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Maiuolo J, Mollace R, Gliozzi M, Musolino V, Carresi C, Paone S, Scicchitano M, Macrì R, Nucera S, Bosco F, Scarano F, Zito MC, Ruga S, Tavernese A, Mollace V. The Contribution of Endothelial Dysfunction in Systemic Injury Subsequent to SARS-Cov-2 Infection. Int J Mol Sci 2020; 21:E9309. [PMID: 33291346 PMCID: PMC7730352 DOI: 10.3390/ijms21239309] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/28/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection is associated, alongside with lung infection and respiratory disease, to cardiovascular dysfunction that occurs at any stage of the disease. This includes ischemic heart disease, arrhythmias, and cardiomyopathies. The common pathophysiological link between SARS-CoV-2 infection and the cardiovascular events is represented by coagulation abnormalities and disruption of factors released by endothelial cells, which contribute in maintaining the blood vessels into an anti-thrombotic state. Thus, early alteration of the functionality of endothelial cells, which may be found soon after SARS-CoV-2 infection, seems to represent the major target of a SARS CoV-2 disease state and accounts for the systemic vascular dysfunction that leads to a detrimental effect in terms of hospitalization and death accompanying the disease. In particular, the molecular interaction of SARS-CoV-2 with the ACE2 receptor located in the endothelial cell surface, either at the pulmonary and systemic level, leads to early impairment of endothelial function, which, in turn, is followed by vascular inflammation and thrombosis of peripheral blood vessels. This highlights systemic hypoxia and further aggravates the vicious circle that compromises the development of the disease, leading to irreversible tissue damage and death of people with SARS CoV-2 infection. The review aims to assess some recent advances to define the crucial role of endothelial dysfunction in the pathogenesis of vascular complications accompanying SARS-CoV-2 infection. In particular, the molecular mechanisms associated with the interaction of SARS CoV-2 with the ACE2 receptor located on the endothelial cells are highlighted to support its role in compromising endothelial cell functionality. Finally, the consequences of endothelial dysfunction in enhancing pro-inflammatory and pro-thrombotic effects of SARS-CoV-2 infection are assessed in order to identify early therapeutic interventions able to reduce the impact of the disease in high-risk patients.
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Affiliation(s)
- Jessica Maiuolo
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
| | - Rocco Mollace
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Department of Medicine, Chair of Cardiology, University of Rome Tor Vergata, 00133 Roma, Italy
| | - Micaela Gliozzi
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
| | - Vincenzo Musolino
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
| | - Cristina Carresi
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
| | - Sara Paone
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
| | - Miriam Scicchitano
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
| | - Roberta Macrì
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
| | - Saverio Nucera
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
| | - Francesca Bosco
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
| | - Federica Scarano
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
| | - Maria Caterina Zito
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
| | - Stefano Ruga
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
| | - Annamaria Tavernese
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Department of Medicine, Chair of Cardiology, University of Rome Tor Vergata, 00133 Roma, Italy
| | - Vincenzo Mollace
- Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (J.M.); (R.M.); (M.G.); (V.M.); (C.C.); (S.P.); (M.S.); (R.M.); (S.N.); (F.B.); (F.S.); (M.C.Z.); (S.R.); (A.T.)
- Nutramed S.c.a.r.l., Complesso Ninì Barbieri, Roccelletta di Borgia, 88021 Catanzaro, Italy
- IRCCS San Raffaele Pisana, 00163 Roma, Italy
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202
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Abstract
Coronavirus infection (COVID-19) is an acute viral disease, which affects all vital organs and is caused by an RNA-genomic virus of the genus Betacoronavirus of the family Coronaviridae. This virus (SARS-CoV-2) enters the body through the respiratory tract and interacts primarily with Toll-like receptors of epithelial cells of the bronchi, alveoli, intestines and vascular endotheliocytes, as well as with angiotensin-converting enzyme 2 receptors. Toll-like receptors activate nuclear factor Kappa B in these cells, which initiates the formation of many cytokines (“cytokine storm”). SARS-CoV-2 affects type II pneumocytes by causing a termination of surfactant formation and, accordingly, alveolar shrinking and the formation of acute respiratory distress syndrome and also fibrosis on the interalveolar-capillary membrane and the formation of acute respiratory failure. SARS-CoV-2 and cytokines disrupt the function of vascular endothelial cells, which leads to endothelial dysfunction. In microvessels forms a mass formation of microthrombi, which causes the failure of organs and systems. “Cytokine storm” turns into cytokine sepsis with the formation of multiple organ dysfunction syndrome.
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Affiliation(s)
- S. B. Bolevich
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S. S. Bolevich
- Sechenov First Moscow State Medical University (Sechenov University)
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203
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Zuo Y, Warnock M, Harbaugh A, Yalavarthi S, Gockman K, Zuo M, Madison JA, Knight JS, Kanthi Y, Lawrence DA. Plasma tissue plasminogen activator and plasminogen activator inhibitor-1 in hospitalized COVID-19 patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32909005 DOI: 10.1101/2020.08.29.20184358] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with coronavirus disease-19 ( COVID-19 ) are at high risk for thrombotic arterial and venous occlusions. However, bleeding complications have also been observed in some patients. Understanding the balance between coagulation and fibrinolysis will help inform optimal approaches to thrombosis prophylaxis and potential utility of fibrinolytic-targeted therapies. 118 hospitalized COVID-19 patients and 30 healthy controls were included in the study. We measured plasma antigen levels of tissue-type plasminogen activator (tPA ) and plasminogen activator inhibitor-1 ( PAI-1 ) and performed spontaneous clot-lysis assays. We found markedly elevated tPA and PAI-1 levels in patients hospitalized with COVID-19. Both factors demonstrated strong correlations with neutrophil counts and markers of neutrophil activation. High levels of tPA and PAI-1 were associated with worse respiratory status. High levels of tPA, in particular, were strongly correlated with mortality and a significant enhancement in spontaneous ex vivo clot-lysis. While both tPA and PAI-1 are elevated among COVID-19 patients, extremely high levels of tPA enhance spontaneous fibrinolysis and are significantly associated with mortality in some patients. These data indicate that fibrinolytic homeostasis in COVID-19 is complex with a subset of patients expressing a balance of factors that may favor fibrinolysis. Further study of tPA as a biomarker is warranted.
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204
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Moliterno AR, Kaizer H. Applied genomics in MPN presentation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:434-439. [PMID: 33275725 PMCID: PMC7727573 DOI: 10.1182/hematology.2020000128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Polycythemia vera, essential thrombocytosis (ET), and primary myelofibrosis (PMF) are grouped together as myeloproliferative neoplasms (MPNs) because of shared clinical, pathologic, and molecular features. The 2005 discovery of the driver mutation JAK2V617F, found in more than 70% of individuals with MPNs and 98% of those with PV, has transformed the diagnosis and management of MPNs. Although PV is the most common phenotype associated with JAK2V617F, roughly 60% of individuals with ET or PMF also have the mutation, and JAK2V617F is now recognized as a common lesion in clonal hematopoiesis (CH). JAK2V617F+ CH and MPN are indolent disorders that evolve over time, with transitions to different disease phases, transformation to bone marrow failure or leukemia, and high thrombosis rates. Genomic assessment has taken center stage as an important tool to define disease phenotype, disease burden, prognosis, and even thrombosis risk of MPNs. Genomics has also unveiled the causes and factors that modify the risk of acquiring and expanding CH and MPNs and points to new pathways for targeted therapies to treat and ultimately prevent them. Genomic assessment of patients with MPNs, like other cancers, enables the clinician to capitalize on large population data sets to inform the individual patient of risk, identify treatment, and improve outcomes.
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Affiliation(s)
| | - Hannah Kaizer
- Johns Hopkins University School of Medicine, Baltimore, MD
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205
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Del Castillo-García S, Minguito-Carazo C, Echarte JC, Rodríguez-Santamarta M, González TB, Terroba Seara S, Martìnez González L, Fernández-Vázquez F. A case report of arterial and venous thromboembolism in a patient with severe COVID-19 pneumonia. Eur Heart J Case Rep 2020; 4:1-6. [PMID: 33437918 PMCID: PMC7717195 DOI: 10.1093/ehjcr/ytaa350] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 04/27/2020] [Accepted: 09/04/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has spread rapidly worldwide since the outbreak originated in Wuhan, China in December 2019. Cardiovascular complications in patients with severe COVID-19 have been reported and are associated with a worse outcome. Coagulopathy is one of the most common life-threatening complication increasing mortality; however, little evidence is available regarding prevention strategies or its treatment in COVID-19 patients. CASE SUMMARY We report a case of a 70-year-old woman admitted to hospital with severe COVID-19 bilateral pneumonia who developed severe coagulopathy with multiple both, venous and arterial, embolisms in major vessels such as bilateral pulmonary embolism, acute thrombus in abdominal aorta, and acute thrombotic occlusion of the right iliac common artery. The patient underwent emergent surgical thrombectomy of the right lower limb; in spite of anticoagulant treatment at therapeutic doses, patient presented poor clinical evolution and an infracondylar amputation of right lower limb was made finally. Subsequently, the patient received low molecular weight heparin (LMWH), antibiotics and antiviral therapy improving her renal function and her pneumonia, so she could be discharged safely. DISCUSSION Prothrombotic coagulopathy due to enhanced acute inflammatory response and diffuse intravascular coagulation has been described in severe critical COVID-19 patients. This state of hypercoagulability is associated with organ dysfunction and mortality and may predispose to both, venous and arterial, thromboembolism. Little data are available regarding the best therapeutic and prevention strategies in this scenario, although thrombosis prophylaxis with LMWH has been associated with a better outcome.
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Affiliation(s)
| | - Carlos Minguito-Carazo
- Cardiology Department, University Hospital of Leon, Altos de Nava s/n, 24008 León, Spain
| | - Julio César Echarte
- Cardiology Department, University Hospital of Leon, Altos de Nava s/n, 24008 León, Spain
| | | | - Tomás Benito González
- Cardiology Department, University Hospital of Leon, Altos de Nava s/n, 24008 León, Spain
| | - Sandra Terroba Seara
- Internal Medicine Department, University Hospital of Leon, Altos de Nava s/n, 24008 León, Spain
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206
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Zuo Y, Estes SK, Ali RA, Gandhi AA, Yalavarthi S, Shi H, Sule G, Gockman K, Madison JA, Zuo M, Yadav V, Wang J, Woodard W, Lezak SP, Lugogo NL, Smith SA, Morrissey JH, Kanthi Y, Knight JS. Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19. Sci Transl Med 2020; 12:eabd3876. [PMID: 33139519 PMCID: PMC7724273 DOI: 10.1126/scitranslmed.abd3876] [Citation(s) in RCA: 410] [Impact Index Per Article: 102.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/14/2020] [Accepted: 10/30/2020] [Indexed: 01/08/2023]
Abstract
Patients with COVID-19 are at high risk for thrombotic arterial and venous occlusions. Lung histopathology often reveals fibrin-based blockages in the small blood vessels of patients who succumb to the disease. Antiphospholipid syndrome is an acquired and potentially life-threatening thrombophilia in which patients develop pathogenic autoantibodies targeting phospholipids and phospholipid-binding proteins (aPL antibodies). Case series have recently detected aPL antibodies in patients with COVID-19. Here, we measured eight types of aPL antibodies in serum samples from 172 patients hospitalized with COVID-19. These aPL antibodies included anticardiolipin IgG, IgM, and IgA; anti-β2 glycoprotein I IgG, IgM, and IgA; and anti-phosphatidylserine/prothrombin (aPS/PT) IgG and IgM. We detected aPS/PT IgG in 24% of serum samples, anticardiolipin IgM in 23% of samples, and aPS/PT IgM in 18% of samples. Antiphospholipid autoantibodies were present in 52% of serum samples using the manufacturer's threshold and in 30% using a more stringent cutoff (≥40 ELISA-specific units). Higher titers of aPL antibodies were associated with neutrophil hyperactivity, including the release of neutrophil extracellular traps (NETs), higher platelet counts, more severe respiratory disease, and lower clinical estimated glomerular filtration rate. Similar to IgG from patients with antiphospholipid syndrome, IgG fractions isolated from patients with COVID-19 promoted NET release from neutrophils isolated from healthy individuals. Furthermore, injection of IgG purified from COVID-19 patient serum into mice accelerated venous thrombosis in two mouse models. These findings suggest that half of patients hospitalized with COVID-19 become at least transiently positive for aPL antibodies and that these autoantibodies are potentially pathogenic.
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Affiliation(s)
- Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Shanea K Estes
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ramadan A Ali
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alex A Gandhi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Srilakshmi Yalavarthi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Hui Shi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Division of Rheumatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gautam Sule
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kelsey Gockman
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jacqueline A Madison
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Melanie Zuo
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Vinita Yadav
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jintao Wang
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD 20892, USA
| | - Wrenn Woodard
- Michigan Clinical Research Unit, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sean P Lezak
- Michigan Clinical Research Unit, University of Michigan, Ann Arbor, MI 48109, USA
| | - Njira L Lugogo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Stephanie A Smith
- Department of Biological Chemistry, University of Michigan, Ann Arbor, MI 48109, USA
| | - James H Morrissey
- Department of Biological Chemistry, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yogendra Kanthi
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD 20892, USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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207
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de Lorenzo Alvarez A, Revilla Á, Corbalán T, Villar A, Espinel L, Martins J, Cubas A. Ischemic stroke and purpuric dermatitis as COVID-19-related complications in a peritoneal dialysis patient. CEN Case Rep 2020; 10:250-254. [PMID: 33205335 PMCID: PMC7671569 DOI: 10.1007/s13730-020-00553-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/31/2020] [Indexed: 12/18/2022] Open
Abstract
Patients on dialysis may have an elevated risk of severe coronavirus disease 2019 (COVID-19) and its complications due to their high prevalence of comorbidities. Here we describe the case of an 80-year-old male undergoing peritoneal dialysis with a moderate SARS-CoV-2 infection who developed a purpuric dermatitis and ischemic stroke after successful recovery from his bilateral pneumonia. Erythemato-papular lesions affecting trunk and lower limbs appeared 17 days after the onset of SARS-CoV-2 symptoms. These kind of lesions are an infrequent cutaneous manifestation of COVID-19. The pathology revealed a moderate purpuric dermatitis affecting superficial dermis and corticoesteroids were prescribed achieving complete resolution. Arterial thrombosis affecting cerebellar vermis emerged 30 days after the onset of COVID-19 symptoms. It occurred 5 days after withdrawal of antithrombotic prophylaxis that the patient received from his admission until 2 weeks after discharge. He completely recovered from his paresis and continued on his regular antiaggregation therapy. This is the first case report published of a patient with PD with such COVID-19-related complications. More experience is needed to determine the appropriate length of antithrombotic prophylaxis especially in high-risk individuals.
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Affiliation(s)
- Alberto de Lorenzo Alvarez
- Department of Nephrology, Hospital Universitario de Getafe, Carr. Madrid-Toledo, Km 12,500, Getafe, 28905, Madrid, Spain.
| | | | - Teresa Corbalán
- Department of Radiology, Hospital Universitario de Getafe, Madrid, Spain
| | - Ana Villar
- Department of Pathology, Hospital Universitario de Getafe, Madrid, Spain
| | - Laura Espinel
- Department of Nephrology, Hospital Universitario de Getafe, Carr. Madrid-Toledo, Km 12,500, Getafe, 28905, Madrid, Spain
| | - Judith Martins
- Department of Nephrology, Hospital Universitario de Getafe, Carr. Madrid-Toledo, Km 12,500, Getafe, 28905, Madrid, Spain
| | - Alfonso Cubas
- Department of Nephrology, Hospital Universitario de Getafe, Carr. Madrid-Toledo, Km 12,500, Getafe, 28905, Madrid, Spain
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208
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Хрыщанович В. Prevention and Management of COVID-19-Associated Venous Thromboembolism. КАРДИОЛОГИЯ В БЕЛАРУСИ 2020. [DOI: 10.34883/pi.2020.12.4.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Распространение новой коронавирусной инфекции SARS-CoV-2, классифицируемой сейчас как COVID-19, приобрело глобальный характер. Врачи, занимающиеся лечением пациентов с COVID-19, ежедневно сталкиваются с новыми и неожиданными проблемами. Коронавирусная болезнь может быть причиной системной коагулопатии и тромботических осложнений. Недавние исследования подтвердили крайне высокую частоту встречаемости тромбоэмболических событий, в особенности в группе пациентов с тяжелым течением коронавирусной пневмонии. Сепсис-индуцированная активация коагуляционного каскада в сочетании с широкой распространенностью в общей популяции известных факторов риска венозной тромбоэмболии (ВТЭ) способствуют развитию в организме протромботического статуса. Аномальные параметры коагуляции связаны с плохим прогнозом для пациентов с COVID-19-пневмонией. Определенные гематологические биомаркеры, включая D-димер, могут выступать в качестве предикторов тромботических событий и неблагоприятных исходов заболевания. Вероятность развития тромботических осложнений следует определять у всех пациентов с COVID-19, которые входят в группу высокого риска ВТЭ и имели несколько неблагоприятных факторов до начала коронавирусной инфекции (более 8 баллов по шкале Caprini). В случаях развития сепсис-индуцированной коагулопатии антикоагулянтная терапия, по-видимому, связана с лучшим прогнозом в отношении смертности. Уровень D-димера может служить показателем эффективности антикоагулянтной терапии, однако такой подход не является общепринятым. В настоящем обзоре литературы обобщены накопленные на сегодняшний день эпидемиологические данные и текущие рекомендации по профилактике и лечению COVID-19-ассоциированной ВТЭ. Дальнейшие исследования должны быть сосредоточены на разработке оптимальных стратегий диагностики и профилактики COVID-19-ассоциированной ВТЭ и связанной с ней летальности
The disease caused by coronavirus SARS-CoV-2, named CoViD-19, has become a global emergency. Physicians that treat patients with COVID-19 face new and unexpected challenges every day. COVID-19 can lead to systemic coagulation activation and thrombotic complications. Recent studies confirmed very high cumulative incidence of thromboembolic events, particularly in critically illpatients with COVID-19 pneumonia. The sepsis-related activation of the coagulation combined with high prevalence of common thrombotic risk factors can contribute to this prothrombotic state. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. Coagulation biomarkers, including D-dimer, can help in the identification of patients with the risk of complications and mortality. D-dimers may be used to monitor the effectiveness of anticoagulants, although this practice is not universally accepted. Risk assessment in admission is important to identify high-risk patients with multiple risk factors before the onset of the viral infection (Caprini score >8). In case of sepsis-induced coagulopathy, anticoagulant therapy appears to be associated with better prognosis in relation to mortality. In this review, we summarize available epidemiological data on venous thromboembolism and recommendations on thromboprophylaxis in COVID-19. Future research should focus on optimal diagnostic and prophylactic strategies to prevent VTE and potentially improve survival.
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209
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Abstract
Background Coronavirus disease 2019 (COVID-19) has become a global pandemic, affecting millions of people. However, the relationship between COVID-19 and acute cerebrovascular diseases is unclear. Aims We aimed to characterize the incidence, risk factors, clinical–radiological manifestations, and outcome of COVID-19-associated stroke. Methods Three medical databases were systematically reviewed for published articles on acute cerebrovascular diseases in COVID-19 (December 2019–September 2020). The review protocol was previously registered (PROSPERO ID = CRD42020185476). Data were extracted from articles reporting ≥5 stroke cases in COVID-19. We complied with the PRISMA guidelines and used the Newcastle–Ottawa Scale to assess data quality. Data were pooled using a random-effect model. Summary of review Of 2277 initially identified articles, 61 (2.7%) were entered in the meta-analysis. Out of 108,571 patients with COVID-19, acute CVD occurred in 1.4% (95%CI: 1.0–1.9). The most common manifestation was acute ischemic stroke (87.4%); intracerebral hemorrhage was less common (11.6%). Patients with COVID-19 developing acute cerebrovascular diseases, compared to those who did not, were older (pooled median difference = 4.8 years; 95%CI: 1.7–22.4), more likely to have hypertension (OR = 7.35; 95%CI: 1.94–27.87), diabetes mellitus (OR = 5.56; 95%CI: 3.34–9.24), coronary artery disease (OR = 3.12; 95%CI: 1.61–6.02), and severe infection (OR = 5.10; 95%CI: 2.72–9.54). Compared to individuals who experienced a stroke without the infection, patients with COVID-19 and stroke were younger (pooled median difference = −6.0 years; 95%CI: −12.3 to −1.4), had higher NIHSS (pooled median difference = 5; 95%CI: 3–9), higher frequency of large vessel occlusion (OR = 2.73; 95%CI: 1.63–4.57), and higher in-hospital mortality rate (OR = 5.21; 95%CI: 3.43–7.90). Conclusions Acute cerebrovascular diseases are not uncommon in patients with COVID-19, especially in those whom are severely infected and have pre-existing vascular risk factors. The pattern of large vessel occlusion and multi-territory infarcts suggests that cerebral thrombosis and/or thromboembolism could be possible causative pathways for the disease.
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Affiliation(s)
- Stefania Nannoni
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Rosa de Groot
- Donor Medicine Research, Sanquin Research, Amsterdam, the Netherlands
| | - Steven Bell
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, UK
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210
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Biswas S, Thakur V, Kaur P, Khan A, Kulshrestha S, Kumar P. Blood clots in COVID-19 patients: Simplifying the curious mystery. Med Hypotheses 2020; 146:110371. [PMID: 33223324 PMCID: PMC7644431 DOI: 10.1016/j.mehy.2020.110371] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/08/2020] [Accepted: 10/21/2020] [Indexed: 12/30/2022]
Abstract
The universal phenomenon of blood clotting is well known to be protective in external cellular/ tissue injury. However, the emergence of unusual thrombotic presentations in COVID-19 patients is the real concern. Interaction of the spike glycoprotein with ACE2 receptor present in the host cell surface mediates the entry of SARS-CoV-2 causing COVID-19 infection. New clinical findings of SARS-CoV-2 pathogenesis are coming out every day, and one such mystery is the formation of mysterious blood clots in the various tissues and organs of COVID-19 patients, which needs critical attention. To address this issue, we hypothesis that, high ACE2 expression in the endothelium of blood vessels facilitates the high-affinity binding of SARS-CoV-2 using spike protein, causing infection and internal injury inside the vascular wall of blood vessels. This viral associated injury may directly/indirectly initiate activation of coagulation and clotting cascades forming internal blood clots. However, the presence of these clots is undesirable as they are responsible for thrombosis and need to be treated with anti-thrombotic intervention.
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Affiliation(s)
- Sourav Biswas
- Faculty of Applied Sciences and Biotechnology, Shoolini University of Biotechnology and Management Sciences, Bajhol, Himachal Pradesh 173229, India
| | - Vikram Thakur
- Department of Virology, Post Graduate Institute of Medical Education and Research, (PGIMER), Sec-12, Chandigarh 160012, India
| | - Parneet Kaur
- Faculty of Applied Sciences and Biotechnology, Shoolini University of Biotechnology and Management Sciences, Bajhol, Himachal Pradesh 173229, India
| | - Azhar Khan
- Faculty of Applied Sciences and Biotechnology, Shoolini University of Biotechnology and Management Sciences, Bajhol, Himachal Pradesh 173229, India
| | - Saurabh Kulshrestha
- Faculty of Applied Sciences and Biotechnology, Shoolini University of Biotechnology and Management Sciences, Bajhol, Himachal Pradesh 173229, India
| | - Pradeep Kumar
- Faculty of Applied Sciences and Biotechnology, Shoolini University of Biotechnology and Management Sciences, Bajhol, Himachal Pradesh 173229, India.
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Ojo AS, Balogun SA, Idowu AO. Acute Ischemic Stroke in COVID-19: Putative Mechanisms, Clinical Characteristics, and Management. Neurol Res Int 2020; 2020:7397480. [PMID: 33224529 PMCID: PMC7673935 DOI: 10.1155/2020/7397480] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 01/06/2023] Open
Abstract
The emergence and spread of the highly contagious novel coronavirus disease (COVID-19) have triggered the greatest public health challenge of the last century. Aside from being a primary respiratory disease, acute ischemic stroke has emerged as a complication of the disease. While current evidence shows COVID-19 could cause ischemic stroke especially in severe disease, there are similarities in the risk factors for severe COVID-19 as well as ischemic stroke, underscoring the complex relationship between these two conditions. The pandemic has created challenges for acute stroke care. Rapid assessment and time-sensitive interventions required for optimum outcomes in acute stroke care have been complicated by COVID-19 due to the need for disease transmission preventive measures. The purpose of this article is to explore the putative mechanisms of ischemic stroke in COVID-19 and the clinical characteristics of COVID-19 patients who develop ischemic stroke. In addition, we discuss the challenges of managing acute ischemic stroke in the setting of COVID-19 and review current management guidelines. We also highlighted potential areas for future research.
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Affiliation(s)
- Ademola S. Ojo
- Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, Grenada
| | - Simon A. Balogun
- Department of Neurological Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Nigeria
| | - Ahmed O. Idowu
- Neurology Division, Department of Medicine, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Nigeria
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212
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Singh S, Zuwasti U, Haas C. Coronavirus-Associated Coagulopathy: Lessons From SARS-CoV1 and MERS-CoV for the Current SARS-CoV2 Pandemic. Cureus 2020; 12:e11310. [PMID: 33282586 PMCID: PMC7714748 DOI: 10.7759/cureus.11310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
To date, several studies have suggested a severe acute respiratory syndrome coronavirus 2 (SARS-CoV2)-mediated hypercoagulability in the forms of pulmonary embolism, stroke, gangrene, “COVID toes,” as well as other acute thrombotic complications, warranting the use of systemic anticoagulation. Currently, there are no definitive recommendations as to the timing and dosing of prophylactic or therapeutic anticoagulation in coronavirus disease 2019 (COVID-19) patients. In this manuscript, we report a case of SARS-CoV2-mediated hypercoagulability and review the literature pertaining to the incidence and pathophysiology of coronavirus-mediated coagulopathies. A 64-year-old female, with a medical history of hypothyroidism and remote tobacco abuse, presented to the ED with fever and nonproductive cough. She had multiple negative SARS-CoV2 nasopharyngeal PCR tests during her hospital stay, but chest imaging and elevated inflammatory markers were suggestive of SARS-CoV2 infection. Computed tomography showed a left upper lobe pulmonary embolism with associated right heart strain, and an enlargement of the main pulmonary artery, for which she was initiated on therapeutic anticoagulation with low molecular weight heparin. Despite the medical management of her pulmonary embolism and conservative management of her SARS-CoV2, her clinical condition worsened requiring intubation and mechanical ventilation. After seven days, she was successfully extubated and was transferred to the medical service where her clinical course remained stable and subsequently discharged home on apixaban. In patients with SARS-CoV1-, SARS-CoV2-, and the Middle East respiratory syndrome coronavirus (MERS-CoV)-mediated hypercoagulability, the risk of thrombosis appears to be multifactorial - direct viral cytopathological effects, a pro-inflammatory state, cytokine storm, hypoxia-inducible thrombosis, and endothelial inflammation culminating in the formation of intra-alveolar or systemic fibrin clots. While initial guidelines have been developed to assist clinicians in selecting appropriate chemoprophylaxis as well as therapeutic anticoagulation, a consensus statement remains lacking. Further studies are needed to evaluate the pathogenesis and treatment of coronavirus-induced thrombosis.
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Affiliation(s)
- Shalinder Singh
- Internal Medicine, MedStar Union Memorial Hospital, Baltimore, USA
| | - Ufara Zuwasti
- Internal Medicine, MedStar Union Memorial Hospital, Baltimore, USA
| | - Christopher Haas
- Internal Medicine, MedStar Union Memorial Hospital, Baltimore, USA
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213
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Abstract
As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic spreads, it is becoming increasingly evident that coronavirus disease 2019 (COVID-19) is not limited to the respiratory system, and that other organs can be affected. In particular, virus-related neurological manifestations are being reported more and more frequently in the scientific literature. In this article, we review the literature on the association between COVID-19 and neurological manifestations, present evidence from preclinical research suggesting that SARS-CoV-2 could be responsible for many of these manifestations, and summarize the biological pathways that could underlie each neurological symptom. Understanding the mechanisms that lead to neurological manifestations in patients with COVID-19 and how these manifestations correlate with clinical outcomes will be instrumental in guiding the optimal use of targeted therapeutic strategies.
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Affiliation(s)
- Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy.
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
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214
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McBane RD, Torres Roldan VD, Niven AS, Pruthi RK, Franco PM, Linderbaum JA, Casanegra AI, Oyen LJ, Houghton DE, Marshall AL, Ou NN, Siegel JL, Wysokinski WE, Padrnos LJ, Rivera CE, Flo GL, Shamoun FE, Silvers SM, Nayfeh T, Urtecho M, Shah S, Benkhadra R, Saadi SM, Firwana M, Jawaid T, Amin M, Prokop LJ, Murad MH. Anticoagulation in COVID-19: A Systematic Review, Meta-analysis, and Rapid Guidance From Mayo Clinic. Mayo Clin Proc 2020; 95:2467-2486. [PMID: 33153635 PMCID: PMC7458092 DOI: 10.1016/j.mayocp.2020.08.030] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/04/2020] [Accepted: 08/26/2020] [Indexed: 12/16/2022]
Abstract
A higher risk of thrombosis has been described as a prominent feature of coronavirus disease 2019 (COVID-19). This systematic review synthesizes current data on thrombosis risk, prognostic implications, and anticoagulation effects in COVID-19. We included 37 studies from 4070 unique citations. Meta-analysis was performed when feasible. Coagulopathy and thrombotic events were frequent among patients with COVID-19 and further increased in those with more severe forms of the disease. We also present guidance on the prevention and management of thrombosis from a multidisciplinary panel of specialists from Mayo Clinic. The current certainty of evidence is generally very low and continues to evolve.
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Key Words
- aptt, activated thromboplastin time
- covid-19, coronavirus disease 2019
- dic, disseminated intravascular coagulation
- doac, direct oral anticoagulant
- dvt, deep venous thrombosis
- icu, intensive care unit
- lmwh, low-molecular-weight heparin
- or, odds ratio
- pe, pulmonary embolism
- pt, prothrombin time
- sars-cov, severe acute respiratory syndrome coronavirus
- sc, subcutaneously
- vte, venous thromboembolism
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Affiliation(s)
- Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Victor D Torres Roldan
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Alexander S Niven
- Division of Pulmonary and Critical Care, Center for Sleep Medicine, Mayo Clinic, Rochester, MN
| | - Rajiv K Pruthi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Lance J Oyen
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Damon E Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ariela L Marshall
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN
| | - Narith N Ou
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | | | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Candido E Rivera
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL
| | - Gayle L Flo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Fadi E Shamoun
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ
| | - Scott M Silvers
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL
| | - Tarek Nayfeh
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Meritxell Urtecho
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Sahrish Shah
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Raed Benkhadra
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Samer Mohir Saadi
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohammed Firwana
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Tabinda Jawaid
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mustapha Amin
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - M Hassan Murad
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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Görlinger K, Dirkmann D, Gandhi A, Simioni P. COVID-19-Associated Coagulopathy and Inflammatory Response: What Do We Know Already and What Are the Knowledge Gaps? Anesth Analg 2020; 131:1324-1333. [PMID: 33079850 PMCID: PMC7389937 DOI: 10.1213/ane.0000000000005147] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with coronavirus disease 2019 (COVID-19) frequently experience a coagulopathy associated with a high incidence of thrombotic events leading to poor outcomes. Here, biomarkers of coagulation (such as D-dimer, fibrinogen, platelet count), inflammation (such as interleukin-6), and immunity (such as lymphocyte count) as well as clinical scoring systems (such as sequential organ failure assessment [SOFA], International Society on Thrombosis and Hemostasis disseminated intravascular coagulation [ISTH DIC], and sepsis-induced coagulopathy [SIC] score) can be helpful in predicting clinical course, need for hospital resources (such as intensive care unit [ICU] beds, intubation and ventilator therapy, and extracorporeal membrane oxygenation [ECMO]) and patient's outcome in patients with COVID-19. However, therapeutic options are actually limited to unspecific supportive therapy. Whether viscoelastic testing can provide additional value in predicting clinical course, need for hospital resources and patient's outcome or in guiding anticoagulation in COVID-19-associated coagulopathy is still incompletely understood and currently under investigation (eg, in the rotational thromboelastometry analysis and standard coagulation tests in hospitalized patients with COVID-19 [ROHOCO] study). This article summarizes what we know already about COVID-19-associated coagulopathy and-perhaps even more importantly-characterizes important knowledge gaps.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany, and Medical Director, Tem Innovations GmbH, Martin-Kollar-Strasse 15, 81829 Munich, Germany, mobile: +49 1726596069, e-mail:
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany, mobile: +49 201 723 84423,
| | - Ajay Gandhi
- Clinical Affairs, Instrumentation Laboratory India Private Limited, New Delhi, India, 1471-76, Agrawal Millennium Tower II, Plot Number E-4, Netaji Subhash Place, Pitampura, New Delhi, India 110034, mobile: +91 9826870517, e-mail:
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Units, Department of Medicine, Padova University Hospital, Via Ospedale Civile 105, 35100 Padova, Italy, phone: +39 0498212667, e-mail:
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216
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Marietta M, Coluccio V, Luppi M. COVID-19, coagulopathy and venous thromboembolism: more questions than answers. Intern Emerg Med 2020; 15:1375-1387. [PMID: 32653981 PMCID: PMC7352087 DOI: 10.1007/s11739-020-02432-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 07/02/2020] [Indexed: 02/06/2023]
Abstract
The acute respiratory illnesses caused by severe acquired respiratory syndrome corona Virus-2 (SARS-CoV-2) is a global health emergency, involving more than 8.6 million people worldwide with more than 450,000 deaths. Among the clinical manifestations of COVID-19, the disease that results from SARS-CoV-2 infection in humans, a prominent feature is a pro-thrombotic derangement of the hemostatic system, possibly representing a peculiar clinicopathologic manifestation of viral sepsis. The severity of the derangement of coagulation parameters in COVID-19 patients has been associated with a poor prognosis, and the use of low molecular weight heparin (LMWH) at doses registered for prevention of venous thromboembolism (VTE) has been endorsed by the World Health Organization and by Several Scientific societies. However, some relevant issues on the relationships between COVID-19, coagulopathy and VTE have yet to be fully elucidated. This review is particularly focused on four clinical questions: What is the incidence of VTE in COVID-19 patients? How do we frame the COVID-19 associated coagulopathy? Which role, if any, do antiphospolipid antibodies have? How do we tackle COVID-19 coagulopathy? In the complex scenario of an overwhelming pandemic, most everyday clinical decisions have to be taken without delay, although not yet supported by a sound scientific evidence. This review discusses the most recent findings of basic and clinical research about the COVID-associated coagulopathy, to foster a more thorough knowledge of the mechanisms underlying this compelling disease.
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Affiliation(s)
- Marco Marietta
- Hematology Unit, Azienda Ospepdaliero-Universitaria, Via del Pozzo 71, 41124, Modena, Italy.
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospepdaliero-Universitaria, Via del Pozzo 71, 41124, Modena, Italy
| | - Mario Luppi
- Hematology Unit, Azienda Ospepdaliero-Universitaria, Via del Pozzo 71, 41124, Modena, Italy
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
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217
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Vinayagam S, Sattu K. SARS-CoV-2 and coagulation disorders in different organs. Life Sci 2020; 260:118431. [PMID: 32946915 PMCID: PMC7490584 DOI: 10.1016/j.lfs.2020.118431] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/06/2020] [Accepted: 09/09/2020] [Indexed: 02/08/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is a prominent pandemic disease that emerged in China and hurriedly stretched worldwide. There are many reports on COVID-19 associated with the amplified incidence of thrombotic events. In this review, we focused on COVID-19 coupled with the coagulopathy contributes to severe outcome inclusive of comorbidities such as venous thromboembolism, stroke, diabetes, lung, heart attack, AKI, and liver injury. Initially, the COVID-19 patient associated coagulation disorders show an elevated level of the D-dimer, fibrinogen, and less lymphocyte count such as lymphopenia. COVID-19 associated with the Kawasaki disease has acute vasculitis in childhood which further affects the vessels found all over the body. COVID-19 linked with the thrombotic microangiopathy triggers the multiple vasculitis along with the arterioles thrombosis, medium, large venous and arterial vessels mediates the disseminated intravascular coagulation (DIC). SARS-Co-V-2 patients have reduced primary platelet production, increased destruction of the platelet, decreased circulating platelet leads to the condition of increased thrombocytopenia which contributes to the coagulation disorder. Endothelial dysfunction plays an important role in the coagulation disorders via increased generation of the thrombin and stops fibrinolysis further leads to hypercoagulopathy. Along with that endothelial dysfunction activates the complement system pathways and contributes to the acute and chronic inflammation via cytokine storm with the production of the cytokines and chemokines, coagulation in different organs such as lung, brain, liver, heart, kidney and further leads to multi-organ failure.
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Affiliation(s)
- Sathishkumar Vinayagam
- Department of Biotechnology, Periyar University PG, Extension Centre, Dharmapuri, Tamil Nadu 636701, India
| | - Kamaraj Sattu
- Department of Biotechnology, Periyar University PG, Extension Centre, Dharmapuri, Tamil Nadu 636701, India.
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218
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Ashour H, Elsayed MH, Elmorsy S, Harb IA. Hypothesis: The potential therapeutic role of nicorandil in COVID-19. Clin Exp Pharmacol Physiol 2020; 47:1791-1797. [PMID: 32881062 PMCID: PMC7436472 DOI: 10.1111/1440-1681.13395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/14/2020] [Accepted: 08/02/2020] [Indexed: 12/16/2022]
Abstract
At present, there is yet no specific antiviral treatment or immunization against the newly identified human severe acute respiratory syndrome virus (SARS-CoV2) that results in a rapidly progressive pandemic coronavirus disease 2019 (COVID-19). We believe in a crucial need for a clinical strategy to counteract this viral pandemic based on the known pathogenesis throughout the disease course. Evidence suggests that exaggerated patient's inflammatory response and oxidative stress are likely to aggravate the disease pathology. The resulting endothelial dysfunction further induces fibrosis and coagulopathy. These disturbances can generate severe acute respiratory distress syndrome (ARDS) that can progress into respiratory and circulatory failure. Nicorandil is an anti-anginal vasodilator drug acts by increasing nitric oxide bioavailability and opening of the KATP channel. Recently, nicorandil has been recognized to possess multiple protective effects against tissue injury. Here, we address a possible modulatory role of nicorandil against COVID-19 pathogenesis. We hypothesise nicorandil would be an effective form of adjuvant therapy against COVID-19.
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Affiliation(s)
- Hend Ashour
- Faculty of MedicineDepartment of PhysiologyKing Khalid UniversityAbhaSaudi Arabia
- Faculty of MedicineDepartment of PhysiologyKasr AlainyCairo UniversityCairoEgypt
| | - Mohamed H. Elsayed
- Department of Pediatrics ICUAl‐Ahrar Teaching HospitalZagazigEgypt
- Department of Pediatrics ICUKing Fahd Armed Forces HospitalKhamis MushaitSaudi Arabia
| | - Soha Elmorsy
- Faculty of MedicineDepartment of Medical PharmacologyCairo UniversityCairoEgypt
| | - Inas A. Harb
- Faculty of MedicineDepartment of Medical PharmacologyCairo UniversityCairoEgypt
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219
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Jhang WK, Park SJ. Evaluation of Sepsis-Induced Coagulopathy in Critically Ill Pediatric Patients with Septic Shock. Thromb Haemost 2020; 121:457-463. [PMID: 33124023 DOI: 10.1055/s-0040-1718736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Coagulopathy is a common serious complication of sepsis and septic shock; thus, its early detection and prompt management are important. For this purpose, recently the sepsis-induced coagulopathy (SIC) score was proposed. METHODS We modified the SIC score for critically ill children with septic shock and evaluated its performance in comparison to several coagulopathy diagnostic scoring systems. RESULTS Among 135 included patients, a significant number of patients were diagnosed with coagulopathy using different coagulopathy diagnostic criteria (up to 84.4% using the SIC score). The modified SIC score, comprising the pediatric sequential organ failure assessment (pSOFA) score, prothrombin time, and D-dimer, was used to diagnose SIC in 68 (50.4%) patients. It was well correlated with the pSOFA score and the International Society on Thrombosis and Haemostasis disseminated intravascular coagulation (DIC) score, as well as the SIC score (p < 0.001). The overall 28-day mortality rate was 18.7%. Patients with coagulopathy had worse clinical outcomes compared to those without coagulopathy. The modified SIC score was identified as an independent prognostic factor for 28-day mortality. The area under the receiver operating characteristic curve for performance of the modified SIC score to predict 28-day mortality evaluated was 0.771 (95% confidence interval: 0.658-0.883), better than those of the SIC and ISTH DIC scores (p < 0.05). CONCLUSION Critically ill pediatric patients with septic shock frequently had concomitant coagulopathy. The modified SIC score showed good ability to predict 28-day mortality, suggesting its potential as a prognostic factor in these critically ill pediatric patients.
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Affiliation(s)
- Won Kyoung Jhang
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Seong Jong Park
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
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220
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Levy JH, Iba T, Connors JM. Editorial commentary: Vascular injury in acute infections and COVID-19: everything old is new again. Trends Cardiovasc Med 2020; 31:6-7. [PMID: 33129973 PMCID: PMC7591865 DOI: 10.1016/j.tcm.2020.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 10/25/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Jean M Connors
- Department of Medicine, Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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221
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Inflammation and thrombosis in patients with COVID-19: A prothrombotic and inflammatory disease caused by SARS coronavirus-2. Anatol J Cardiol 2020; 24:224-234. [PMID: 33001051 PMCID: PMC7585960 DOI: 10.14744/anatoljcardiol.2020.56727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) caused by “Severe Acute Respiratory Syndrome Coronavirus-2” (SARS-CoV-2) infection emerged in Wuhan, a city of China, and spread to the entire planet in early 2020. The virus enters the respiratory tract cells and other tissues via ACE2 receptors. Approximately 20% of infected subjects develop severe or critical disease. A cytokine storm leads to over inflammation and thrombotic events. The most common clinical presentation in COVID-19 is pneumonia, typically characterized by bilateral, peripheral, and patchy infiltrations in the lungs. However multi-systemic involvement including peripheral thromboembolic skin lesions, central nervous, gastrointestinal, circulatory, and urinary systems are reported. The disease has a higher mortality compared to other viral agents causing pneumonia and unfortunately, no approved specific therapy, nor vaccine has yet been discovered. Several clinical trials are ongoing with hydroxychloroquine, remdesivir, favipiravir, and low molecular weight heparins. This comprehensive review aimed to summarize coagulation abnormalities reported in COVID-19, discuss the thrombosis, and inflammation-driven background of the disease, emphasize the impact of thrombotic and inflammatory processes on the progression and prognosis of COVID-19, and to provide evidence-based therapeutic guidance, especially from antithrombotic and anti-inflammatory perspectives.
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222
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Sattar SBA, Iqbal QZ, Haider MA, Zia Z, Niazi MRK, Hanif M, Ali MJ, Khan MA. Locked-in Syndrome in a Young Patient Due to SARS-CoV-2: A Case Report. Front Med (Lausanne) 2020; 7:574690. [PMID: 33178718 PMCID: PMC7593446 DOI: 10.3389/fmed.2020.574690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/31/2020] [Indexed: 01/12/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), apart from commonly involving the respiratory system, has its impact on the central nervous system, with a wide spectrum of clinical presentations ranging from headaches to ischemic strokes. The ongoing research regarding this novel disease has found that there is a very high prevalence of thrombotic episodes especially in critically ill patients when compared to severe presentation of other viral illnesses. This COVID-19-associated coagulopathy has a very complex etiology with the ability to form thrombus in arteries, veins, and microvasculatures of different organs. We present a unique case of a young woman with underlying COVID-19 who unfortunately developed locked-in syndrome due to bilateral pontine infarction during the course of her illness.
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Affiliation(s)
| | - Qasim Zafar Iqbal
- Staten Island University Hospital, Northwell Health, New York, NY, United States
| | | | - Zeeshan Zia
- Staten Island University Hospital, Northwell Health, New York, NY, United States
| | | | - Muhammad Hanif
- Khyber Medical College, Hayatabad Medical Complex, Peshawar, Pakistan
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223
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Wool GD, Miller JL. The Impact of COVID-19 Disease on Platelets and Coagulation. Pathobiology 2020; 88:15-27. [PMID: 33049751 PMCID: PMC7649697 DOI: 10.1159/000512007] [Citation(s) in RCA: 263] [Impact Index Per Article: 65.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/05/2020] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) causes a spectrum of disease; some patients develop a severe proinflammatory state which can be associated with a unique coagulopathy and procoagulant endothelial phenotype. Initially, COVID-19 infection produces a prominent elevation of fibrinogen and D-dimer/fibrin(ogen) degradation products. This is associated with systemic hypercoagulability and frequent venous thromboembolic events. The degree of D-dimer elevation positively correlates with mortality in COVID-19 patients. COVID-19 also leads to arterial thrombotic events (including strokes and ischemic limbs) as well as microvascular thrombotic disorders (as frequently documented at autopsy in the pulmonary vascular beds). COVID-19 patients often have mild thrombocytopenia and appear to have increased platelet consumption, together with a corresponding increase in platelet production. Disseminated intravascular coagulopathy (DIC) and severe bleeding events are uncommon in COVID-19 patients. Here, we review the current state of knowledge of COVID-19 and hemostasis.
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Affiliation(s)
- Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, Illinois, USA,
| | - Jonathan L Miller
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
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224
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Long X, Zhang Z, Zou W, Ling J, Li D, Jing L, Yu S, Zou X, Bian Y, Wu W, Li S, Fang M. Coagulopathy of Patients with COVID-19 is Associated with Infectious and Inflammatory Markers. Risk Manag Healthc Policy 2020; 13:1965-1975. [PMID: 33116977 PMCID: PMC7548327 DOI: 10.2147/rmhp.s268238] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/12/2020] [Indexed: 01/13/2023] Open
Abstract
Background SARS-CoV-2 infection activates coagulation and stimulates innate immune system. Little is known about coagulopathy and response of inflammation and infection in ICU patients with COVID-19. Derangement of coagulation and markers of infection and inflammation induced by SARS-CoV-2 infection, as well as their correlations were elucidated. Methods One hundred eight ICU patients with COVID-19 (28 survivors and 80 non-survivors) in Tongji hospital and Wuhan Jinyintan hospital, in Wuhan, China were included. Coagulation parameters, infectious and inflammatory markers were dynamically analysed. The correlation between coagulopathy of patients and infectious and inflammatory markers was verified. Results SARS-CoV-2-associated coagulopathy occurred in most cases of critical illness. Raised values of d-dimer and FDP were measured in all patients, especially in non-survivors, who had longer PT, APTT, INR, as well as TT, and lower PTA and AT compared to survivors. SIC and DIC mostly occurred in non-survivors. CRP, ESR, serum ferritin, IL-8, and IL-2R increased in all patients, and were much higher in non-survivors who had significantly higher levels of IL-6 and IL-10. D-dimer was positively associated with CRP, serum ferritin (p = 0.02), PCT (p < 0.001), and IL-2R (p = 0.007). SIC scores were positively correlated with CRP (p = 0.006), PCT (p = 0.0007), IL-1β (p = 0.048), and IL-6 (p = 0.009). DIC scores were positively associated with CRP (p < 0.0001), ESR (p = 0.02), PCT (p < 0.0001), serum ferritin (p < 0.0001), IL-10 (p = 0.02), and IL-2R (p = 0.0005). Conclusion Prothrombotic state, SIC, and DIC are the characteristics of coagulation in ICU patients with COVID-19. CRP, ESR, serum ferritin, IL-8, IL-2R, IL-6, and PCT were stimulated by SARS-CoV-2 infection. CRP, PCT, serum ferritin, and IL-2R indicate the coagulopathy severity of patients with COVID-19.
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Affiliation(s)
- Xin Long
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Zhanguo Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Wenbin Zou
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Jianmin Ling
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Donghui Li
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Liang Jing
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Shanshan Yu
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Xiaojing Zou
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Yi Bian
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Wenjuan Wu
- Department of Intensive Care Unit, Jinyintan Hospital, Wuhan 430023, People's Republic of China
| | - Shusheng Li
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Minghao Fang
- Department of Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
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225
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Chen EC, Zon RL, Battinelli EM, Connors JM. Approach to the Patient with COVID-19-Associated Thrombosis: A Case-Based Review. Oncologist 2020; 25:e1500-e1508. [PMID: 32881209 PMCID: PMC7461375 DOI: 10.1634/theoncologist.2020-0682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/04/2020] [Indexed: 01/12/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a current global pandemic caused by the novel coronavirus SARS-CoV-2. Alongside its potential to cause severe respiratory illness, studies have reported a distinct COVID-19-associated coagulopathy that is characterized by elevated D-dimer levels, hyperfibrinogenemia, mild thrombocytopenia, and slight prolongation of the prothrombin time. Studies have also reported increased rates of thromboembolism in patients with COVID-19, but variations in study methodologies, patient populations, and anticoagulation strategies make it challenging to distill implications for clinical practice. Here, we present a practical review of current literature and uses a case-based format to discuss the diagnostic approach and management of COVID-19-associated coagulopathy. IMPLICATIONS FOR PRACTICE: Coronavirus disease 2019 (COVID-19)-associated coagulopathy is characterized by elevated D-dimer levels, hyperfibrinogenemia, and increased rates of thromboembolism. Current management guidelines are based on limited evidence from retrospective studies that should be interpreted carefully. At this time, all hospitalized patients with suspected or confirmed COVID-19 should receive coagulation test surveillance and standard doses of prophylactic anticoagulation until prospective randomized controlled trials yield definitive information in support of higher prophylactic doses.
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Affiliation(s)
- Evan C. Chen
- Department of Hematology, Brigham and Women's HospitalBostonMassachusettsUSA
| | - Rebecca L. Zon
- Department of Hematology, Brigham and Women's HospitalBostonMassachusettsUSA
| | | | - Jean M. Connors
- Department of Hematology, Brigham and Women's HospitalBostonMassachusettsUSA
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226
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Abstract
An ongoing global pandemic of viral pneumonia (coronavirus disease [COVID-19]), due to the virus SARS-CoV-2, has infected millions of people and remains a threat to many more. Most critically ill patients have respiratory failure and there is an international effort to understand mechanisms and predictors of disease severity. Coagulopathy, characterized by elevations in D-dimer and fibrin(ogen) degradation products (FDPs), is associated with critical illness and mortality in patients with COVID-19. Furthermore, increasing reports of microvascular and macrovascular thrombi suggest that hemostatic imbalances may contribute to the pathophysiology of SARS-CoV-2 infection. We review the laboratory and clinical findings of patients with COVID-19-associated coagulopathy, and prior studies of hemostasis in other viral infections and acute respiratory distress syndrome. We hypothesize that an imbalance between coagulation and inflammation may result in a hypercoagulable state. Although thrombosis initiated by the innate immune system is hypothesized to limit SARS-CoV-2 dissemination, aberrant activation of this system can cause endothelial injury resulting in loss of thromboprotective mechanisms, excess thrombin generation, and dysregulation of fibrinolysis and thrombosis. The role various components including neutrophils, neutrophil extracellular traps, activated platelets, microparticles, clotting factors, inflammatory cytokines, and complement play in this process remains an area of active investigation and ongoing clinical trials target these different pathways in COVID-19.
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Affiliation(s)
- Meaghan E Colling
- Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Yogendra Kanthi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, and Ann Arbor Veterans Administration Healthcare System, Ann Arbor, MI, USA
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227
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Tyler PD, Yang LM, Snider SB, Lerner AB, Aird WC, Shapiro NI. New Uses for Thromboelastography and Other Forms of Viscoelastic Monitoring in the Emergency Department: A Narrative Review. Ann Emerg Med 2020; 77:357-366. [PMID: 32988649 DOI: 10.1016/j.annemergmed.2020.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Patients frequently visit the emergency department with conditions that place them at risk of worse outcomes when accompanied by coagulopathy. Routine tests of coagulation-prothrombin time, partial thromboplastin time, platelets, and fibrinogen-have shortcomings that limit their use in providing emergency care. One alternative is to investigate coagulation disturbance with viscoelastic monitoring (VEM), a coagulation test that measures the timing and strength of blood clot development in real time. VEM is widely used and studied in cardiac surgery, liver transplant surgery, anesthesia, and trauma. In this article, we review the technique of VEM and the biologic rationale of using it in addition to routine tests of coagulation in emergency clinical situations. Then, we review the evidence (or lack thereof) for using VEM in the diagnosis and treatment of specific conditions. Finally, we describe the limitations of the test and future directions for clinical use and research in emergency medicine.
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Affiliation(s)
- Patrick D Tyler
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Lauren M Yang
- Department of Medicine, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Samuel B Snider
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Adam B Lerner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - William C Aird
- Department of Medicine, Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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228
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Bordallo B, Bellas M, Cortez AF, Vieira M, Pinheiro M. Severe COVID-19: what have we learned with the immunopathogenesis? Adv Rheumatol 2020; 60:50. [PMID: 32962761 PMCID: PMC7506814 DOI: 10.1186/s42358-020-00151-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global major concern. In this review, we addressed a theoretical model on immunopathogenesis associated with severe COVID-19, based on the current literature of SARS-CoV-2 and other epidemic pathogenic coronaviruses, such as SARS and MERS. Several studies have suggested that immune dysregulation and hyperinflammatory response induced by SARS-CoV-2 are more involved in disease severity than the virus itself.Immune dysregulation due to COVID-19 is characterized by delayed and impaired interferon response, lymphocyte exhaustion and cytokine storm that ultimately lead to diffuse lung tissue damage and posterior thrombotic phenomena.Considering there is a lack of clinical evidence provided by randomized clinical trials, the knowledge about SARS-CoV-2 disease pathogenesis and immune response is a cornerstone to develop rationale-based clinical therapeutic strategies. In this narrative review, the authors aimed to describe the immunopathogenesis of severe forms of COVID-19.
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Affiliation(s)
- Bruno Bordallo
- Departament of Internal Medicine / Emergence, Hospital Universitário Antônio Pedro / Univesidade Federal Fluminense, Niterói, RJ, Brazil.
| | - Mozart Bellas
- Departament of Internal Medicine / Emergence, Hospital Universitário Antônio Pedro / Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Arthur Fernandes Cortez
- Hospital Universitário Gaffré e Guinle / Universidade Federal do Estado do Rio de Janeiro, Internal Medicine Departament, Rio de Janeiro, RJ, Brazil
| | - Matheus Vieira
- Departament of Internal Medicine, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, RJ, Brazil
| | - Marcelo Pinheiro
- Departament of Rheumatology, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
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229
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Bhattacharjee S, Banerjee M, Pal R. COVID-19 Associated Hemophagocytic Lymphohistiocytosis and Coagulopathy: Targeting the Duumvirate. Indian Pediatr 2020. [PMID: 32583809 PMCID: PMC7498551 DOI: 10.1007/s13312-020-1962-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Context Preliminary data on coexistence of secondary hemophagocytic lymphohistiocytosis syndrome (HLH) and disseminated intravascular coagulation (DIC) in critically ill children with novel coronavirus disease (COVID-19) are emerging. Herein, we summarize the available literature and fill-in the gaps in this regard. Evidence Acquisition We have performed a literature search for articles in PubMed, EMBASE and Google Scholar databases till May 12, 2020, with following keywords: “COVID-19”, “SARS-CoV-2”, “HLH”, “HScore”, “coagulopathy”, “D-dimer”, “cytokine storm”, “children” and “pediatrics” with interposition of Boolean operator “AND”. Results Children presenting with moderate-severe COVID-19 and Kawasaki disease shock-like syndrome exhibit peripheral blood picture analogous to HLH. HScore, a validated tool to diagnose HLH, has been suggested to screen severe COVID-19 patients for cytokine storm. However, HScore faces certain limitations in this scenario. It may be more pragmatic to use ‘high D-dimer’ (> 3 µg/mL) instead of ‘low fibrinogen’ to facilitate early detection of cytokine storm. COVID-19 associated coagulopathy resembles hypercoagulable form of DIC with bleeding being rarely reported. Although the International Society on Thrombosis and Haemostasis (ISTH) interim guidance recommends low molecular weight heparin in all hospitalized patients, data is lacking in population below 14 years of age. However, in the presence of life-threatening thromboembolic event or symptomatic acro-ischemia, unfractionated heparin (UFH) should be used with caution. Conclusions HScore can be used as a complement to clinical decision for initiating immunosuppression. Children with moderate-to-severe COVID-19, especially those with documented thrombocytopenia or chilblains, should be regularly monitored for coagulopathy.
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Affiliation(s)
- Sukrita Bhattacharjee
- Institute of Hematology and Transfusion Medicine, Medical College and Hospital, Kolkata, West Bengal, India. Correspondence to: Dr Sukrita Bhattacharjee, Department of Hematology, Institute of Hematology and Transfusion Medicine, Medical College and Hospital, Kolkata, India.
| | - Mainak Banerjee
- Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Rimesh Pal
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
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230
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Noun P, Ibrahim A, Hodroj MH, Bou-Fakhredin R, Taher AT. COVID-19 in benign hematology: emerging challenges and special considerations for healthcare professionals. Expert Rev Hematol 2020; 13:1081-1092. [DOI: 10.1080/17474086.2020.1819785] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- Peter Noun
- Division of Pediatric Hematology-Oncology, Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Ahmad Ibrahim
- Division of Hematology and Oncology, Department of Internal Medicine, Makassed General Hospital, Beirut, Lebanon
- Middle East Institute of Health, Lebanese University, Beirut, Lebanon
| | - Mohammad Hassan Hodroj
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rayan Bou-Fakhredin
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T. Taher
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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231
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Zuo Y, Estes SK, Ali RA, Gandhi AA, Yalavarthi S, Shi H, Sule G, Gockman K, Madison JA, Zuo M, Yadav V, Wang J, Woodard W, Lezak SP, Lugogo NL, Smith SA, Morrissey JH, Kanthi Y, Knight JS. Prothrombotic antiphospholipid antibodies in COVID-19. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32587992 DOI: 10.1101/2020.06.15.20131607] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients with coronavirus disease 19 (COVID-19) are at high risk for thrombotic arterial and venous occlusions. At the same time, lung histopathology often reveals fibrin-based occlusion in the small vessels of patients who succumb to the disease. Antiphospholipid syndrome (APS) is an acquired and potentially life-threatening thrombophilia in which patients develop pathogenic autoantibodies (aPL) targeting phospholipids and phospholipid-binding proteins. Case series have recently detected aPL in patients with COVID-19. Here, we measured eight types of aPL [anticardiolipin IgG/IgM/IgA, anti-beta-2 glycoprotein I IgG/IgM/IgA, and anti- phosphatidylserine/prothrombin (aPS/PT) IgG/IgM] in the sera of 172 patients hospitalized with COVID-19. We detected aPS/PT IgG in 24%, anticardiolipin IgM in 23%, and aPS/PT IgM in 18%. Any aPL was present in 52% of patients using the manufacturer's threshold and in 30% using a more stringent cutoff (≥40 units). Higher levels of aPL were associated with neutrophil hyperactivity (including the release of neutrophil extracellular traps/NETs), higher platelet count, more severe respiratory disease, and lower glomerular filtration rate. Similar to patients with longstanding APS, IgG fractions isolated from patients with COVID-19 promoted NET release from control neutrophils. Furthermore, injection of these COVID-19 IgG fractions into mice accelerated venous thrombosis. Taken together, these studies suggest that a significant percentage of patients with COVID-19 become at least transiently positive for aPL and that these aPL are potentially pathogenic.
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232
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Hematological Phenotype of COVID-19-Induced Coagulopathy: Far from Typical Sepsis-Induced Coagulopathy. J Clin Med 2020; 9:jcm9092875. [PMID: 32899532 PMCID: PMC7564381 DOI: 10.3390/jcm9092875] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Blood coagulation disorders commonly occur with severe coronavirus disease 2019 (COVID-19). However, there is only limited evidence on differentiating the pattern of the hemostatic parameters from those of typical sepsis-induced coagulopathy (SIC). Methods: To elucidate the specific pattern of coagulopathy induced by COVID-19 pneumonia, this retrospective, observational study targeted consecutive adult patients with COVID-19-induced acute respiratory distress syndrome (ARDS) and compared hemostatic biomarkers with non-COVID-19-induced septic ARDS. Multilevel mixed-effects regression analysis was performed and Kaplan–Meier failure curves were constructed. Results: We enrolled 24 patients with COVID-19-induced ARDS and 200 patients with non-COVID-19-induced ARDS. Platelet count, antithrombin activity, and prothrombin time in the COVID-19 group were almost within normal range and time series alterations of these markers were significantly milder than the non-COVID-19 group (p = 0.052, 0.037, and 0.005, respectively). However, fibrin/fibrinogen degradation product and D-dimer were significantly higher in the COVID-19 group (p = 0.001, 0.002, respectively). COVID-19 patients had moderately high levels of thrombin–antithrombin complex and plasmin-alpha2-plasmin inhibitor complex but normal plasminogen activator inhibitor-1 level. Conclusions: The hematological phenotype of COVID-19-induced coagulopathy is quite different from that in typical SIC characterized by systemic hypercoagulation and suppressed fibrinolysis. Instead, local thrombus formation might be promoted in severe COVID-19.
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Reyes M, Filbin MR, Bhattacharyya RP, Sonny A, Mehta A, Billman K, Kays KR, Pinilla-Vera M, Benson ME, Cosimi LA, Hung DT, Levy BD, Villani AC, Sade-Feldman M, Baron RM, Goldberg MB, Blainey PC, Hacohen N. Induction of a regulatory myeloid program in bacterial sepsis and severe COVID-19. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2020. [PMID: 32908980 DOI: 10.1101/2020.09.02.280180] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A recent estimate suggests that one in five deaths globally are associated with sepsis 1 . To date, no targeted treatment is available for this syndrome, likely due to substantial patient heterogeneity 2,3 and our lack of insight into sepsis immunopathology 4 . These issues are highlighted by the current COVID-19 pandemic, wherein many clinical manifestations of severe SARS-CoV-2 infection parallel bacterial sepsis 5-8 . We previously reported an expanded CD14+ monocyte state, MS1, in patients with bacterial sepsis or non-infectious critical illness, and validated its expansion in sepsis across thousands of patients using public transcriptomic data 9 . Despite its marked expansion in the circulation of bacterial sepsis patients, its relevance to viral sepsis and association with disease outcomes have not been examined. In addition, the ontogeny and function of this monocyte state remain poorly characterized. Using public transcriptomic data, we show that the expression of the MS1 program is associated with sepsis mortality and is up-regulated in monocytes from patients with severe COVID-19. We found that blood plasma from bacterial sepsis or COVID-19 patients with severe disease induces emergency myelopoiesis and expression of the MS1 program, which are dependent on the cytokines IL-6 and IL-10. Finally, we demonstrate that MS1 cells are broadly immunosuppressive, similar to monocytic myeloid-derived suppressor cells (MDSCs), and have decreased responsiveness to stimulation. Our findings highlight the utility of regulatory myeloid cells in sepsis prognosis, and the role of systemic cytokines in inducing emergency myelopoiesis during severe bacterial and SARS-CoV-2 infections.
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234
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Satre Buisson L. Coagulopathie associée au COVID-19 : les éléments essentiels pour l’anesthésiste-réanimateur. LE PRATICIEN EN ANESTHESIE REANIMATION 2020; 24:190-195. [PMID: 32837214 PMCID: PMC7357462 DOI: 10.1016/j.pratan.2020.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Coagulation disorders are commonly reported in patients suffering from COVID-19 pneumonia. These are associated to an increase incidence of thrombotic disorders associated with an increase mortality rate. D-Dimers concentrations > 3 μg/L, fibrinogen > 8 g/L and decreased platelets count are associated with an increased thrombotic risk. These biological markers have to be closely monitored during ICU stay. The diagnosis of pulmonary embolism could be difficult in this setting. However, it has to be evoked in case of worsening hypoxemia unexplained by other reason and/or right ventricular failure. The thrombotic risk can be scored to adapt the thromboprophylactic treatment, impaired renal function and overweight making it even more difficult.
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Affiliation(s)
- Léa Satre Buisson
- Service d’anesthésie-réanimation, hôpital Saint-Antoine, DMU DREAM, hôpitaux Sorbonne université, Assistance publique–Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
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Iba T, Levy JH, Levi M, Thachil J. Coagulopathy in COVID-19. J Thromb Haemost 2020; 18:2103-2109. [PMID: 32558075 PMCID: PMC7323352 DOI: 10.1111/jth.14975] [Citation(s) in RCA: 363] [Impact Index Per Article: 90.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/07/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023]
Abstract
The COVID-19 pandemic has become an urgent issue in every country. Based on recent reports, the most severely ill patients present with coagulopathy, and disseminated intravascular coagulation (DIC)-like massive intravascular clot formation is frequently seen in this cohort. Therefore, coagulation tests may be considered useful to discriminate severe cases of COVID-19. The clinical presentation of COVID-19-associated coagulopathy is organ dysfunction primarily, whereas hemorrhagic events are less frequent. Changes in hemostatic biomarkers represented by increase in D-dimer and fibrin/fibrinogen degradation products indicate the essence of coagulopathy is massive fibrin formation. In comparison with bacterial-sepsis-associated coagulopathy/DIC, prolongation of prothrombin time, and activated partial thromboplastin time, and decrease in antithrombin activity is less frequent and thrombocytopenia is relatively uncommon in COVID-19. The mechanisms of the coagulopathy are not fully elucidated, however. It is speculated that the dysregulated immune responses orchestrated by inflammatory cytokines, lymphocyte cell death, hypoxia, and endothelial damage are involved. Bleeding tendency is uncommon, but the incidence of thrombosis in COVID-19 and the adequacy of current recommendations regarding standard venous thromboembolic dosing are uncertain.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Marcel Levi
- Department of Medicine, and Cardio-metabolic Programme-NIHR UCLH/UCL BRC, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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Liao D, Zhou F, Luo L, Xu M, Wang H, Xia J, Gao Y, Cai L, Wang Z, Yin P, Wang Y, Tang L, Deng J, Mei H, Hu Y. Haematological characteristics and risk factors in the classification and prognosis evaluation of COVID-19: a retrospective cohort study. Lancet Haematol 2020; 7:e671-e678. [PMID: 32659214 PMCID: PMC7351397 DOI: 10.1016/s2352-3026(20)30217-9] [Citation(s) in RCA: 313] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/27/2020] [Accepted: 06/16/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND COVID-19 is an ongoing global pandemic. Changes in haematological characteristics in patients with COVID-19 are emerging as important features of the disease. We aimed to explore the haematological characteristics and related risk factors in patients with COVID-19. METHODS This retrospective cohort study included patients with COVID-19 admitted to three designated sites of Wuhan Union Hospital (Wuhan, China). Demographic, clinical, laboratory, treatment, and outcome data were extracted from electronic medical records and compared between patients with moderate, severe, and critical disease (defined according to the diagnosis and treatment protocol for novel coronavirus pneumonia, trial version 7, published by the National Health Commission of China). We assessed the risk factors associated with critical illness and poor prognosis. Dynamic haematological and coagulation parameters were investigated with a linear mixed model, and coagulopathy screening with sepsis-induced coagulopathy and International Society of Thrombosis and Hemostasis overt disseminated intravascular coagulation scoring systems was applied. FINDINGS Of 466 patients admitted to hospital from Jan 23 to Feb 23, 2020, 380 patients with COVID-19 were included in our study. The incidence of thrombocytopenia (platelet count <100 × 109 cells per L) in patients with critical disease (42 [49%] of 86) was significantly higher than in those with severe (20 [14%] of 145) or moderate (nine [6%] of 149) disease (p<0·0001). The numbers of lymphocytes and eosinophils were significantly lower in patients with critical disease than those with severe or moderate disease (p<0·0001), and prothrombin time, D-dimer, and fibrin degradation products significantly increased with increasing disease severity (p<0·0001). In multivariate analyses, death was associated with increased neutrophil to lymphocyte ratio (≥9·13; odds ratio [OR] 5·39 [95% CI 1·70-17·13], p=0·0042), thrombocytopenia (platelet count <100 × 109 per L; OR 8·33 [2·56-27·15], p=0·00045), prolonged prothrombin time (>16 s; OR 4·94 [1·50-16·25], p=0·0094), and increased D-dimer (>2 mg/L; OR 4·41 [1·06-18·30], p=0·041). Thrombotic and haemorrhagic events were common complications in patients who died (19 [35%] of 55). Sepsis-induced coagulopathy and International Society of Thrombosis and Hemostasis overt disseminated intravascular coagulation scores (assessed in 12 patients who survived and eight patients who died) increased over time in patients who died. The onset of sepsis-induced coagulopathy was typically before overt disseminated intravascular coagulation. INTERPRETATION Rapid blood tests, including platelet count, prothrombin time, D-dimer, and neutrophil to lymphocyte ratio can help clinicians to assess severity and prognosis of patients with COVID-19. The sepsis-induced coagulopathy scoring system can be used for early assessment and management of patients with critical disease. FUNDING National Key Research and Development Program of China.
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Affiliation(s)
- Danying Liao
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Fen Zhou
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Department of Paediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lili Luo
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Min Xu
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Hongbo Wang
- Department of Obstetrics and Gynaecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiahong Xia
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Gao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liqiong Cai
- Department of Obstetrics and Gynaecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhihui Wang
- Drug Clinical Trial Institution, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yadan Wang
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Lu Tang
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Jun Deng
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Heng Mei
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Yu Hu
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China.
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237
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COVID-19 and Thrombosis Predisposition. JOURNAL OF INTERDISCIPLINARY MEDICINE 2020. [DOI: 10.2478/jim-2020-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The novel coronavirus disease first appeared in Wuhan (China) is an infectious disease spreading throughout the world, causing life-threatening conditions in vulnerable or even healthy individuals. The great impact of this virus on healthcare urges physicians to investigate all aspects of the disease in order to overcome its complications. A particularly investigated aspect of the SARS-CoV-2 infection is represented by the coagulation disorders among infected and critically ill patients. Several studies observed modified blood coagulation parameters such as D-dimers, fibrinogen, and coagulation times. Moreover, the severe thrombotic complications, mainly pulmonary embolism, could be responsible for the high mortality and poorer outcomes of COVID-19 infected patients. The aim of this article is to present the current knowledge related to thrombosis predisposition in patients infected with the new coronavirus.
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238
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Mackman N, Antoniak S, Wolberg AS, Kasthuri R, Key NS. Coagulation Abnormalities and Thrombosis in Patients Infected With SARS-CoV-2 and Other Pandemic Viruses. Arterioscler Thromb Vasc Biol 2020; 40:2033-2044. [PMID: 32657623 PMCID: PMC7447001 DOI: 10.1161/atvbaha.120.314514] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023]
Abstract
The world is amid a pandemic caused by severe acute respiratory syndrome-coronavirus 2. Severe acute respiratory syndrome-coronavirus causes serious respiratory tract infections that can lead to viral pneumonia, acute respiratory distress syndrome, and death. Some patients with coronavirus disease 2019 (COVID-19) have an activated coagulation system characterized by elevated plasma levels of d-dimer-a biomarker of fibrin degradation. Importantly, high levels of D-dimer on hospital admission are associated with increased risk of mortality. Venous thromboembolism is more common than arterial thromboembolism in hospitalized COVID-19 patients. Pulmonary thrombosis and microvascular thrombosis are observed in autopsy studies, and this may contribute to the severe hypoxia observed in COVID-19 patients. It is likely that multiple systems contribute to thrombosis in COVID-19 patients, such as activation of coagulation, platelet activation, hypofibrinolysis, endothelial cell dysfunction, inflammation, neutrophil extracellular traps, and complement. Targeting these different pathways may reduce thrombosis and improve lung function in COVID-19 patients.
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Affiliation(s)
- Nigel Mackman
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Division of Hematology, Department of Medicine (N.M., R.K., N.S.K.), University of North Carolina at Chapel Hill
| | - Silvio Antoniak
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Department of Pathology and Laboratory Medicine (S.A., A.S.W.), University of North Carolina at Chapel Hill
| | - Alisa S. Wolberg
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Department of Pathology and Laboratory Medicine (S.A., A.S.W.), University of North Carolina at Chapel Hill
| | - Raj Kasthuri
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Division of Hematology, Department of Medicine (N.M., R.K., N.S.K.), University of North Carolina at Chapel Hill
| | - Nigel S. Key
- From the Department of Medicine, UNC Blood Research Center (N.M., S.A., A.S.W., R.K., N.S.K.), University of North Carolina at Chapel Hill
- Division of Hematology, Department of Medicine (N.M., R.K., N.S.K.), University of North Carolina at Chapel Hill
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239
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Moores LK, Tritschler T, Brosnahan S, Carrier M, Collen JF, Doerschug K, Holley AB, Jimenez D, Le Gal G, Rali P, Wells P. Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019: CHEST Guideline and Expert Panel Report. Chest 2020; 158:1143-1163. [PMID: 32502594 PMCID: PMC7265858 DOI: 10.1016/j.chest.2020.05.559] [Citation(s) in RCA: 443] [Impact Index Per Article: 110.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Emerging evidence shows that severe coronavirus disease 2019 (COVID-19) can be complicated by a significant coagulopathy, that likely manifests in the form of both microthrombosis and VTE. This recognition has led to the urgent need for practical guidance regarding prevention, diagnosis, and treatment of VTE. METHODS A group of approved panelists developed key clinical questions by using the PICO (Population, Intervention, Comparator, Outcome) format that addressed urgent clinical questions regarding the prevention, diagnosis, and treatment of VTE in patients with COVID-19. MEDLINE (via PubMed or Ovid), Embase, and Cochrane Controlled Register of Trials were systematically searched for relevant literature, and references were screened for inclusion. Validated evaluation tools were used to grade the level of evidence to support each recommendation. When evidence did not exist, guidance was developed based on consensus using the modified Delphi process. RESULTS The systematic review and critical analysis of the literature based on 13 Population, Intervention, Comparator, Outcome questions resulted in 22 statements. Very little evidence exists in the COVID-19 population. The panel thus used expert consensus and existing evidence-based guidelines to craft the guidance statements. CONCLUSIONS The evidence on the optimal strategies to prevent, diagnose, and treat VTE in patients with COVID-19 is sparse but rapidly evolving.
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Affiliation(s)
- Lisa K Moores
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Shari Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University Langone Health System, New York, NY
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jacob F Collen
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD; Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Kevin Doerschug
- Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, IA
| | - Aaron B Holley
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD; Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - David Jimenez
- Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Gregoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Philip Wells
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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240
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Consenso colombiano para la prevención, el diagnóstico y el tratamiento de condiciones trombóticas en adultos con COVID-19: aplicando el Marco de la Evidencia a la Decisión (EtD) GRADE. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [PMCID: PMC7531431 DOI: 10.1016/j.rccar.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introducción estudios recientes han reportado fenómenos trombóticos o coagulopatía en pacientes con COVID-19. Hay posiciones divergentes en cuanto a la prevención, el diagnóstico y el tratamiento de estos fenómenos, y la práctica clínica actual está basada únicamente en deducciones por extensión a partir de estudios retrospectivos, series de casos, estudios observacionales y guías internacionales desarrolladas previas a la pandemia. Objetivo establecer una serie de recomendaciones sobre prevención, diagnóstico y manejo de las complicaciones trombóticas asociadas a COVID-19. Métodos se desarrolló una guía rápida en la que se aplicó el marco de la evidencia a la decisión (EtD) de GRADE y un sistema de participación iterativo, con análisis estadísticos y cualitativos de sus resultados. Resultados se generaron 31 recomendaciones clínicas enfocadas a: a) Pruebas de coagulación en adultos sintomáticos con sospecha de infección o infección confirmada por SARS-CoV-2; b) Tromboprofilaxis en personas adultas con diagnóstico de COVID-19 (escalas de riesgo, tromboprofilaxis de manejo ambulatorio, intrahospitalario y duración de tromboprofilaxis después del egreso de hospitalización), c) Diagnóstico y tratamiento de las complicaciones trombóticas y d) Manejo de personas con indicación previa a usar agentes anticoagulantes. Conclusiones las recomendaciones clínicas de este consenso orientan la toma de decisiones clínicas respecto a prevención, diagnóstico y tratamiento de fenómenos trombóticos en pacientes con COVID-19, y representan un acuerdo que ayudará a disminuir la dispersión en las prácticas clínicas acorde con el desafío que impone la pandemia.
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241
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Luo L, Xu M, Du M, Kou H, Liao D, Cheng Z, Mei H, Hu Y. Early coagulation tests predict risk stratification and prognosis of COVID-19. Aging (Albany NY) 2020; 12:15918-15937. [PMID: 32860672 PMCID: PMC7485702 DOI: 10.18632/aging.103581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/09/2020] [Indexed: 01/08/2023]
Abstract
The ongoing outbreak of Coronavirus Disease 2019 (COVID-19) is hitting the world hard, but the relationship between coagulation disorders and COVID-19 is still not clear. This study aimed to explore whether early coagulation tests can predict risk stratification and prognosis. PubMed, Web of Science, Cochrane Library, and Scopus were searched electronically for relevant research studies published up to March 24, 2020, producing 24 articles for the final inclusion. The pooled standard mean difference (SMD) of coagulation parameters at admission were calculated to determine severe and composite endpoint conditions (ICU or death) in COVID-19 patients. Meta-analyses revealed that platelet count was not statistically related to disease severity and composite endpoint; elevated D-dimer correlated positively with disease severity (SMD 0.787 (0.277-1.298), P= 0.003, I2= 96.7%) but had no significant statistical relationship with composite endpoints. Similarly, patients with prolonged prothrombin time (PT) had an increased risk of ICU and increased risk of death (SMD 1.338 (0.551-2.125), P = 0.001, I2 = 92.7%). Besides, increased fibrin degradation products (FDP) and decreased antithrombin might also mean the disease is worsening. Therefore, early coagulation tests followed by dynamic monitoring is useful for recognizing coagulation disorders accompanied by COVID-19 and guiding timely therapy to improve prognosis.
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Affiliation(s)
- Lili Luo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Hubei Clinical and Research Centre of Thrombosis and Hemostasis, Wuhan 430022, China
| | - Min Xu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Hubei Clinical and Research Centre of Thrombosis and Hemostasis, Wuhan 430022, China
| | - Mengyi Du
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Hubei Clinical and Research Centre of Thrombosis and Hemostasis, Wuhan 430022, China
| | - Haiming Kou
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Hubei Clinical and Research Centre of Thrombosis and Hemostasis, Wuhan 430022, China
| | - Danying Liao
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Hubei Clinical and Research Centre of Thrombosis and Hemostasis, Wuhan 430022, China
| | - Zhipeng Cheng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Hubei Clinical and Research Centre of Thrombosis and Hemostasis, Wuhan 430022, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Hubei Clinical and Research Centre of Thrombosis and Hemostasis, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.,Hubei Clinical and Research Centre of Thrombosis and Hemostasis, Wuhan 430022, China
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242
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Luo LL, Mei H, Hu Y. [Progress in quantitative diagnosis of sepsis-induced disseminated intravascular coagulation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:433-436. [PMID: 32536146 PMCID: PMC7342063 DOI: 10.3760/cma.j.issn.0253-2727.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- L L Luo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - H Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Y Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Abstract
Abstract
At the end of 2019, a new coronavirus infection occurred in the People’s Republic of China with an epicentre in the city of Wuhan. On February 11th, 2020, the World Health Organization assigned the official name of the infection caused by the new coronavirus – COVID-19. COVID-19 has affected people from all over the world given that the infection was noted in 200 countries resulting in annunciation of the pandemic situation. Human corona viruses cause mild to moderate respiratory infections. At the end of 2002, a new coronavirus appeared (SARS-CoV), the causal agent of atypical pneumonia, which caused acute respiratory distress syndrome (ARDS). The initial stage of COVID-19 infection is the penetration of SARS-CoV-2 into target cells that have angiotensin converting enzyme type II receptors. The virus enters the body through the respiratory tract and interacts primarily with toll-like receptors (TLRs). The events in SARS-Cov-2 induced infection follow the next scenario: epithelial cells via TLRs recognize and identify SARS-Cov-2, and after that the information is transmitted to the transcriptional NF-κB, which causes expression of the corresponding genes. Activated in this way, the epithelial cells begin to synthesize various biologically active molecules. The results obtained on preclinical material indicate that ROS generation increases and the antioxidant protection decreases, which plays a major role in the pathogenesis of SARS-CoV, as well as in the progression and severity of this respiratory disease.
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244
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Gozzo L, Viale P, Longo L, Vitale DC, Drago F. The Potential Role of Heparin in Patients With COVID-19: Beyond the Anticoagulant Effect. A Review. Front Pharmacol 2020; 11:1307. [PMID: 32973526 PMCID: PMC7472559 DOI: 10.3389/fphar.2020.01307] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is responsible of variable clinical manifestations, ranging from no symptoms to severe pneumonia with acute respiratory distress syndrome, septic shock, and multi-organ failure resulting in death. To date no specific antiviral drug have been approved for COVID-19, so the treatment of the disease is mainly focused on symptomatic treatment and supportive care. Moreover, there are no treatments of proven efficacy to reduce the progression of the disease from mild/moderate to severe/critical. An activation of the coagulation cascade leading to severe hypercoagulability has been detected in these patients, therefore early anticoagulation may reduce coagulopathy, microthrombus formation, and the risk of organ damages. The role of heparin in COVID-19 is supported by a lot of studies describing its pleiotropic activity but it must be proven in clinical trials. Several protocols have been designed to assess the risk-benefit profile of heparin (low-molecular-weight or unfractionated heparin) in hospitalized subjects. Although prophylactic doses may be adequate in most patients, it is important to wait the results of clinical trials in order to define the appropriate effective dose able to improve disease outcome.
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Affiliation(s)
- Lucia Gozzo
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant’Orsola, University of Bologna, Bologna, Italy
| | - Laura Longo
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Daniela Cristina Vitale
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Filippo Drago
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
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Rogero MM, Leão MDC, Santana TM, Pimentel MVDMB, Carlini GCG, da Silveira TFF, Gonçalves RC, Castro IA. Potential benefits and risks of omega-3 fatty acids supplementation to patients with COVID-19. Free Radic Biol Med 2020; 156:190-199. [PMID: 32653511 PMCID: PMC7350587 DOI: 10.1016/j.freeradbiomed.2020.07.005] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/26/2020] [Accepted: 07/05/2020] [Indexed: 12/13/2022]
Abstract
Studies have shown that infection, excessive coagulation, cytokine storm, leukopenia, lymphopenia, hypoxemia and oxidative stress have also been observed in critically ill Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) patients in addition to the onset symptoms. There are still no approved drugs or vaccines. Dietary supplements could possibly improve the patient's recovery. Omega-3 fatty acids, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), present an anti-inflammatory effect that could ameliorate some patients need for intensive care unit (ICU) admission. EPA and DHA replace arachidonic acid (ARA) in the phospholipid membranes. When oxidized by enzymes, EPA and DHA contribute to the synthesis of less inflammatory eicosanoids and specialized pro-resolving lipid mediators (SPMs), such as resolvins, maresins and protectins. This reduces inflammation. In contrast, some studies have reported that EPA and DHA can make cell membranes more susceptible to non-enzymatic oxidation mediated by reactive oxygen species, leading to the formation of potentially toxic oxidation products and increasing the oxidative stress. Although the inflammatory resolution improved by EPA and DHA could contribute to the recovery of patients infected with SARS-CoV-2, Omega-3 fatty acids supplementation cannot be recommended before randomized and controlled trials are carried out.
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Affiliation(s)
- Marcelo M Rogero
- Nutritional Genomics and Inflammation Laboratory, Department of Nutrition, School of Public Health, University of São Paulo, 01246-904, São Paulo, Brazil; Food Research Center (FoRC), CEPID-FAPESP, Research Innovation and Dissemination Center of São Paulo Research Foundation, São Paulo, 05468-140, Brazil
| | - Matheus de C Leão
- LADAF, Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo-SP, Brazil
| | - Tamires M Santana
- Food Research Center (FoRC), CEPID-FAPESP, Research Innovation and Dissemination Center of São Paulo Research Foundation, São Paulo, 05468-140, Brazil; LADAF, Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo-SP, Brazil
| | - Mariana V de M B Pimentel
- LADAF, Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo-SP, Brazil
| | - Giovanna C G Carlini
- LADAF, Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo-SP, Brazil
| | - Tayse F F da Silveira
- LADAF, Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo-SP, Brazil
| | - Renata C Gonçalves
- Department of Cell and Developmental Biology. Institute of Biomedical Sciences. University of São Paulo, São Paulo, Brazil
| | - Inar A Castro
- Food Research Center (FoRC), CEPID-FAPESP, Research Innovation and Dissemination Center of São Paulo Research Foundation, São Paulo, 05468-140, Brazil; LADAF, Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo-SP, Brazil.
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246
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Vizcaychipi MP, Shovlin CL, McCarthy A, Godfrey A, Patel S, Shah PL, Hayes M, Keays RT, Beveridge I, Davies G. Increase in COVID-19 inpatient survival following detection of Thromboembolic and Cytokine storm risk from the point of admission to hospital by a near real time Traffic-light System (TraCe-Tic). Braz J Infect Dis 2020; 24:412-421. [PMID: 32857990 PMCID: PMC7434453 DOI: 10.1016/j.bjid.2020.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/21/2020] [Accepted: 07/31/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction Our goal was to evaluate if traffic-light driven personalized care for COVID-19 was associated with improved survival in acute hospital settings. Methods Discharge outcomes were evaluated before and after prospective implementation of a real-time dashboard with feedback to ward-based clinicians. Thromboembolism categories were “medium-risk” (D-dimer >1000 ng/mL or CRP >200 mg/L); “high-risk” (D-dimer >3000 ng/mL or CRP >250 mg/L) or “suspected” (D-dimer >5000 ng/mL). Cytokine storm risk was categorized by ferritin. Results 939/1039 COVID-19 positive patients (median age 67 years, 563/939 (60%) male) completed hospital encounters to death or discharge by 21st May 2020. Thromboembolism flag criteria were reached by 568/939 (60.5%), including 238/275 (86.6%) of the patients who died, and 330/664 (49.7%) of the patients who survived to discharge, p < 0.0001. Cytokine storm flag criteria were reached by 212 (22.6%) of admissions, including 80/275 (29.1%) of the patients who died, and 132/664 (19.9%) of the patients who survived, p < 0.0001. The maximum thromboembolism flag discriminated completed encounter mortality (no flag: 37/371 [9.97%] died; medium-risk: 68/239 [28.5%]; high-risk: 105/205 [51.2%]; and suspected thromboembolism: 65/124 [52.4%], p < 0.0001). Flag criteria were reached by 535 consecutive COVID-19 positive patients whose hospital encounter completed before traffic-light introduction: 173/535 (32.3% [95% confidence intervals 28.0, 36.0]) died. For the 200 consecutive admissions after implementation of real-time traffic light flags, 46/200 (23.0% [95% confidence intervals 17.1, 28.9]) died, p = 0.013. Adjusted for age and sex, the probability of death was 0.33 (95% confidence intervals 0.30, 0.37) before traffic light implementation, 0.22 (0.17, 0.27) after implementation, p < 0.001. In subgroup analyses, older patients, males, and patients with hypertension (p ≤ 0.01), and/or diabetes (p = 0.05) derived the greatest benefit from admission under the traffic light system. Conclusion Personalized early interventions were associated with a 33% reduction in early mortality. We suggest benefit predominantly resulted from early triggers to review/enhance anticoagulation management, without exposing lower-risk patients to potential risks of full anticoagulation therapy.
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Affiliation(s)
- Marcela P Vizcaychipi
- Chelsea & Westminster Hospital NHS Foundation Trust, Anaesthesia and Intensive Care, London, United Kingdom; Imperial College London, Department of Surgery and Cancer, London, United Kingdom.
| | - Claire L Shovlin
- Imperial College London, NHLI Vascular Science, London, United Kingdom.
| | - Alex McCarthy
- Chelsea & Westminster Hospital NHS Foundation Trust, Information, Data Quality and Clinical Coding, London, United Kingdom
| | - Andrew Godfrey
- Chelsea & Westminster Hospital NHS Foundation Trust, Haematology, London, United Kingdom
| | - Sheena Patel
- Chelsea & Westminster Hospital NHS Foundation Trust, Pharmacy, London, United Kingdom
| | - Pallav L Shah
- Chelsea & Westminster Hospital NHS Foundation Trust, Respiratory Medicine, London, United Kingdom
| | - Michelle Hayes
- Chelsea & Westminster Hospital NHS Foundation Trust, Anaesthesia and Intensive Care, London, United Kingdom
| | - Richard T Keays
- Chelsea & Westminster Hospital NHS Foundation Trust, Anaesthesia and Intensive Care, London, United Kingdom; Imperial College London, Department of Surgery and Cancer, London, United Kingdom
| | - Iain Beveridge
- West Middlesex University Hospital NHS Foundation Trust, Department of Anaesthesia & Intensive Care Medicine, Isleworth, United Kingdom
| | - Gary Davies
- Chelsea & Westminster Hospital NHS Foundation Trust, Respiratory Medicine, London, United Kingdom
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Dunkel B. Science-in-brief: The role of the glycocalyx in critically ill patients with reference to the horse. Equine Vet J 2020; 52:790-793. [PMID: 32786127 DOI: 10.1111/evj.13328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Bettina Dunkel
- Department of Veterinary Clinical Sciences, The Royal Veterinary College, North Mymms, Hatfield, Hertfordshire, UK
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248
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Colombo L, Macheda A, Gentile D, Panizzardi F, Pierini S, Codazzi C, Meloni L, Bianchi F, Santangelo G. How to manage thromboembolic risk in patient with SARS-CoV-2-related disease in the Emergency Department: A case report of cardiogenic shock due to massive pulmonary embolism. Respir Med Case Rep 2020; 31:101185. [PMID: 32834988 PMCID: PMC7419271 DOI: 10.1016/j.rmcr.2020.101185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/02/2020] [Accepted: 08/05/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although the most known feature of SARS-CoV-2 associated infection is a mild to severe pneumonia, increasing evidence suggests the existence of an infection-associated risk of both arterial and venous thromboembolism (VTE), but the exact magnitude of this phenomenon is still unknown.Given that, it is important for the Emergency Physician to remember that a SARS-CoV-2 associated respiratory failure can be caused not only by the pulmonary parenchymal inflammation that characterizes the pneumonia, but also by an associated pulmonary thromboembolism. CASE REPORT A healthy 73-years old woman admitted to the ED for dyspnea, fever and thoracic pain. Cardiac ultrasound, electrocardiogram and clinical findings suggested a diagnosis of cardiogenic obstructive shock due to acute pulmonary embolism, successfully treated with thrombolysis. A CT angiography confirmed the pulmonary embolism (EP) diagnosis and showed bilateral pneumonia, caused by SARS-CoV-2 infection. CONCLUSION Considering the high prevalence of thromboembolic events in COVID-19 patients it is mandatory for the emergency physician to systematically evaluate signs of pulmonary thromboembolism, in order to perform the most patient-tailored therapy as soon as possible.
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Affiliation(s)
- L. Colombo
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - A. Macheda
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - D. Gentile
- Cardiology Department, Ospedale San Paolo, Milano, Italy
| | - F. Panizzardi
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - S. Pierini
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - C. Codazzi
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - L. Meloni
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - F. Bianchi
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - G. Santangelo
- Cardiology Department, Ospedale San Paolo, Milano, Italy
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Hemostatic Abnormalities in COVID-19: An Update. Indian J Hematol Blood Transfus 2020; 36:616-626. [PMID: 32837053 PMCID: PMC7418883 DOI: 10.1007/s12288-020-01328-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/03/2020] [Indexed: 12/27/2022] Open
Abstract
COVID-19 has emerged as a pandemic with lung being the primarily afflicted organ. Deranged hemostasis has been observed in patients with COVID-19 with scales tipped towards a prothrombotic state. The pathogenesis differs from disseminated intravascular coagulation with a primary pulmonary localization. This is referred to as pulmonary intravascular coagulopathy with strong component of thrombo-inflammation. This is reflected in the lab tests with an increase in D-dimer which correlates with severity and outcomes of disease. Common coagulation tests such as prothrombin time, activated partial thromboplastin time are only mildly prolonged while most patients have normal to increased fibrinogen and marginal thrombocytopenia. Overall, the patients have an increase in venous and arterial thrombotic events especially in ICU patients. Routine thromboprophylaxis with low molecular weight heparin is recommended in all hospitalized patients to reduce the incidence of thrombosis. Bleeding is uncommon and treated with blood products transfusion. This review shall discuss the hemostatic abnormalities in COVID-19 patients and their impact on prognosis. In addition, strategy of thromboprophylaxis and various academic society guidelines are discussed in detail.
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250
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Luo L, Xu M, Liao D, Deng J, Mei H, Hu Y. PECAM-1 protects against DIC by dampening inflammatory responses via inhibiting macrophage pyroptosis and restoring vascular barrier integrity. Transl Res 2020; 222:1-16. [PMID: 32417429 DOI: 10.1016/j.trsl.2020.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/12/2020] [Accepted: 04/07/2020] [Indexed: 12/16/2022]
Abstract
Disseminated intravascular coagulation (DIC) is a frequent complication of sepsis that affects patient outcomes due to accompanying thrombo-inflammation and microvascular permeability changes. Platelet endothelial cell adhesion molecule-1 (PECAM-1), a cellular adhesion and signaling receptor that is expressed on both hematopoietic and endothelial cells, plays an important anti-inflammatory role in acute and chronic inflammatory disease models. Little is known, however, about role and mechanism of PECAM-1 in septic DIC. Here, we investigated whether PECAM-1 might play a protective role in hindering the development of septic DIC. Plasma levels of soluble PECAM-1 were markedly elevated in septic patients that developed DIC, with a correspondingly poorer outcome. PECAM-1 knockout exhibited more severe DIC and poorer outcome in the LPS induced- and cecal ligation and puncture-induced DIC model, which could be alleviated by tissue factor inhibitor. This phenomenon seemed to be equally linked to PECAM-1 expression by both endothelial and blood cells. Furthermore, PECAM-1 was found to exert its protective effect on developing septic DIC by the following 2 distinct mechanisms: the inhibition of macrophage pyroptosis and the acceleration of the restoration of the endothelial cell barrier. Taken together, these results implicate PECAM-1 as a potentially attractive target for the development of novel therapeutics to manage and treat septic DIC.
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Affiliation(s)
- Lili Luo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Min Xu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Danying Liao
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jun Deng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China.
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China
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