Indexed: 12/16/2022]
Abstract
Coronavirus disease 2019 (COVID-19) results from infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first reported in Wuhan, China in patients suffering from severe pneumonia and acute respiratory distress syndrome and has now grown into the first pandemic in over 100 years. Patients infected with SARS-CoV-2 develop arterial thrombosis including stroke, myocardial infarction and peripheral arterial thrombosis, all of which result in poor outcomes despite maximal medical, endovascular, and microsurgical treatment compared with non-COVID-19-infected patients. In this review we provide a brief overview of SARS-CoV-2, the infectious agent responsible for the COVID-19 pandemic, and describe the mechanisms responsible for COVID-19-associated coagulopathy. Finally, we discuss the impact of COVID-19 on ischemic stroke, focusing on large vessel occlusion.
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Affiliation(s)
- Amanda Zakeri
- Neurosurgery, The Ohio State University Medical Center, Columbus, Ohio, USA
| | | | - Bruce A Sullenger
- Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Shahid M Nimjee
- Neurosurgery, The Ohio State University Medical Center, Columbus, Ohio, USA
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127
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Alonso MN, Mata-Forte T, García-León N, Vullo PA, Ramirez-Olivencia G, Estébanez M, Álvarez-Marcos F. Incidence, Characteristics, Laboratory Findings and Outcomes in Acro-Ischemia in COVID-19 Patients. Vasc Health Risk Manag 2020; 16:467-478. [PMID: 33262599 PMCID: PMC7699992 DOI: 10.2147/vhrm.s276530] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/05/2020] [Indexed: 12/15/2022] Open
Abstract
Aim In addition to its respiratory impact of SARS-CoV2, skin lesions of probable vascular origin have been described. This study intends to quantify the incidence of acro-ischemic lesions in COVID-19 infected adult subjects in our population, describing clinical patterns and associated findings. Methods All adult confirmed cases of COVID-19 infection who presented with acro-ischemic lesions and received care in our institution were prospectively enrolled up to May 15th, 2020. The variables included demographics, comorbidities, analytical parameters, clinical presentations and COVID-19 treatment. Results We enrolled 24 patients. The overall rate of acro-ischemic findings in COVID-19 patients was 1.2% [0.6% for outpatients and 2.9% for hospitalized (ICU and non-ICU patients)], but the observed incidence for acro-ischemia in ICU patients was remarkably higher (23.0%, p<0.001). We have described four different clinical patterns of acroischemia: atypical Raynaud´s phenomenon (ARP), (4); pseudo-pernio (PP), (5); severe microcirculatory ischemia with preserved pulse (SMI), (6); and dry gangrene with arteriosclerosis obliterans (AO), (9). Kendall´s τ correlation with lung disease severity was 0.877 (95% CI, 0.756 to 0.968); p<0.01). ARP individuals were predominantly female, while SMI appeared lately in elderly hospitalized subjects with better prognosis. AO occurred in patients with more comorbidity and younger than those with SMI. We observed other associated lesions of suggestive ischemic nature in other organs in all groups (15 patients of total sample). Plasma procalcitonin was significantly higher in patients who developed SMI (median and interquartile range: 9.99 (4.2, 12.3) mg/mL vs 0.26 (0.11, 0.89) mg/mL; p<0.001), and D-dimer level at hospital admission was significantly higher in AO patients (median and interquartile range: 1166 (1050, 2111) mg/L vs 502 (448, 777) mg/L; p<0.001). Conclusion The observed risk for acroischemia in COVID-19 is high in ICU patients (23%). We have described four different clinical patterns of acroischemia (ARP, PP, SMI and AO) associated with lung disease severity. Authors have communicated various lesions of suggestive ischemic nature in other organs. Raynaud-like pattern is reported as a "novelty".
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Affiliation(s)
- María Noelia Alonso
- Vascular Surgery Department, Central Defense Gómez Ulla Hospital, Madrid, Spain.,Thrombosis and Anticoagulation Committee, Central Defense Gómez Ulla Hospital, Madrid, Spain
| | - Tatiana Mata-Forte
- Infectious Diseases Department, Central Defense Gómez Ulla Hospital, Madrid, Spain
| | - Natalia García-León
- Thrombosis and Anticoagulation Committee, Central Defense Gómez Ulla Hospital, Madrid, Spain.,Hematology Department, Central Defense Gómez Ulla Hospital, Madrid, Spain
| | - Paula Agostina Vullo
- Thrombosis and Anticoagulation Committee, Central Defense Gómez Ulla Hospital, Madrid, Spain.,Anesthesiology Department, Central Defense Gómez Ulla Hospital, Madrid, Spain
| | | | - Miriam Estébanez
- Infectious Diseases Department, Central Defense Gómez Ulla Hospital, Madrid, Spain
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128
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Sweeney JM, Barouqa M, Krause GJ, Gonzalez-Lugo JD, Rahman S, Gil MR. Evidence for secondary thrombotic microangiopathy in COVID-19. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.10.20.20215608. [PMID: 33106812 PMCID: PMC7587832 DOI: 10.1101/2020.10.20.20215608] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The causes of coagulopathy associated with COVID-19 disease are poorly understood. We aimed to investigate the relationship between markers of endothelial activation, intravascular hemolysis, coagulation, and organ damage in COVID-19 patients and study their association with disease severity and mortality. We conducted a retrospective study of 181 hospitalized COVID-19 patients randomly selected with equal distribution of survivors and non-survivors. Patients who died had significantly lower ADAMTS13 activity, significantly higher LDH, schistocytes and von Willebrand Factor levels compared to patients discharged alive. Only 30% of patients with an initial ADAMTS13 activity <43% survived vs. 60% with ADAMTS13 ≥43% who survived. In conclusion, COVID-19 may manifest as a TMA-like illness in a subset of hospitalized patients. Presence of schistocytes on admission may warrant a work-up for TMA. These findings indicate the need for future investigation to study the relationship between endothelial and coagulation activation and the efficacy of TMA treatments in COVID-19.
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Affiliation(s)
- Joseph M. Sweeney
- Department Physiology and Biophysics. Albert Einstein College of Medicine, Bronx, NY
| | - Mohammad Barouqa
- Department of Pathology Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Gregory J. Krause
- Department of Developmental and Molecular Biology. Albert Einstein College of Medicine, Bronx, NY
- Institute of Aging Studies. Albert Einstein College of Medicine, Bronx, NY
| | - Jesus D. Gonzalez-Lugo
- Division of Hematology, Department of Medical Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Shafia Rahman
- Division of Hematology, Department of Medical Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Morayma Reyes Gil
- Department of Pathology Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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129
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Borghi MO, Beltagy A, Garrafa E, Curreli D, Cecchini G, Bodio C, Grossi C, Blengino S, Tincani A, Franceschini F, Andreoli L, Lazzaroni MG, Piantoni S, Masneri S, Crisafulli F, Brugnoni D, Muiesan ML, Salvetti M, Parati G, Torresani E, Mahler M, Heilbron F, Pregnolato F, Pengo M, Tedesco F, Pozzi N, Meroni PL. Anti-Phospholipid Antibodies in COVID-19 Are Different From Those Detectable in the Anti-Phospholipid Syndrome. Front Immunol 2020; 11:584241. [PMID: 33178218 PMCID: PMC7593765 DOI: 10.3389/fimmu.2020.584241] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/25/2020] [Indexed: 12/14/2022] Open
Abstract
Background Critically ill patients with coronavirus disease 2019 (COVID-19) have a profound hypercoagulable state and often develop coagulopathy which leads to organ failure and death. Because of a prolonged activated partial-thromboplastin time (aPTT), a relationship with anti-phospholipid antibodies (aPLs) has been proposed, but results are controversial. Functional assays for aPL (i.e., lupus anticoagulant) can be influenced by concomitant anticoagulation and/or high levels of C reactive protein. The presence of anti-cardiolipin (aCL), anti-beta2-glycoprotein I (anti-β2GPI), and anti-phosphatidylserine/prothrombin (aPS/PT) antibodies was not investigated systematically. Epitope specificity of anti-β2GPI antibodies was not reported. Objective To evaluate the prevalence and the clinical association of aPL in a large cohort of COVID-19 patients, and to characterize the epitope specificity of anti-β2GPI antibodies. Methods ELISA and chemiluminescence assays were used to test 122 sera of patients suffering from severe COVID-19. Of them, 16 displayed major thrombotic events. Results Anti-β2GPI IgG/IgA/IgM was the most frequent in 15.6/6.6/9.0% of patients, while aCL IgG/IgM was detected in 5.7/6.6% by ELISA. Comparable values were found by chemiluminescence. aPS/PT IgG/IgM were detectable in 2.5 and 9.8% by ELISA. No association between thrombosis and aPL was found. Reactivity against domain 1 and 4-5 of β2GPI was limited to 3/58 (5.2%) tested sera for each domain and did not correlate with aCL/anti-β2GPI nor with thrombosis. Conclusions aPL show a low prevalence in COVID-19 patients and are not associated with major thrombotic events. aPL in COVID-19 patients are mainly directed against β2GPI but display an epitope specificity different from antibodies in antiphospholipid syndrome.
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Affiliation(s)
- Maria Orietta Borghi
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Asmaa Beltagy
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Rheumatology and Clinical Immunology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Emirena Garrafa
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
- Department of Laboratory Diagnostics, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili, Brescia, Italy
| | - Daniele Curreli
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Germana Cecchini
- Department of Chemical Chemistry, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Caterina Bodio
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Claudia Grossi
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Simonetta Blengino
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), San Luca Hospital, Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili and University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili and University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili and University of Brescia, Brescia, Italy
| | - Maria Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili and University of Brescia, Brescia, Italy
| | - Silvia Piantoni
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili and University of Brescia, Brescia, Italy
| | - Stefania Masneri
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili and University of Brescia, Brescia, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili and University of Brescia, Brescia, Italy
| | - Duilio Brugnoni
- Department of Laboratory Diagnostics, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili, Brescia, Italy
| | - Maria Lorenza Muiesan
- Unità Operativa Complessa (UOC) 2° Medicina, Department of Clinical and Experimental Sciences, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili and University of Brescia, Brescia, Italy
| | - Massimo Salvetti
- Unità Operativa Complessa (UOC) 2° Medicina, Department of Clinical and Experimental Sciences, Azienda Socio-Sanitaria Territoriale (ASST) Spedali Civili and University of Brescia, Brescia, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), San Luca Hospital, Milan, Italy
| | - Erminio Torresani
- Department of Chemical Chemistry, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Michael Mahler
- Research and Development, Inova Diagnostics, Inc., San Diego, CA, United States
| | - Francesca Heilbron
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), San Luca Hospital, Milan, Italy
| | - Francesca Pregnolato
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Martino Pengo
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), San Luca Hospital, Milan, Italy
| | - Francesco Tedesco
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Nicola Pozzi
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Istituto di Ricovero Cura a Carattere Scientifico (IRCCS), Milan, Italy
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130
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Lumpuy-Castillo J, Lorenzo-Almorós A, Pello-Lázaro AM, Sánchez-Ferrer C, Egido J, Tuñón J, Peiró C, Lorenzo Ó. Cardiovascular Damage in COVID-19: Therapeutic Approaches Targeting the Renin-Angiotensin-Aldosterone System. Int J Mol Sci 2020; 21:E6471. [PMID: 32899833 PMCID: PMC7555368 DOI: 10.3390/ijms21186471] [Citation(s) in RCA: 16] [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: 08/02/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is usually more severe and associated with worst outcomes in individuals with pre-existing cardiovascular pathologies, including hypertension or atherothrombosis. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) can differentially infect multiple tissues (i.e., lung, vessel, heart, liver) in different stages of disease, and in an age- and sex-dependent manner. In particular, cardiovascular (CV) cells (e.g., endothelial cells, cardiomyocytes) could be directly infected and indirectly disturbed by systemic alterations, leading to hyperinflammatory, apoptotic, thrombotic, and vasoconstrictive responses. Until now, hundreds of clinical trials are testing antivirals and immunomodulators to decrease SARS-CoV-2 infection or related systemic anomalies. However, new therapies targeting the CV system might reduce the severity and lethality of disease. In this line, activation of the non-canonical pathway of the renin-angiotensin-aldosterone system (RAAS) could improve CV homeostasis under COVID-19. In particular, treatments with angiotensin-converting enzyme inhibitors (ACEi) and angiotensin-receptor blockers (ARB) may help to reduce hyperinflammation and viral propagation, while infusion of soluble ACE2 may trap plasma viral particles and increase cardioprotective Ang-(1-9) and Ang-(1-7) peptides. The association of specific ACE2 polymorphisms with increased susceptibility of infection and related CV pathologies suggests potential genetic therapies. Moreover, specific agonists of Ang-(1-7) receptor could counter-regulate the hypertensive, hyperinflammatory, and hypercoagulable responses. Interestingly, sex hormones could also regulate all these RAAS components. Therefore, while waiting for an efficient vaccine, we suggest further investigations on the non-canonical RAAS pathway to reduce cardiovascular damage and mortality in COVID-19 patients.
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Affiliation(s)
- Jairo Lumpuy-Castillo
- Laboratory of Diabetes and Vascular pathology. Instituto de Investigaciones Sanitarias-Hospital Fundación Jiménez Díaz. Universidad Autónoma, 28040 Madrid, Spain; (J.L.-C.); (J.E.); (J.T.)
| | - Ana Lorenzo-Almorós
- Department of Internal Medicine. Hospital Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | | | - Carlos Sánchez-Ferrer
- Department of Pharmacology, School of Medicine, Universidad Autónoma de Madrid, 28049 Madrid, Spain; (C.S.-F.); (C.P.)
| | - Jesús Egido
- Laboratory of Diabetes and Vascular pathology. Instituto de Investigaciones Sanitarias-Hospital Fundación Jiménez Díaz. Universidad Autónoma, 28040 Madrid, Spain; (J.L.-C.); (J.E.); (J.T.)
- Spanish Biomedical Research Centre on Diabetes and Associated Metabolic Disorders (CIBERDEM) Network, 28029 Madrid, Spain
| | - José Tuñón
- Laboratory of Diabetes and Vascular pathology. Instituto de Investigaciones Sanitarias-Hospital Fundación Jiménez Díaz. Universidad Autónoma, 28040 Madrid, Spain; (J.L.-C.); (J.E.); (J.T.)
- Department of Cardiology. Hospital Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Concepción Peiró
- Department of Pharmacology, School of Medicine, Universidad Autónoma de Madrid, 28049 Madrid, Spain; (C.S.-F.); (C.P.)
| | - Óscar Lorenzo
- Laboratory of Diabetes and Vascular pathology. Instituto de Investigaciones Sanitarias-Hospital Fundación Jiménez Díaz. Universidad Autónoma, 28040 Madrid, Spain; (J.L.-C.); (J.E.); (J.T.)
- Spanish Biomedical Research Centre on Diabetes and Associated Metabolic Disorders (CIBERDEM) Network, 28029 Madrid, Spain
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131
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Siegal DM, Gross PL. Narrowing in on the True Rate of Venous Thromboembolism in Hospitalized Patients With COVID-19 Disease. Arterioscler Thromb Vasc Biol 2020; 40:1958-1960. [PMID: 32762455 PMCID: PMC7447057 DOI: 10.1161/atvbaha.120.314977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Deborah M Siegal
- From the Department of Medicine, McMaster University, Hamilton, Ontario, Canada; and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Peter L Gross
- From the Department of Medicine, McMaster University, Hamilton, Ontario, Canada; and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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