Combination of thrombolytic and immunosuppressive therapy for coronavirus disease 2019: A case report

Pharmacotherapy consideration of thrombolytic medications in COVID-19-associated ARDS

BACKGROUND

In late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is responsible for coronavirus disease (COVID-19), was identified as the new pathogen to lead pneumonia in Wuhan, China, which has spread all over the world and developed into a pandemic. Despite the over 1 year of pandemic, due to the lack of an effective treatment plan, the morbidity and mortality of COVID-19 remains high. Efforts are underway to find the optimal management for this viral disease.

MAIN BODY

SARS-CoV-2 could simultaneously affect multiple organs with variable degrees of severity, from mild to critical disease. Overproduction of pro-inflammatory mediators, exacerbated cellular and humoral immune responses, and coagulopathy such as Pulmonary Intravascular Coagulopathy (PIC) contributes to cell injuries. Considering the pathophysiology of the disease and multiple microthrombi developments in COVID-19, thrombolytic medications seem to play a role in the management of the disease. Beyond the anticoagulation, the exact role of thrombolytic medications in the management of patients with COVID-19-associated acute respiratory distress syndrome (ARDS) is not explicit. This review focuses on current progress in underlying mechanisms of COVID-19-associated pulmonary intravascular coagulopathy, the historical use of thrombolytic drugs in the management of ARDS, and pharmacotherapy considerations of thrombolytic therapy, their possible benefits, and pitfalls in COVID-19-associated ARDS.

CONCLUSIONS

Inhaled or intravenous administration of thrombolytics appears to be a salvage therapy for severe ARDS associated with COVID-19 by prompt attenuation of lung injury. Considering the pathogenesis of COVID-19-related ARDS and mechanism of action of thrombolytic agents, thrombolytics appear attractive options in stable patients without contraindications.

A systematic review of dermatologic manifestations among adult patients with COVID-19 diagnosis

BACKGROUND

Infection with COVID-19 is characterized by respiratory, gastrointestinal and neurologic symptoms. However, limited evidence exists of the involvement of the integumentary system among COVID-19 patients and evidence suggests that these symptoms may even be the first presenting sign.

OBJECTIVE

To systematically evaluate the literature published on dermatologic signs of COVID-19 in order to educate doctors about the dermatologic signs of COVID-19 infection.

METHODS

Lit COVID, World Health Organization COVID-19 database and PubMed were searched using terminology to identify adult patients with confirmed COVID-19 infection and dermatologic manifestations of disease. The last search was completed on 13 July 2020.

RESULTS

There were 802 reports found. After exclusion, 20 articles were found with 347 patients with confirmed COVID-19 infection. Within these articles, 27 different skin signs were reported.

LIMITATIONS

Limitations of this review include the recency of COVID-19 infection; so, there are limited published reports and that many reports are not by dermatologists, and so, the cutaneous signs may be misdiagnosed or misdescribed.

CONCLUSION

Dermatologic manifestations of COVID-19 may be the first presenting sign of infection; so, dermatologists and doctors examining the skin should be aware of the virus's influence on the integumentary system in order to promptly diagnose and treat the infected patients.

Associations of D-Dimer on Admission and Clinical Features of COVID-19 Patients: A Systematic Review, Meta-Analysis, and Meta-Regression

Background

Dynamic D-dimer level is a key biomarker for the severity and mortality of COVID-19 (coronavirus disease 2019). How aberrant fibrinolysis influences the clinical progression of COVID-19 presents a clinicopathological dilemma challenging intensivists.

Methods

We performed meta-analysis and meta regression to analyze the associations of plasma D-dimer with 106 clinical variables to identify a panoramic view of the derangements of fibrinolysis in 14,862 patients of 42 studies. There were no limitations of age, gender, race, and country. Raw data of each group were extracted separately by two investigators. Individual data of case series, median and interquartile range, and ranges of median or mean were converted to SDM (standard deviation of mean).

Findings

The weighted mean difference of D-dimer was 0.97 µg/mL (95% CI 0.65, 1.29) between mild and severe groups, as shown by meta-analysis. Publication bias was significant. Meta-regression identified 58 of 106 clinical variables were associated with plasma D-dimer levels. Of these, 11 readouts were negatively related to the level of plasma D-dimer. Further, age and gender were confounding factors. There were 22 variables independently correlated with the D-dimer level, including respiratory rate, dyspnea plasma K+, glucose, SpO2, BUN (blood urea nitrogen), bilirubin, ALT (alanine aminotransferase), AST (aspartate aminotransferase), systolic blood pressure, and CK (creatine kinase).

Interpretation

These findings support elevated D-dimer as an independent predictor for both mortality and complications. The identified D-dimer-associated clinical variables draw a landscape integrating the aggregate effects of systemically suppressive and pulmonary hyperactive derangements of fibrinolysis, and the D-dimer-associated clinical biomarkers, and conceptually parameters could be combined for risk stratification, potentially for tracking thrombolytic therapy or alternative interventions.

Newly Diagnosed Acute Myeloid Leukemia in a Patient With Severe SARS-CoV-2 Infection

We present a 68-year-old male patient with persistent and complicated SARS-CoV-2 infection who was diagnosed with acute myeloid leukemia (AML). The patient suffered from fever, cough and progressive dyspnea for 10 days and he was admitted to the intensive care unit due to respiratory failure and cytokine release syndrome (CRS). Despite a transient improvement of CRS by the implementation of supportive care, including also the administration of recombinant tissue plasminogen activator (rt-PA) and tocilizumab, his clinical course worsened over time. Thus, a bone marrow aspiration was performed revealing the presence of myeloblasts in a proportion of 32% and flow cytometry confirmed the diagnosis of AML-M1 according to FAB classification. Re-evaluation of peripheral blood tests revealed that the patient was admitted with anemia and thrombocytopenia that were never recovered during hospitalization. Due to the patient's poor clinical condition, no chemotherapy was applied, and he died of sepsis and multi-organ failure two days later. This case suggests that in all patients with a persistent and/or complicated infection, even during pandemics, the presence of an underlying hematologic malignancy should always be taken into consideration.

Mechanisms of COVID-19-induced heart failure: a short review

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) has infected more than 42.5 million people globally resulting in the death of over 1.15 million subjects. It has inflicted severe public health and economic hardships across the world. In addition to acute respiratory distress syndrome, respiratory failure, sepsis, and acute kidney injury, COVID-19 also causes heart failure (HF). COVID-19-induced HF is manifested via different mechanisms, including, but not limited to, (1) virus-induced infiltration of inflammatory cells, which could impair the function of the heart; (2) pro-inflammatory cytokines (monocyte chemoattractant protein-1, interleukin-1β; interleukin-6; tumor necrosis factor-α) that could cause necrosis and death of the myocardium; (3) endothelial injury coupled with micro-thrombosis which could damage the endocardium; and (4) acute respiratory distress syndrome and respiratory failure that could lead to heart failure due to severe hypoxia. It is concluded that the etiology of COVID-19-induced HF is multifactorial and mitigation of the development of HF in patients with COVID-19 will require different approaches such as social distancing, drug therapy, and the urgent development of a vaccine to eradicate the disease.

Blood viscosity of COVID-19 patient: a preliminary report

COVID-19 is the important global problem. This new coronavirus can cause several hematological changes. Thrombosis is a problem might occur in COVID-19. In COVID-19, thrombosis might be the result of endothelial dysfunction, platelet activation, increasd blood viscosity, and blood flow disturbance. The change of blood viscosity in the patients with COVID-19 is possible but little mentioned. Here, the authors report on a preliminary data on blood viscosity assessment among 41 COVID-19 patients. According to the estimation, the estimated blood viscosity values are 72.4 ± 18.6 and 18.2 ± 2.2 for high and low shear rates. Based on this preliminary report, the increased blood viscosity is detected in COVID-19 patient and it might be associated with thrombohemostatic problem.

Recombinant tissue plasminogen activator treatment for COVID-19 associated ARDS and acute cor pulmonale

Existing literature highlights the fact that patients with COVID-19 exhibit alterations in the coagulation process and are associated with respiratory and cardiovascular diseases, including acute respiratory distress syndrome and acute cor pulmonale. In this report, we describe the effects of systemic thrombolysis on acute cor pulmonale in a patient suffering from COVID-19. We demonstrated that systemic thrombolysis successfully improved the hemodynamics of our patient and resulted in a prominent reduction in hypercapnia, alveolar dead space, and ventilatory ratio.

Fibrinolysis influences SARS-CoV-2 infection in ciliated cells

Rapid spread of COVID-19 has caused an unprecedented pandemic worldwide, and an inserted furin site in SARS-CoV-2 spike protein (S) may account for increased transmissibility. Plasmin, and other host proteases, may cleave the furin site of SARS-CoV-2 S protein and γ subunits of epithelial sodium channels (γ ENaC), resulting in an increment in virus infectivity and channel activity. As for the importance of ENaC in the regulation of airway surface and alveolar fluid homeostasis, whether SARS-CoV-2 will share and strengthen the cleavage network with ENaC proteins at the single-cell level is urgently worthy of consideration. To address this issue, we analyzed single-cell RNA sequence (scRNA-seq) datasets, and found the PLAU (encoding urokinase plasminogen activator), SCNN1G (γENaC), and ACE2 (SARS-CoV-2 receptor) were co-expressed in alveolar epithelial, basal, club, and ciliated epithelial cells. The relative expression level of PLAU, TMPRSS2, and ACE2 were significantly upregulated in severe COVID-19 patients and SARS-CoV-2 infected cell lines using Seurat and DESeq2 R packages. Moreover, the increments in PLAU, FURIN, TMPRSS2, and ACE2 were predominately observed in different epithelial cells and leukocytes. Accordingly, SARS-CoV-2 may share and strengthen the ENaC fibrinolytic proteases network in ACE2 positive airway and alveolar epithelial cells, which may expedite virus infusion into the susceptible cells and bring about ENaC associated edematous respiratory condition.

SARS-CoV-2 and limb ischemia: A systematic review

BACKGROUND

Recent spread of severe acute respiratory coronavirus syndrome-2 (SARS-CoV-2) has led to the coronavirus disease (COVID-19) pandemic, resulting in new challenges across all medical specialties. Limb and digit ischemia have been associated with COVID-19 infection. This systematic review includes primary studies of COVID-19 limb ischemia to identify risk factors, comorbidities, case characteristics, and treatment strategies to better understand the nature of this disease and its effects on the extremities.

METHODS

A literature search for studies detailing COVID-19 infected patients with limb or digit ischemia was performed, identifying 157 articles, 12 of which met inclusion criteria, accounting for 47 patients. Inclusion criteria were (1) primary studies, (2) positive disease diagnosis (3) limb ischemia, (4) reported treatment. Demographic data, case characteristics, treatments, outcomes and mortality were collected and pooled.

RESULTS

The average patient age was 67.6 years, predominantly male (79.6%). Of the 44 cases discussing treatment, 13 (30%) patients underwent medical treatment alone, while 23 (52.3%) patients underwent medical plus surgical treatment. Four patients (9.1%) were treated with observation. In 10 of the 12 studies, lab findings, thrombosis, or conclusions supporting a hypercoagulable state as a cause of limb/digit ischemia were cited. Five patients (10.6%) were on vasopressors and 8 patients (17.0%) were on a ventilator. Of those treated with observation alone, there was 100% resolution of symptoms. Of those treated medically without surgical intervention (17 patients), 6 patients (35.3%) were reported to have revascularization, 6 patients (35.3%) died, and the remaining outcomes were not reported. Medical and surgical treatment resulted in one limb amputation (4.4%) and altogether 74% of patients achieved revascularization of the affected limb/digit. Mortality rate was 45%.

CONCLUSIONS

COVID-19 infection may be associated with increased risk of limb or digital ischemia, although the quality of evidence supporting this theory is limited. Evidence of inflammatory-mediated thrombosis and endothelial injury are possible explanations which would support the use of immunotherapy in addition to anticoagulation for treatment or prevention of thromboembolic events. Current outcomes and treatment strategies are variable.

LEVEL OF EVIDENCE

IV.

Multi-omics-based identification of SARS-CoV-2 infection biology and candidate drugs against COVID-19

SARS-CoV-2 has ushered a global pandemic with no effective drug being available at present. Although several FDA-approved drugs are currently under clinical trials for drug repositioning, there is an on-going global effort for new drug identification. In this paper, using multi-omics (interactome, proteome, transcriptome, and bibliome) data and subsequent integrated analysis, we present the biological events associated with SARS-CoV-2 infection and identify several candidate drugs against this viral disease. We found that: (i) Interactome-based infection pathways differ from the other three omics-based profiles. (ii) Viral process, mRNA splicing, cytokine and interferon signaling, and ubiquitin mediated proteolysis are important pathways in SARS-CoV-2 infection. (iii) SARS-CoV-2 infection also shares pathways with Influenza A, Epstein-Barr virus, HTLV-I, Measles, and Hepatitis virus. (iv) Further, bacterial, parasitic, and protozoan infection pathways such as Tuberculosis, Malaria, and Leishmaniasis are also shared by this virus. (v) A total of 50 candidate drugs, including the prophylaxis agents and pathway specific inhibitors are identified against COVID-19. (vi) Betamethasone, Estrogen, Simvastatin, Hydrocortisone, Tositumomab, Cyclosporin A etc. are among the important drugs. (vii) Ozone, Nitric oxide, plasma components, and photosensitizer drugs are also identified as possible therapeutic candidates. (viii) Curcumin, Retinoic acids, Vitamin D, Arsenic, Copper, and Zinc may be the candidate prophylaxis agents. Nearly 70% of our identified agents are previously suggested to have anti-COVID-19 effects or under clinical trials. Among our identified drugs, the ones that are not yet tested, need validation with caution while an appropriate drug combination from these candidate drugs along with a SARS-CoV-2 specific antiviral agent is needed for effective COVID-19 management.

Insufficient hyperfibrinolysis in COVID-19: a systematic review of thrombolysis based on meta-analysis and meta-regression

Background How aberrant fibrinolysis influences the clinical progression of COVID-19 presents a clinicopathological dilemma challenging intensivists. To investigate whether abnormal fibrinolysis is a culprit or protector or both, we associated elevated plasma D-dimer with clinical variables to identify a panoramic view of the derangements of fibrinolysis that contribute to the pathogenesis of COVID-19 based on studies available in the literature. Methods We performed this systematic review based on both meta-analysis and meta-regression to compute the correlation of D-dimer at admission with clinical features of COVID-19 patients in retrospective studies or case series. We searched the databases until Aug 18, 2020, with no limitations by language. The first hits were screened, data extracted, and analyzed in duplicate. We did the random-effects meta-analyses and meta-regressions (both univariate and multivariate). D-dimer associated clinical variables and potential mechanisms were schematically reasoned and graphed. Findings Our search identified 42 observational, or retrospective, or case series from six countries (n=14,862 patients) with all races and ages from 1 to 98-year-old. The weighted mean difference of D-dimer was 0.97 μg/mL (95% CI 0.65, 1.29) between relatively mild (or healthy control) and severely affected groups with significant publication bias. Univariate meta-regression identified 58 of 106 clinical variables were associated with plasma D-dimer levels, including 3 demographics, 5 comorbidies, 22 laboratory tests, 18 organ injury biomarkers, 8 severe complications, and 2 outcomes (discharge and death). Of these, 11 readouts were negatively associated with the level of plasma D-dimer. Further, age and gender were confounding factors for the identified D-dimer associated variables. There were 22 variables independently correlated with the D-dimer level, including respiratory rate, dyspnea plasma K+, glucose, SpO2, BUN, bilirubin, ALT, AST, systolic blood pressure, and CK. We thus propose that "insufficient hyperfibrinolysis (fibrinolysis is accelerated but unable to prevent adverse clinical impact for clinical deterioration COVID-19)" as a peculiar mechanism. Interpretation The findings of this meta-analysis- and meta-regression-based systematic review supports elevated D-dimer as an independent predictor for mortality and severe complications. D-dimer-associated clinical variables draw a landscape integrating the aggregate effects of systemically suppressive and locally (i.e., in the lung) hyperactive derangements of fibrinolysis. D-dimer and associated clinical biomarkers and conceptually parameters could be combined for risk stratification, potentially for tracking thrombolytic therapy or alternative interventions.