Coagulopathy in COVID-19

Neuroimaging Patterns in Patients with COVID-19-Associated Neurological Complications: A Review

Background

A variety of neuroimaging abnormalities in COVID-19 have been described.

Objectives

In this article, we reviewed the varied neuroimaging patterns in patients with COVID-19-associated neurological complications.

Methods

We searched PubMed, Google Scholar, Scopus and preprint databases (medRxiv and bioRxiv). The search terms we used were "COVID -19 and encephalitis, encephalopathy, neuroimaging or neuroradiology" and "SARS-CoV-2 and encephalitis, encephalopathy, neuroimaging or neuroradiology".

Results

Neuroimaging abnormalities are common in old age and patients with comorbidities. Neuroimaging abnormalities are largely vascular in origin. COVID-19-associated coagulopathy results in large vessel occlusion and cerebral venous thrombosis. COVID-19-associated intracerebral hemorrhage resembles anticoagulant associated intracerebral hemorrhage. On neuroimaging, hypoxic-ischemic damage along with hyperimmune reaction against the SARS-COV-2 virus manifests as small vessel disease. Small vessel disease appears as diffuse leukoencephalopathy and widespread microbleeds, and subcortical white matter hyperintensities. Occasionally, gray matter hyperintensity, similar to those observed seen in autoimmune encephalitis, has been noted. In many cases, white matter lesions similar to that in acute disseminated encephalomyelitis have been described. Acute disseminated encephalomyelitis in COVID-19 seems to be a parainfectious event and autoimmune in origin. Many cases of acute necrotizing encephalitis resulting in extensive damage to thalamus and brain stem have been described; cytokine storm has been considered a pathogenic mechanism behind this. None of the neuroimaging abnormalities can provide a clue to the possible pathogenic mechanism.

Conclusions

Periventricular white-matter MR hyperintensity, microbleeds, arterial and venous infarcts, and hemorrhages are apparently distinctive neuroimaging abnormalities in patients with COVID-19.

Comparing COVID-19 and Influenza Presentation and Trajectory

Background: COVID-19 is a newly recognized illness with a predominantly respiratory presentation. It is important to characterize the differences in disease presentation and trajectory between COVID-19 patients and other patients with common respiratory illnesses. These differences can enhance knowledge of pathogenesis and help in guiding treatment. Methods: Data from electronic medical records were obtained from individuals admitted with respiratory illnesses to Rambam Health Care Campus, Haifa, Israel, between October 1st, 2014 and October 1st, 2020. Four groups of patients were defined: COVID-19 (693), influenza (1,612), severe acute respiratory infection (SARI) (2,292), and Others (4,054). The variable analyzed include demographics (7), vital signs (8), lab tests (38), and comorbidities (15) from a total of 8,651 hospitalized adult patients. Statistical analysis was performed on biomarkers measured at admission and for their disease trajectory in the first 48 h of hospitalization, and on comorobidity prevalence. Results: COVID-19 patients were overall younger in age and had higher body mass index, compared to influenza and SARI. Comorbidity burden was lower in the COVID-19 group compared to influenza and SARI. Severely- and moderately-ill COVID-19 patients older than 65 years of age suffered higher rate of in-hospital mortality compared to hospitalized influenza patients. At admission, white blood cells and neutrophils were lower among COVID-19 patients compared to influenza and SARI patients, while pulse rate and lymphoctye percentage were higher. Trajectories of variables during the first 2 days of hospitalization revealed that white blood count, neutrophils percentage and glucose in blood increased among COVID-19 patients, while decreasing among other patients. Conclusions: The intrinsic virulence of COVID-19 appeared higher than influenza. In addition, several critical functions, such as immune response, coagulation, heart and respiratory function, and metabolism were uniquely affected by COVID-19.

Coagulopathy of Coronavirus Disease 2019: A Case Series

BACKGROUND: In Coronavirus disease 2019 (COVID-19), the main manifestations were fever, cough, and anosmia. AIM: We aimed to investigate coagulopathy and disseminated intravascular coagulation in severe COVID-19 patients. METHODS: Five cases of COVID-19 with coagulopathy have been reported. RESULTS: All patients presented with various main complaints such as fever, cough, shortness of breath, and diarrhea. An increase in D-dimer value was found in all cases, with an increase of 4–5 times from the upper limit of normal. All patients were evaluated with the IMPROVE-VTE and PADUA thrombotic risk assessment models. Thromboprophylaxis with low molecular weight heparin LMWH intensive dosage was given to four patients. However, one patient was not given thromboprophylaxis because of the high risk of bleeding. All cases were not given long-term thromboprophylaxis after the patients were discharged from the hospital. All hospitalized COVID-19 patients can be considered to give thromboprophylaxis unless contraindicated. Thromboprophylaxis is preferable to use LMWH with a dose adjusted to the severity of COVID-19. Administration of thromboprophylaxis after hospitalization may be considered in patients who have thromboembolic risk factors. CONCLUSION: More research is being encouraged to increase understanding of the prevention and treatment of thrombotic complications of COVID-19.

Pulmonary Procoagulant and Innate Immune Responses in Critically Ill COVID-19 Patients

Rationale

Systemic activation of procoagulant and inflammatory mechanisms has been implicated in the pathogenesis of COVID-19. Knowledge of activation of these host response pathways in the lung compartment of COVID-19 patients is limited.

Objectives

To evaluate local and systemic activation of coagulation and interconnected inflammatory responses in critically ill COVID-19 patients with persistent acute respiratory distress syndrome.

Methods

Paired bronchoalveolar lavage fluid and plasma samples were obtained from 17 patients with COVID-19 related persistent acute respiratory distress syndrome (mechanical ventilation > 7 days) 1 and 2 weeks after start mechanical ventilation and compared with 8 healthy controls. Thirty-four host response biomarkers stratified into five functional domains (coagulation, complement system, cytokines, chemokines and growth factors) were measured.

Measurements and Main Results

In all patients, all functional domains were activated, especially in the bronchoalveolar compartment, with significantly increased levels of D-dimers, thrombin-antithrombin complexes, soluble tissue factor, C1-inhibitor antigen and activity levels, tissue type plasminogen activator, plasminogen activator inhibitor type I, soluble CD40 ligand and soluble P-selectin (coagulation), next to activation of C3bc and C4bc (complement) and multiple interrelated cytokines, chemokines and growth factors. In 10 patients in whom follow-up samples were obtained between 3 and 4 weeks after start mechanical ventilation many bronchoalveolar and plasma host response biomarkers had declined.

Conclusions

Critically ill, ventilated patients with COVID-19 show strong responses relating to coagulation, the complement system, cytokines, chemokines and growth factors in the bronchoalveolar compartment. These results suggest a local pulmonary rather than a systemic procoagulant and inflammatory “storm” in severe COVID-19.

Endothelial Dysfunction and SARS-CoV-2 Infection: Association and Therapeutic Strategies

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), has been recently considered a systemic disorder leading to the procoagulant state. Preliminary studies have shown that SARS-CoV-2 can infect endothelial cells, and extensive evidence of inflammation and endothelial dysfunction has been found in advanced COVID-19. Endothelial cells play a critical role in many physiological processes, such as controlling blood fluidity, leukocyte activation, adhesion, platelet adhesion and aggregation, and transmigration. Therefore, it is reasonable to think that endothelial dysfunction leads to vascular dysfunction, immune thrombosis, and inflammation associated with COVID-19. This article summarizes the association of endothelial dysfunction and SARS-CoV-2 infection and its therapeutic strategies.

The Systemic Immune Response in COVID-19 Is Associated with a Shift to Formyl-Peptide Unresponsive Eosinophils

A malfunction of the innate immune response in COVID-19 is associated with eosinopenia, particularly in more severe cases. This study tested the hypothesis that this eosinopenia is COVID-19 specific and is associated with systemic activation of eosinophils. Blood of 15 healthy controls and 75 adult patients with suspected COVID-19 at the ER were included before PCR testing and analyzed by point-of-care automated flow cytometry (CD10, CD11b, CD16, and CD62L) in the absence or presence of a formyl peptide (fNLF). Forty-five SARS-CoV-2 PCR positive patients were grouped based on disease severity. PCR negative patients with proven bacterial (n = 20) or other viral (n = 10) infections were used as disease controls. Eosinophils were identified with the use of the FlowSOM algorithm. Low blood eosinophil numbers (<100 cells/μL; p < 0.005) were found both in patients with COVID-19 and with other infectious diseases, albeit less pronounced. Two discrete eosinophil populations were identified in healthy controls both before and after activation with fNLF based on the expression of CD11b. Before activation, the CD11b^bright population consisted of 5.4% (CI_95% = 3.8, 13.4) of total eosinophils. After activation, this population of CD11b^bright cells comprised nearly half the population (42.21%, CI_95% = 35.9, 54.1). Eosinophils in COVID-19 had a similar percentage of CD11b^bright cells before activation (7.6%, CI_95% = 4.5, 13.6), but were clearly refractory to activation with fNLF as a much lower percentage of cells end up in the CD11b^bright fraction after activation (23.7%, CI_95% = 18.5, 27.6; p < 0.001). Low eosinophil numbers in COVID-19 are associated with refractoriness in responsiveness to fNLF. This might be caused by migration of fully functional cells to the tissue.

We stand ready … Blood collection organizations and the COVID-19 pandemic

See article on page 1471–1478, in this issue

Cellular Immune Response to COVID-19 and Potential Immune Modulators

Coronavirus disease 2019 (COVID-19) is a respiratory infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Droplets and contacts serve as the main route of transmission of SARS-CoV-2. The characteristic of the disease is rather heterogeneous, ranging from no symptoms to critical illness. The factors associated with the outcome of COVID-19 have not been completely characterized to date. Inspired by previous studies on the relevance of infectious diseases, viral and host factors related to clinical outcomes have been identified. The severity of COVID-19 is mainly related to host factors, especially cellular immune responses in patients. Patients with mild COVID-19 and improved patients with severe COVID-19 exhibit a normal immune response to effectively eliminate the virus. The immune response in patients with fatal severe COVID-19 includes three stages: normal or hypofunction, hyperactivation, and anergy. Eventually, the patients were unable to resist viral infection and died. Based on our understanding of the kinetics of immune responses during COVID-19, we suggest that type I interferon (IFN) could be administered to patients with severe COVID-19 in the hypofunctional stage, intravenous immunoglobulin (IVIG) and glucocorticoid therapy could be administered in the immune hyperactivation stage. In addition, low molecular weight heparin (LMWH) anticoagulation therapy and anti-infective therapy with antibiotics are recommended in the hyperactivation stage.

Coronavirus Disease and Cardiovascular Disease: A Literature Review

BACKGROUND AND AIM

Although severe acute respiratory syndrome coronavirus 2 primarily affects the respiratory system, involvement of cardiovascular system is not uncommon and a range of cardiac manifestations among Coronavirus Disease (COVID-19) patients were reported in the literature. Furthermore, it is evident from scientific literature that the incidence of deaths and hospitalizations has been increasingly more among COVID-19 subjects with pre-existing cardiovascular disease (CVD). Various pathophysiological mechanisms have been proposed to explain the cardiovascular involvement in COVID-19. Another emerging significant concern is the varying presentations of COVID-19 and side effects due to the medication used in the management of COVID-19 patients. This review attempts to provide a comprehensive overview of the existing literature on the possible association between CVD and COVID-19 with emphasis on the pathophysiological mechanisms, cardiac manifestations, and impact of medications used for COVID-19 on cardiovascular health. Based on the available literature, we conclude that though CVD could not be reckoned as an independent risk factor for COVID-19 infection, it is evident that pre-existing CVD has an influence on the severity of COVID-19 infection and associated mortality.

RELEVANCE FOR PATIENTS

Literature suggests that people with pre-existing CVD are at increased risk for COVID-19 and associated severity. Consequently, it becomes important to thoroughly gain insights into the possible pathophysiological mechanisms, cardiac manifestations in COVID-19, and the impact of COVID-19 treatment on the cardiovascular system.

Evaluating the elimination status of medications used for COVID-19 during hemoperfusion and therapeutic plasma exchange: A review

Since late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, better known as COVID-19) has rapidly spread worldwide. The primary pathophysiology by which COVID-19 leads to severe lung damage is cytokine releasing syndrome (CRS), which can cause death. Therefore, removing cytokines via therapeutic plasma exchange or hemoperfusion could be a therapeutic approach to treat CRS. However, hemoperfusion or therapeutic plasma exchange could alter the effectiveness of concomitant medications. Thus, concomitant medication doses might need to be adjusted to prevent their elimination via therapeutic plasma exchange or hemoperfusion, thus ensuring that these medications remain effective. This narrative review investigates the elimination status of current medications used to manage COVID-19 during hemoperfusion and therapeutic plasma exchange, with a focus on their pharmacokinetic profiles.

[Microvascular thrombosis and clinical implications]

Thrombosis is often present in the microcirculation in a variety of significant human diseases, such as disseminated intravascular coagulation, thrombotic microangiopathy, sickle cell disease, and others. Microvascular thrombosis has also recently been demonstrated in patients with COVID-19 and has been proposed to mediate the pathogenesis of organ injury in the lung and other organs. In many of these conditions, microvascular thrombosis is accompanied by inflammation, an association referred to as thromboinflammation or immunothrombosis. A greater understanding of the links between inflammation and thrombosis in the microcirculation will provide new therapeutic options for human diseases accompanied by microvascular thrombosis.

Ultramicronized Palmitoylethanolamide (um-PEA): A New Possible Adjuvant Treatment in COVID-19 patients

The Coronavirus Disease-19 (COVID-19) pandemic has caused more than 100,000,000 cases of coronavirus infection in the world in just a year, of which there were 2 million deaths. Its clinical picture is characterized by pulmonary involvement that culminates, in the most severe cases, in acute respiratory distress syndrome (ARDS). However, COVID-19 affects other organs and systems, including cardiovascular, urinary, gastrointestinal, and nervous systems. Currently, unique-drug therapy is not supported by international guidelines. In this context, it is important to resort to adjuvant therapies in combination with traditional pharmacological treatments. Among natural bioactive compounds, palmitoylethanolamide (PEA) seems to have potentially beneficial effects. In fact, the Food and Drug Administration (FDA) authorized an ongoing clinical trial with ultramicronized (um)-PEA as an add-on therapy in the treatment of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. In support of this hypothesis, in vitro and in vivo studies have highlighted the immunomodulatory, anti-inflammatory, neuroprotective and pain-relieving effects of PEA, especially in its um form. The purpose of this review is to highlight the potential use of um-PEA as an adjuvant treatment in SARS-CoV-2 infection.

'Long-COVID': a cross-sectional study of persisting symptoms, biomarker and imaging abnormalities following hospitalisation for COVID-19

Large numbers of people are being discharged from hospital following COVID-19 without assessment of recovery. In 384 patients (mean age 59.9 years; 62% male) followed a median 54 days post discharge, 53% reported persistent breathlessness, 34% cough and 69% fatigue. 14.6% had depression. In those discharged with elevated biomarkers, 30.1% and 9.5% had persistently elevated d-dimer and C reactive protein, respectively. 38% of chest radiographs remained abnormal with 9% deteriorating. Systematic follow-up after hospitalisation with COVID-19 identifies the trajectory of physical and psychological symptom burden, recovery of blood biomarkers and imaging which could be used to inform the need for rehabilitation and/or further investigation.

The molecular basis of immune-based platelet disorders

Platelets have a predominant role in haemostasis, the maintenance of blood volume and emerging roles as innate immune cells, in wound healing and in inflammatory responses. Platelets express receptors that are important for platelet adhesion, aggregation, participation in inflammatory responses, and for triggering degranulation and enhancing thrombin generation. They carry a cargo of granules bearing enzymes, adhesion molecules, growth factors and cytokines, and have the ability to generate reactive oxygen species. The platelet is at the frontline of a host of cellular responses to invading pathogens, injury, and infection. Perhaps because of this intrinsic responsibility of a platelet to rapidly respond to thrombotic, pathological and immunological factors as part of their infantry role; platelets are susceptible to targeted attack by the adaptive immune system. Such attacks are often transitory but result in aberrant platelet activation as well as significant loss of platelet numbers and platelet function, paradoxically leading to elevated risks of both thrombosis and bleeding. Here, we discuss the main molecular events underlying immune-based platelet disorders with specific focus on events occurring at the platelet surface leading to activation and clearance.

The Age-AST-D Dimer (AAD) Regression Model Predicts Severe COVID-19 Disease

AIM

Coronavirus disease (COVID-19) ranges from mild clinical phenotypes to life-threatening conditions like severe acute respiratory syndrome (SARS). It has been suggested that early liver injury in these patients could be a risk factor for poor outcome. We aimed to identify early biochemical predictive factors related to severe disease development with intensive care requirements in patients with COVID-19.

METHODS

Data from COVID-19 patients were collected at admission time to our hospital. Differential biochemical factors were identified between seriously ill patients requiring intensive care unit (ICU) admission (ICU patients) versus stable patients without the need for ICU admission (non-ICU patients). Multiple linear regression was applied, then a predictive model of severity called Age-AST-D dimer (AAD) was constructed (n = 166) and validated (n = 170).

RESULTS

Derivation cohort: from 166 patients included, there were 27 (16.3%) ICU patients that showed higher levels of liver injury markers (P < 0.01) compared with non-ICU patients: alanine aminotrasnferase (ALT) 225.4 ± 341.2 vs. 41.3 ± 41.1, aspartate aminotransferase (AST) 325.3 ± 382.4 vs. 52.8 ± 47.1, lactic dehydrogenase (LDH) 764.6 ± 401.9 vs. 461.0 ± 185.6, D-dimer (DD) 7765 ± 9109 vs. 1871 ± 4146, and age 58.6 ± 12.7 vs. 49.1 ± 12.8. With these finding, a model called Age-AST-DD (AAD), with a cut-point of <2.75 (sensitivity = 0.797 and specificity = 0.391, c - statistic = 0.74; 95%IC: 0.62-0.86, P < 0.001), to predict the risk of need admission to ICU (OR = 5.8; 95% CI: 2.2-15.4, P = 0.001), was constructed. Validation cohort: in 170 different patients, the AAD model < 2.75 (c - statistic = 0.80 (95% CI: 0.70-0.91, P < 0.001) adequately predicted the risk (OR = 8.8, 95% CI: 3.4-22.6, P < 0.001) to be admitted in the ICU (27 patients, 15.95%).

CONCLUSIONS

The elevation of AST (a possible marker of early liver injury) along with DD and age efficiently predict early (at admission time) probability of ICU admission during the clinical course of COVID-19. The AAD model can improve the comprehensive management of COVID-19 patients, and it could be useful as a triage tool to early classify patients with a high risk of developing a severe clinical course of the disease.

Renal angiomyolipoma rupture in a young female with COVID-19

While primarily a respiratory illness, infection with the novel coronavirus (COVID-19) is associated with pathologic changes in coagulation, characterized by both thromboembolic and bleeding events. We present the case of a 22-year-old female diagnosed with renal angiomyolipoma (AML) rupture 2 weeks after COVID-19 infection, ultimately requiring admission for hemorrhage control via endovascular embolization. Emergency medicine physicians should maintain a high index of suspicion for renal AML rupture and other spontaneous bleeding events in patients with recent COVID-19 infection due to a possible correlation between the two.

Modulation of Hemostasis in COVID-19; Blood Platelets May Be Important Pieces in the COVID-19 Puzzle

Although the precise pathogenesis of coronavirus disease 2019 (COVID-19) currently remains unknown, its complex nature is gradually being revealed. COVID-19 is a disease caused by the SARS-CoV-2 virus and leads to respiratory dysfunction. Studies on hemostatic parameters have showed that COVID-19 significantly affects the disruption of the coagulation system and may contribute to coagulation and thrombotic events. A relevant cause of hemostasis disorders is inflammation and cytokine storms, which cause, for example, endothelial dysfunction in blood vessels. In order to prevent and treat states of hypercoagulability and thrombosis, the administration of anticoagulants, e.g., heparin, is recommended. The present mini-review describes the relationship between hemostasis and COVID-19, and discusses whether this relationship may cast light on the nature of COVID-19. The present short manuscript also examines the relationship between blood platelets and COVID-19. In addition, the paper explores the potential use of antiplatelet drugs in COVID-19 cases. The studies were identified by searching electronic databases, including PubMed and SCOPUS.

Managing thrombosis and cardiovascular complications of COVID-19: answering the questions in COVID-19-associated coagulopathy

INTRODUCTION

The first patients with Coronavirus disease 2019 (COVID-19) emerged at the end of 2019. This novel viral infection demonstrated unique features that include prothrombotic clinical presentations. However, one year after the first occurrence, there remain many unanswered questions. We tried to address some of the important queries in this review.

AREAS COVERED

We raised the following critical questions. 'Why is COVID-19 so hypercoagulable?', 'Why are most coagulation test results relatively normal?', 'Why is COVID-19-associated coagulopathy more thrombotic than most other infectious diseases?', 'Why is arterial thrombus formed frequently?', 'Is anticoagulant therapy for COVID-19 effective?', and 'Are there racial disparities in thrombosis in COVID-19?'

EXPERT OPINION

There are commonalities and differences in the pathogeneses and clinical features between COVID-19 and other infectious diseases. Correct understanding will help discussing appropriate anticoagulation prophylaxis or treatment for thromboembolism.

Low ADAMTS13 Activity Correlates with Increased Mortality in COVID-19 Patients

The causes of coagulopathy associated with coronavirus disease 2019 (COVID-19) are poorly understood. We aimed to investigate the relationship between von Willebrand factor (VWF) biomarkers, intravascular hemolysis, coagulation, and organ damage in COVID-19 patients and study their association with disease severity and mortality. We conducted a retrospective study of 181 hospitalized COVID-19 patients randomly selected with balanced distribution of survivors and nonsurvivors. Patients who died had significantly lower ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity, significantly elevated lactate dehydrogenase levels, significantly increased shistocyte/RBC fragment counts, and significantly elevated VWF antigen and activity levels compared with patients discharged alive. These biomarkers correlate with markedly elevated D-dimers. Additionally, only 30% of patients who had an ADAMTS13 activity level of less than 43% on admission survived, yet 60% of patients survived who had an ADAMTS13 activity level of greater than 43% on admission. In conclusion, COVID-19 may present with low ADAMTS13 activity in a subset of hospitalized patients. Presence of schistocytes/RBC fragment and elevated D-dimer on admission may warrant a work-up for ADAMTS13 activity and VWF antigen and activity levels. These findings indicate the need for future investigation to study the relationship between endothelial and coagulation activation and the efficacy of treatments aimed at prevention and/or amelioration of microangiopathy in COVID-19.

Antibody-induced procoagulant platelets in severe COVID-19 infection

Severe COVID-19 is associated with increased antibody-mediated procoagulant platelets.

Procoagulant platelets and platelet apoptosis in severe COVID-19 is correlated with D-dimer and higher incidence of thromboembolisms.

The pathophysiology of COVID-19–associated thrombosis seems to be multifactorial. We hypothesized that COVID-19 is accompanied by procoagulant platelets with subsequent alteration of the coagulation system. We investigated depolarization of mitochondrial inner transmembrane potential (ΔΨm), cytosolic calcium (Ca²⁺) concentration, and phosphatidylserine (PS) externalization. Platelets from COVID-19 patients in the intensive care unit (ICU; n = 21) showed higher ΔΨm depolarization, cytosolic Ca²⁺, and PS externalization compared with healthy controls (n = 18) and non-ICU COVID-19 patients (n = 4). Moreover, significant higher cytosolic Ca²⁺ and PS were observed compared with a septic ICU control group (ICU control; n = 5). In the ICU control group, cytosolic Ca2⁺ and PS externalization were comparable with healthy controls, with an increase in ΔΨm depolarization. Sera from COVID-19 patients in the ICU induced a significant increase in apoptosis markers (ΔΨm depolarization, cytosolic Ca²⁺, and PS externalization) compared with healthy volunteers and septic ICU controls. Interestingly, immunoglobulin G fractions from COVID-19 patients induced an Fcγ receptor IIA–dependent platelet apoptosis (ΔΨm depolarization, cytosolic Ca²⁺, and PS externalization). Enhanced PS externalization in platelets from COVID-19 patients in the ICU was associated with increased sequential organ failure assessment score (r = 0.5635) and D-dimer (r = 0.4473). Most importantly, patients with thrombosis had significantly higher PS externalization compared with those without. The strong correlations between markers for apoptosic and procoagulant platelets and D-dimer levels, as well as the incidence of thrombosis, may indicate that antibody-mediated procoagulant platelets potentially contributes to sustained increased thromboembolic risk in ICU COVID-19 patients.

COVID-19 coagulopathy: is it disseminated intravascular coagulation?

One of the significant complications of severe COVID-19 infections is a coagulopathy that seems to be related to the occurrence of venous and arterial thromboembolic disease. The coagulation changes mimic but are not identical to disseminated intravascular coagulation (DIC). The vast majority of patients with COVID-19 do not meet the criteria for usual forms of DIC. In addition, there seem to be features of a strong local pulmonary thrombotic microangiopathy and direct endothelial cell infection and injury by the virus that affect the coagulopathic response to severe COVID-19. It seems COVID-19 leads to a distinct intravascular coagulation syndrome that may need separate diagnostic criteria.

A Rare Case of SARS-CoV-2 Infection Associated With Pituitary Apoplexy Without Comorbidities

Pituitary apoplexy is a medical and surgical emergency caused by hemorrhage or infarction of the hypophysis, which typically occurs within a pituitary adenoma. It is usually characterized by severe (often thunderclap) headache, visual disturbances, cranial nerve impairments, and hormonal deficiencies. We herein report a case of a previously healthy woman with severe acute respiratory syndrome coronavirus 2 infection associated with pituitary apoplexy. The plausible pathophysiological mechanisms of pituitary apoplexy in infectious coronavirus disease 2019 are discussed.

Hematological and Inflammatory Parameters to Predict the Prognosis in COVID-19

We aimed to evaluate the predictive ability of hematological and inflammatory parameters for mortality in COVID-19 patients. This was a retrospective study of hospitalized COVID-19 patients over 18 years old between March 2020 and May 2020. Patients were diagnosed to have COVID-19 based either on chest computed tomography findings or reverse transcriptase-polymerase chain reaction test. Age, gender, chronic medical conditions, and laboratory values including hemogram parameters (white blood cell, neutrophil, lymphocyte, and platelet counts), neutrophil to lymphocyte ratio, D-dimer, ferritin, fibrinogen, C-reactive protein, procalcitonin, prothrombin time, activated partial thromboplastin time and the international normalized ratio were recorded. Overall, we included 302 patients. Of these, 148 patients were male; the male to female ratio was 0.961. The mean age of the entire study cohort was 57.1 ± 17.6 years. The most common chronic medical condition was hypertension (38.1%). Half of the patients received low molecular weight heparin. During the study period, 25 patients (8.2%) died. White blood cell count and neutrophil count were significantly higher, whereas lymphocyte count was significantly lower in the deceased patients. The median neutrophil to lymphocyte ratio was 11.6 in the deceased patients, it was significantly higher than the surviving patients (p < 0.001). The values of C-reactive protein, procalcitonin, D-dimer, and ferritin were significantly higher among the deceased patients. Prothrombin time, activated partial thromboplastin time and the international normalized ratio were significantly longer in the deceased group compared with the surviving group. Logistic regression analysis showed age > 65 years, neutrophil to lymphocyte ratio, activated partial thromboplastin time, and hypertension as the independent predictors of mortality. The rate of abnormal inflammatory and hematologic-coagulation parameters increased with the COVID-19 severity. Age > 65 years, hypertension, activated partial thromboplastin time and neutrophil to lymphocyte ratio were the independent predictors of mortality.

Cerebral venous sinus thrombosis associated with COVID-19: a case series and literature review

BACKGROUND

Since the emergence of COVID-19 pandemic, several cases of cerebral venous sinus thrombosis (CVST) have been reported in SARS-CoV-2 infected individuals.

METHODS

Consecutive patients with documented SARS-CoV-2 infection, as well as clinical and radiological characteristics of CVST, were reported from three teaching hospitals in the South West, North West, and the center of Iran between June and July 2020. We also searched the abstract archives until the end of August 2020 and gathered 28 reported cases. The diagnostic criteria for SARS-CoV-2 infection were determined according to SARS-CoV-2 detection in oropharyngeal or nasopharyngeal samples in clinically suspected patients. Demographics, prominent COVID-19 symptoms, confirmatory tests for SARS-CoV-2 infection diagnosis, the interval between the diagnosis of SARS-CoV-2 infection and CVST, clinical and radiological features of CVST, therapeutic strategies, CVST outcomes, rate of hemorrhagic transformation, and mortality rate were investigated.

RESULTS

Six patients (31-62 years-old) with confirmed CVST and SARS-CoV-2 infection were admitted to our centers. Four patients had no respiratory symptoms of SARS-CoV-2 infection. Five patients developed the clinical manifestations of CVST and SARS-CoV-2 infection simultaneously. Three patients had known predisposing factors for CVST. Despite receiving CVST and SARS-CoV-2 infection treatments, four patients died. SARS-COV-2 associated CVST patients were older (49.26 vs. 37.77 years-old), had lower female/male ratio (1.42 vs. 2.19), and higher mortality rate (35.29% vs. 6.07%) than CVST not associated with COVID-19.

CONCLUSIONS

The role of SARS-CoV-2 as a "cause" versus an "additive contributor" remains to be elucidated. Practitioners should be aware of the possibility of CVST in SARS-CoV-2 infection.

COVID-19 induces a hyperactive phenotype in circulating platelets

Coronavirus Disease 2019 (COVID-19), caused by the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has affected over 30 million globally to date. Although high rates of venous thromboembolism and evidence of COVID-19-induced endothelial dysfunction have been reported, the precise aetiology of the increased thrombotic risk associated with COVID-19 infection remains to be fully elucidated. Therefore, we assessed clinical platelet parameters and circulating platelet activity in patients with severe and nonsevere COVID-19. An assessment of clinical blood parameters in patients with severe COVID-19 disease (requiring intensive care), patients with nonsevere disease (not requiring intensive care), general medical in-patients without COVID-19, and healthy donors was undertaken. Platelet function and activity were also assessed by secretion and specific marker analysis. We demonstrated that routine clinical blood parameters including increased mean platelet volume (MPV) and decreased platelet:neutrophil ratio are associated with disease severity in COVID-19 upon hospitalisation and intensive care unit (ICU) admission. Strikingly, agonist-induced ADP release was 30- to 90-fold higher in COVID-19 patients compared with hospitalised controls and circulating levels of platelet factor 4 (PF4), soluble P-selectin (sP-selectin), and thrombopoietin (TPO) were also significantly elevated in COVID-19. This study shows that distinct differences exist in routine full blood count and other clinical laboratory parameters between patients with severe and nonsevere COVID-19. Moreover, we have determined all COVID-19 patients possess hyperactive circulating platelets. These data suggest abnormal platelet reactivity may contribute to hypercoagulability in COVID-19 and confirms the role that platelets/clotting has in determining the severity of the disease and the complexity of the recovery path.

Timing of VV-ECMO therapy implementation influences prognosis of COVID-19 patients

Introduction

Current knowledge on the use of extracorporeal membrane oxygenation (ECMO) in COVID‐19 remains limited to small series and registry data. In the present retrospective monocentric study, we report on our experience, our basic principles, and our results in establishing and managing ECMO in critically ill COVID‐19 patients.

Methods

A cohort study was conducted in patients with severe acute respiratory distress syndrome (ARDS) related to COVID‐19 pneumonia admitted to the ICU of the Geneva University Hospitals and supported by VV‐ECMO from March 14 to May 31. The VV‐ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit and the Swiss Society of Intensive Care Medicine.

Results

Out of 137 ARDS patients admitted to our ICU, 10 patients (age 57 ± 4 years, BMI 31.5 ± 5 kg/m², and SAPS II score 56 ± 3) were put on VV‐ECMO. The mean duration of mechanical ventilation before ECMO and mean time under ECMO were 7 ± 3 days and 19 ± 11 days, respectively. The ICU and hospital length of stay were 26 ± 11 and 35 ± 10 days, respectively. The survival rate for patients on ECMO was 40%. The comparative analysis between survivors and non‐survivors highlighted that survivors had a significantly shorter mechanical ventilation duration before ECMO (4 ± 2 days vs. 9 ± 2 days, p = 0.01). All the patients who had more than 150 h of mechanical ventilation before the application of ECMO ultimately died.

Conclusion

The present results suggest that VV‐ECMO can be safely utilized in appropriately selected COVID‐19 patients with refractory hypoxemia. The main information for clinicians is that late VV‐ECMO therapy (i.e., beyond the seventh day of mechanical ventilation) seems futile.

American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19)-related critical illness and acute illness are associated with a risk of venous thromboembolism (VTE).

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis for patients with COVID-19-related critical illness and acute illness who do not have confirmed or suspected VTE.

METHODS

ASH formed a multidisciplinary guideline panel and applied strict management strategies to minimize potential bias from conflicts of interest. The panel included 3 patient representatives. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic evidence reviews (up to 19 August 2020). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 2 recommendations. The panel issued conditional recommendations in favor of prophylactic-intensity anticoagulation over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19-related critical illness or acute illness who do not have confirmed or suspected VTE.

CONCLUSIONS

These recommendations were based on very low certainty in the evidence, underscoring the need for high-quality, randomized controlled trials comparing different intensities of anticoagulation. They will be updated using a living recommendation approach as new evidence becomes available.

American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19)-related critical illness and acute illness are associated with a risk of venous thromboembolism (VTE).

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis for patients with COVID-19-related critical illness and acute illness who do not have confirmed or suspected VTE.

METHODS

ASH formed a multidisciplinary guideline panel and applied strict management strategies to minimize potential bias from conflicts of interest. The panel included 3 patient representatives. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic evidence reviews (up to 19 August 2020). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 2 recommendations. The panel issued conditional recommendations in favor of prophylactic-intensity anticoagulation over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19-related critical illness or acute illness who do not have confirmed or suspected VTE.

CONCLUSIONS

These recommendations were based on very low certainty in the evidence, underscoring the need for high-quality, randomized controlled trials comparing different intensities of anticoagulation. They will be updated using a living recommendation approach as new evidence becomes available.

Atteintes pulmonaires liées à la COVID-19

Le SARS-CoV-2, responsable de la COVID-19, est un nouveau bêta-coronavirus.

Il engendre une réaction inflammatoire intense pouvant aller jusqu’à l’« orage cytokinique », avec des atteintes pulmonaires épithéliales sévères et un tableau de coagulopathie intravasculaire pulmonaire.

Le tableau clinique est polymorphe, avec possible survenue d’un syndrome de détresse respiratoire aigu (SDRA).

La ventilation non invasive et l’oxygénothérapie à haut débit permettent de traiter efficacement plus de la moitié des patients graves sans recours à l’intubation et sans risque pour le personnel soignant.

Le seul traitement actuellement validé est la dexaméthasone à dose modérée (6 mg/j pendant 10 jours).

Le haut risque thrombotique justifie en fonction des cas une anticoagulation préventive voire curative.

Thrombocytopenia as a prognostic marker in COVID-19 patients: diagnostic test accuracy meta-analysis

This systematic review and meta-analysis aimed to evaluate thrombocytopenia as a prognostic biomarker in patients with coronavirus disease 2019 (COVID-19). We performed a systematic literature search using PubMed, Embase and EuropePMC. The main outcome was composite poor outcome, a composite of mortality, severity, need for intensive care unit care and invasive mechanical ventilation. There were 8963 patients from 23 studies. Thrombocytopenia occurred in 18% of the patients. Male gender (P = 0.037) significantly reduce the incidence. Thrombocytopenia was associated with composite poor outcome (RR 1.90 (1.43-2.52), P < 0.001; I2: 92.3%). Subgroup analysis showed that thrombocytopenia was associated with mortality (RR 2.34 (1.23-4.45), P < 0.001; I2: 96.8%) and severity (RR 1.61 (1.33-1.96), P < 0.001; I2: 62.4%). Subgroup analysis for cut-off <100 × 109/l showed RR of 1.93 (1.37-2.72), P < 0.001; I2: 83.2%). Thrombocytopenia had a sensitivity of 0.26 (0.18-0.36), specificity of 0.89 (0.84-0.92), positive likelihood ratio of 2.3 (1.6-3.2), negative likelihood ratio of 0.83 (0.75-0.93), diagnostic odds ratio of 3 (2, 4) and area under curve of 0.70 (0.66-0.74) for composite poor outcome. Meta-regression analysis showed that the association between thrombocytopenia and poor outcome did not vary significantly with age, male, lymphocyte, d-dimer, hypertension, diabetes and CKD. Fagan's nomogram showed that the posterior probability of poor outcome was 50% in patients with thrombocytopenia, and 26% in those without thrombocytopenia. The Deek's funnel plot was relatively symmetrical and the quantitative asymmetry test was non-significant (P = 0.14). This study indicates that thrombocytopenia was associated with poor outcome in patients with COVID-19.PROSPERO ID: CRD42020213974.

Pharmacological approach for the reduction of inflammatory and prothrombotic hyperactive state in COVID-19 positive patients by acting on complement cascade

The novel Coronavirus SARS-CoV-2 is the viral pathogen responsible for the ongoing global pandemic, COVID-19 (Coronavirus disease 2019). To date, the data recorded indicate 1.62 Mln deaths and 72.8 Mln people infected (WHO situation report Dec 2020). On December 27, the first anti-COVID-19 vaccinations started in Europe. There are no direct antivirals against SARS-CoV-2. Understanding the pathophysiological and inflammatory/immunological processes of SARS-CoV-2 infection is essential to identify new drug therapies. In the most severe COVID-19 cases, an unregulated immunological/inflammatory system results in organ injury that can be fatal to the host in some cases. Pharmacologic approaches to normalize the unregulated inflammatory/immunologic response is an important therapeutic solution. Evidence associates a non-regulation of the “complement system” as one of the causes of generalized inflammation causing multi-organ dysfunction. Serum levels of a complement cascade mediator, factor “C5a”, have been found in high concentrations in the blood of COVID-19 patients with severe disease. In this article we discuss the correlation between complement system and COVID-19 infection and pharmacological solutions directed to regulate.

The Immunopathological and Histological Landscape of COVID-19-Mediated Lung Injury

A complete understanding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) physiopathology and related histopathologic lesions is necessary to improve treatment and outcome of coronavirus disease 2019 (COVID-19) patients. Many studies have focused on autopsy findings in COVID-19-related deaths to try and define any possible specific pattern. Histopathologic alterations are principally found within lungs and blood vessels, and these abnormalities also seem to have the highest clinical impact. Nevertheless, many of the morphological data collected so far are non-specific, fickle, and possibly associated with other co-existing factors. The aim of this minireview is to describe the main histopathological features related to COVID-19 and the mechanism known as "cytokine storm".

Role of hematological parameters in the stratification of COVID-19 disease severity

Objective

COVID-19 virus involves respiratory as well as other body systems including cardiovascular, gastrointestinal, neurological, immunological and hematopoietic system. Patient of covid-19 pneumonia presents with wide range of hemostatic abnormalities. These hemostatic abnormalities in COVID-19 are related with disease progression, severity and mortality. The Objective of our study is to evaluate the role of hematological parameters in determination of COVID-19 disease severity.

Material and method

This was a retrospective study, conducted in Department of Pathology and Department of medicine, FMH college of Medicine and Dentistry from May 2020 to July 2020. Total of 101, confirmed cases of covid-19 disease, both genders between 17 and 75-year age were included. Hematological parameters were compared in mild, moderate, severe and critical disease group. Continuous variables were analyzed by using non parametric, Kruskal Wallis test while categorical variables were analyzed by chi-square test.

Results

Out of 101 patients, 20.8%, 51.8%,19.8% and 7.9% were in mild, moderate, severe and critical group respectively. Median (IQR) values of WBCs (p-value 0.004), ANC (p-value 0.002), NLR (p-value 0.001), D-dimer level (p-value 0.001), ferritin (0.0001), LDH (0.0001) were significantly increased in patients with critical disease. Median (IQR) values of APTT (p-value 0.003) and CRP (p- value 0.0001) were suggestively higher in patients with severe disease. Other parameters like Hemoglobin, MCV, HCT, ALC, Platelet count, prothrombin time did not show statistically significant association with severity of disease.

Conclusion

The study concluded that Leukocytosis, neutrophilia, elevated Neutrophil to lymphocyte ratio, APTT, D-dimer, LDH and serum ferritin and CRP are associated with severity of covid-19 disease.

•

Hematological abnormalities in COVID-19 are related with disease progression, severity and mortality.

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The hematological and inflammatory biomarkers like Complete Blood Count, coagulation profile, d-dimer, C-Reactive Protein and Ferritin can play a vital role in early prediction of disease severity.

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Leukocytosis, neutrophilia, elevated Neutrophil to lymphocyte ratio, APTT, D-dimer, LDH and serum ferritin and CRP are significantly increased in patients with severe and critical disease.

COVID-19-Induced Ischemic Infarcts With Normal Coagulation Profile and Excellent Outcome: A Case Report With Highlights on the Thrombotic Diathesis, Recent Transcranial Doppler Findings, and Neuropathology Update

We present the case of a previously healthy 41-year-old man right-handed man diagnosed with coronavirus disease 2019 (COVID-19) who developed multiple cortical ischemic infarcts. Our patient developed mild neurologic deficits despite the total volume of cerebral ischemic lesions, presumably due to involvement of non-eloquent cortex, the integrity of the collateral circulation due to his youth and good health, and mild COVID-19 disease without any significant pulmonary involvement. We discuss the coagulopathy and direct vascular effects, if any, of COVID-19 disease and compare it to other agents such as the filovirus, ad Ebola. We also outline the recent intriguing findings of vasodilation of the pulmonary vessels and the potential shunting of micro-emboli into the brain, which may explain the formation of embolic ischemic infarcts in even mild disease. Lastly, we discuss the neuropathology of COVID-19 in patients that who have succumbed to the disease and note the striking lack of direct involvement of the cerebral blood vessels.

Pharmacologic Thromboprophylaxis and Thrombosis in Hospitalized Patients with COVID-19: A Pooled Analysis

BACKGROUND

 Coronavirus disease 2019 (COVID-19) increases thrombosis in hospitalized patients prompting adoption of different thromboprophylaxis strategies. Safety and efficacy of escalated-dose pharmacologic thromboprophylaxis are not established.

OBJECTIVES

 To determine the pooled incidence of thrombosis/bleeding in hospitalized patients with COVID-19 for standard-dose, intermediate-dose, therapeutic anticoagulation, and no pharmacologic thromboprophylaxis.

METHODS

 MEDLINE, EMBASE, and Cochrane CENTRAL were searched up to August 29, 2020 for studies reporting pharmacologic thromboprophylaxis and thrombosis or bleeding. Pooled event rates were calculated using a random-effects model.

RESULTS

 Thirty-five observational studies were included. The pooled incidence rates of total venous thromboembolism (N = 4,685) were: no prophylaxis 41.9% (95% confidence interval [CI]: 28.1-57.2, I 2 = 76%), standard-dose prophylaxis 19.8% (95% CI: 13.2-28.6, I 2 = 95%), intermediate-dose prophylaxis 11.9% (95% CI: 4.3-28.6, I 2 = 91%), and therapeutic-dose anticoagulants 10.5% (95% CI: 4.2-23.8, I 2 = 82%, p = 0.003). The pooled incidence rates of arterial thrombosis (N = 1,464) were: no prophylaxis 11.3% (95% CI: 5.2-23.0, I 2 = 0%), standard-dose prophylaxis 2.5% (95% CI: 1.4-4.3, I 2 = 45%), intermediate-dose prophylaxis 2.1% (95% CI: 0.5-7.7, I 2 = 45%), and therapeutic-dose anticoagulants 1.3% (95% CI: 0.2-8.8, I 2 = 0, p = 0.009). The pooled bleeding event rates (N = 6,393) were nonsignificantly higher in therapeutic-dose anticoagulants compared with standard-dose prophylaxis, (6.3 vs. 1.7%, p = 0.083).

CONCLUSION

 Thrombosis rates were lower in hospitalized COVID-19 patients who received pharmacologic thromboprophylaxis. Thrombosis and bleeding rates for patients receiving intermediate-dose thromboprophylaxis or therapeutic anticoagulation were similar to those who received standard-dose pharmacologic thromboprophylaxis.

Blood Hemoglobin Substantially Modulates the Impact of Gender, Morbid Obesity, and Hyperglycemia on COVID-19 Death Risk: A Multicenter Study in Italy and Spain

BACKGROUND

Hyperglycemia and obesity are associated with a worse prognosis in subjects with COVID-19 independently. Their interaction as well as the potential modulating effects of additional confounding factors is poorly known. Therefore, we aimed to identify and evaluate confounding factors affecting the prognostic value of obesity and hyperglycemia in relation to mortality and admission to the intensive care unit (ICU) due to COVID-19.

METHODS

Consecutive patients admitted in two Hospitals from Italy (Bologna and Rome) and three from Spain (Barcelona and Girona) as well as subjects from Primary Health Care centers. Mortality from COVID-19 and risk for ICU admission were evaluated using logistic regression analyses and machine learning (ML) algorithms.

RESULTS

As expected, among 3,065 consecutive patients, both obesity and hyperglycemia were independent predictors of ICU admission. A ML variable selection strategy confirmed these results and identified hyperglycemia, blood hemoglobin and serum bilirubin associated with increased mortality risk. In subjects with blood hemoglobin levels above the median, hyperglycemic and morbidly obese subjects had increased mortality risk than normoglycemic individuals or non-obese subjects. However, no differences were observed among individuals with hemoglobin levels below the median. This was particularly evident in men: those with severe hyperglycemia and hemoglobin concentrations above the median had 30 times increased mortality risk compared with men without hyperglycemia. Importantly, the protective effect of female sex was lost in subjects with increased hemoglobin levels.

CONCLUSIONS

Blood hemoglobin substantially modulates the influence of hyperglycemia on increased mortality risk in patients with COVID-19. Monitoring hemoglobin concentrations seem of utmost importance in the clinical settings to help clinicians in the identification of patients at increased death risk.

COVID-19 and Obesity: Overlapping of Two Pandemics

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has recently led to worldwide research efforts to identify subjects at greater risk of developing more severe illness: overall obesity displayed a strong correlation with critical illness and major severity of COVID-19 manifestations.

SUMMARY

Obesity and metabolic disorders are closely linked to chronic systemic inflammation. The adipose tissue constitutes a source of cytokines, which configure a low-grade inflammation and a hypercoagulation status; in addition, diagnosis and care of obese patients are often complicated by excess weight and ventilation difficulties. Key Messages: This review aims to examine the intersection between obesity and adverse outcomes of COVID-19, in order to investigate its preventive and/or therapeutic potential in the management of obesity-related COVID-19 complications.

Cardiovascular diseases and complication in COVID-19

From the late fall of 2019 until the beginning of 2020, SARS-CoV-2 infection is becoming the biggest global challenge of health systems worldwide. Characteristic of the encounter with the disease caused by COVID-19 was a certain wandering in the mechanisms of action of the virus, its consequences, and thus in therapy. Various manifestations of the disease confirm the assumption that it is a systemic infection with the respiratory system as an entry route. We were also faced with the fact that the SARS-CoV-2 virus has great implications for the cardiovascular system. Patients with cardiovascular risk factors, including male gender, advanced age, diabetes, hypertension, and obesity, as well as patients with established cardiovascular and cerebrovascular disease, have been identified as particularly susceptible populations with increased morbidity and mortality from COVID-19. The effects on the cardiovascular system are reminiscent of other diseases caused by this group of viruses. There are biochemical, electrocardiographic and echocardiographic confirmations of functional disorders. It is basically an immune response caused by tissue inflammation, which results in prothrombogenicity as the dominant and biggest problem, coupled with the highest risk of a possible bad outcome. Being a systemic disease with numerous and different repercussions on the cardiovascular system, COVID-19 can lead to the appearance of all cardiovascular diseases that the patient did not have before, or to a significant worsening of the existing cardiovascular disease. The condition after the disease in most cases also means recovery, but great caution is needed due to possible time-distant complications. Since there is a high risk of death in the end, it is necessary to apply all available measures, especially in the field of prevention of thromboembolic complications, as a factor of the greatest risk of a bad outcome.

Repurposing FIB-4 index as a predictor of mortality in patients with hematological malignancies and COVID-19

BACKGROUND

In this study, we aimed to investigate whether FIB-4 index is useful in predicting mortality in patients with concurrent hematological malignancies and COVID-19. We also aimed to determine the optimal cut-off point for the prediction.

METHODS

This is a single-center retrospective cohort study conducted in Dharmais National Cancer Hospital, Indonesia. Consecutive sampling of adults with hematological malignancies and COVID-19 was performed between May 2020 and January 2021. COVID-19 screening test using the reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal samples were performed prior to hospitalization for chemotherapy. FIB-4 index is derived from [age (years) × AST (IU/L)]/[platelet count (109/L) × √ALT (U/L)]. The primary outcome of this study is mortality, defined as clinically validated death/non-survivor during a 3-months (90 days) follow-up.

RESULTS

There were a total of 70 patients with hematological malignancies and COVID-19 in this study. Median FIB-4 Index was higher in non-survivors (13.1 vs 1.02, p<0.001). FIB-4 index above 3.85 has a sensitivity of 79%, specificity of 84%, PLR of 5.27, and NLR of 0.32. The AUC was 0.849 95% CI 0.735-0.962, p<0.001. This cut-off point was associated with OR of 16.70 95% CI 4.07-66.67, p<0.001. In this study, a FIB-4 >3.85 confers to 80% posterior probability of mortality and FIB-4 <3.85 to 19% probability. FIB-4 >3.85 was associated with shorter time-to-mortality (HR 9.10 95% CI 2.99-27.65, p<0.001). Multivariate analysis indicated that FIB-4 >3.85 (HR 4.09 95% CI 1.32-12.70, p = 0.015) and CRP> 71.57 mg/L (HR 3.36 95% CI 1.08-10.50, p = 0.037) were independently associated with shorter time-to-mortality.

CONCLUSION

This study indicates that a FIB-4 index >3.85 was independent predictor of mortality in patients with hematological malignancies and COVID-19 infection.

An Update on the Pathogenesis of COVID-19 and the Reportedly Rare Thrombotic Events Following Vaccination

Today the coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has become a global health problem. After more than a year with the pandemic, although our knowledge has progressed on COVID-19, there are still many unknowns in virological, pathophysiological and immunological aspects. It is obvious that the most efficient solution to end this pandemic are safe and efficient vaccines. This manuscript summarizes the pathophysiological and thrombotic features of COVID-19 and the safety and efficacy of currently approved COVID-19 vaccines with an aim to clarify the recent concerns of thromboembolic events after COVID-19 vaccination. The influx of newer information is rapid, requiring periodic updates and objective assessment of the data on the pathogenesis of COVID-19 variants and the safety and efficacy of currently available vaccines.

Review: Obesity and COVID-19: A Detrimental Intersection

Obesity has been recognized as an independent risk factor for critical illness and major severity in subjects with coronavirus disease 2019 (COVID-19). The role of fat distribution, particularly visceral fat (often linked to metabolic abnormalities), is still unclear. The adipose tissue represents a direct source of cytokines responsible for the pathological modifications occurring within adipose tissue in obese subjects. Adipokines are a crucial connection between metabolism and immune system: their dysregulation in obesity contributes to chronic low-grade systemic inflammation and metabolic comorbidities. Therefore the increased amount of visceral fat can lead to a proinflammatory phenotypic shift. This review analyzes the interrelation between obesity and COVID-19 severity, as well as the cellular key players and molecular mechanisms implicated in adipose inflammation, investigating if adipose tissue can constitute a reservoir for viral spread, and contribute to immune activation and cytokines storm. Targeting the underlying molecular mechanisms might have therapeutic potential in the management of obesity-related complications in COVID-19 patients.

COVID-19 infection and stroke risk

Coronavirus disease 2019 (COVID-19), due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan city, China in December 2019 and rapidly spread to other countries. The most common reported symptoms are fever, dry cough, myalgia and fatigue, headache, anorexia, and breathlessness. Anosmia and dysgeusia as well as gastrointestinal symptoms including nausea and diarrhea are other notable symptoms. This virus also can exhibit neurotropic properties and may also cause neurological diseases, including epileptic seizures, cerebrovascular accident, Guillian barre syndrome, acute transverse myelitis, and acute encephalitis. In this study, we discuss stroke as a complication of the new coronavirus and its possible mechanisms of damage.

Coronavirus-induced coagulopathy during the course of disease

BACKGROUND

A significant proportion of patients with coronavirus disease 19 (COVID-19) suffer from excessive coagulation activation and coagulopathy which is associated with an increased risk of venous and arterial thromboembolism and adverse outcome. Our study investigates coagulation markers and the incidence of thromboembolic events in COVID-19 patients receiving recommended anticoagulation strategies.

METHODS

In a retrospective single-center analysis at the University Hospital Zurich, Switzerland, we investigated 31 adult COVID-19 patients between April 6th and May 13th, 2020 and with at least one laboratory assessment of the coagulation markers prothrombin time/Quick, thrombin time, fibrinogen and D-dimers. For antithrombotic prophylaxis low-molecular-weight-heparin or unfractionated heparin was administered and two patients with heparin-induced thrombocytopenia received argatroban.

RESULTS

We analyzed 31 patients (68% male, mean age 60± SD 15 years). 22 (71%) of these required intensive care unit treatment, 5 (16%) were hospitalized in a ward, and 4 (13%) were outpatients. Mean fibrinogen levels were markedly elevated to 6.4± SD 1.8g/l, with a peak in the third week of the disease and no significant decrease over time. D-dimers were elevated to a mean value of 5.1±4.4mg/l with peak levels of 6.8±5.3mg/l in the fourth week of disease, and a subsequent decrease. Platelet count (308±136G/l) and PT/Quick (85±22%) showed no significant changes over time. Sensitivity analyses for patients treated in the ICU showed that D-dimer levels were higher in this group. The results of other sensitivity analyses were comparable. Thromboembolic events were diagnosed in 4 (13%) patients and 5 (16%) patients died during the observation period.

CONCLUSION

We find coagulation alterations in COVID-19 patients indicating significant hypercoagulability. These alterations are visible despite antithrombotic treatment, and peak around week 3-4 of the disease.

Vaccination Criteria Based on Factors Influencing COVID-19 Diffusion and Mortality

SARS-CoV-2 is highly contagious, rapidly turned into a pandemic, and is causing a relevant number of critical to severe life-threatening COVID-19 patients. However, robust statistical studies of a large cohort of patients, potentially useful to implement a vaccination campaign, are rare. We analyzed public data of about 19,000 patients for the period 28 February to 15 May 2020 by several mathematical methods. Precisely, we describe the COVID-19 evolution of a number of variables that include age, gender, patient’s care location, and comorbidities. It prompts consideration of special preventive and therapeutic measures for subjects more prone to developing life-threatening conditions while affording quantitative parameters for predicting the effects of an outburst of the pandemic on public health structures and facilities adopted in response. We propose a mathematical way to use these results as a powerful tool to face the pandemic and implement a mass vaccination campaign. This is done by means of priority criteria based on the influence of the considered variables on the probability of both death and infection.