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Colosio M, Brocca L, Gatti MF, Neri M, Crea E, Cadile F, Canepari M, Pellegrino MA, Polla B, Porcelli S, Bottinelli R. Structural and functional impairments of skeletal muscle in patients with postacute sequelae of SARS-CoV-2 infection. J Appl Physiol (1985) 2023; 135:902-917. [PMID: 37675472 DOI: 10.1152/japplphysiol.00158.2023] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023] Open
Abstract
Following acute coronavirus disease 2019 (COVID-19), a substantial proportion of patients showed symptoms and sequelae for several months, namely the postacute sequelae of COVID-19 (PASC) syndrome. Major phenomena are exercise intolerance, muscle weakness, and fatigue. We aimed to investigate the physiopathology of exercise intolerance in patients with PASC syndrome by structural and functional analyses of skeletal muscle. At least 3 mo after infection, nonhospitalized patients with PASC (n = 11, age: 54 ± 11 yr; PASC) and patients without long-term symptoms (n = 12, age: 49 ± 9 yr; CTRL) visited the laboratory on four nonconsecutive days. Spirometry, lung diffusion capacity, and quality of life were assessed at rest. A cardiopulmonary incremental exercise test was performed. Oxygen consumption (V̇o2) kinetics were determined by moderate-intensity exercises. Muscle oxidative capacity (k) was assessed by near-infrared spectroscopy. Histochemical analysis, O2 flux (JO2) by high-resolution respirometry, and quantification of key molecular markers of mitochondrial biogenesis and dynamics were performed in vastus lateralis biopsies. Pulmonary and cardiac functions were within normal range in all patients. V̇o2peak was lower in PASC than CTRL (24.7 ± 5.0 vs. 32.9 ± 7.4 mL·min-1·kg-1, respectively, P < 0.05). V̇o2 kinetics was slower in PASC than CTRL (41 ± 12 vs. 30 ± 9 s-1, P < 0.05). k was lower in PASC than CTRL (1.54 ± 0.49 vs. 2.07 ± 0.51 min-1, P < 0.05). Citrate synthase, peroxisome proliferator-activated receptor-γ coactivator (PGC)1α, and JO2 for mitochondrial complex II were significantly lower in PASC vs. CTRL (all P values <0.05). In our cohort of patients with PASC, we showed limited exercise tolerance mainly due to "peripheral" determinants. Substantial reductions were observed for biomarkers of mitochondrial function, content, and biogenesis. PASC syndrome, therefore, appears to negatively impact skeletal muscle function, although the disease is a heterogeneous condition.NEW & NOTEWORTHY Several months after mild acute SARS-CoV-2 infection, a substantial proportion of patients present persisting, and often debilitating, symptoms and sequelae. These patients show reduced quality of life due to exercise intolerance, muscle weakness, and fatigue. The present study supports the hypothesis that "peripheral" impairments at skeletal muscle level, namely, reduced mitochondrial function and markers of mitochondrial biogenesis, are major determinants of exercise intolerance and fatigue, "central" phenomena at respiratory, and cardiac level being less relevant.
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Affiliation(s)
- Marta Colosio
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Lorenza Brocca
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Marco F Gatti
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Marianna Neri
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Emanuela Crea
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Francesca Cadile
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Monica Canepari
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Maria Antonietta Pellegrino
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Interdepartmental Centre of Biology and Sport Medicine, University of Pavia, Pavia, Italy
| | - Biagio Polla
- Rehabilitation Center, Teresio Borsalino, Alessandria, Italy
| | - Simone Porcelli
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Roberto Bottinelli
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- IRCCS Mondino Foundation, Pavia, Italy
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Sakibuzzaman M, Hassan A, Hayee S, Haque FA, Bushra SS, Maliha M, Tania MK, Sadat A, Akter F, Mazumder T, Razzaque J, Kapuria P, Jalal I, Shah-Riar P. Exacerbation of Pre-existing Neurological Symptoms With COVID-19 in Patients With Chronic Neurological Diseases: An Updated Systematic Review. Cureus 2022; 14:e29297. [PMID: 36277564 PMCID: PMC9578565 DOI: 10.7759/cureus.29297] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 01/08/2023] Open
Abstract
The neurotropism of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can potentially explain the worsening of symptoms in patients with a history of neurological conditions such as stroke, Parkinson's disease, Alzheimer's, and epilepsy. Several studies have reported that these pre-existing conditions may worsen with a higher frequency of flare-ups, thus resulting in a more significant risk of patient mortality. In this review, we sought to provide an overview of the relationship between pre-existing neurological disorders and COVID-19, focusing on whether the initial infection directly influenced the severity of symptoms. We systematically searched the electronic database PubMed (MEDLINE) and used specific keywords related to our aims from January 2020 to July 2022. All articles published on COVID-19 with keywords pertaining to pre-existing neurological diseases were retrieved and subsequently analyzed. After independent review, the data from 107 articles were selected and evaluated. After analyzing the data from selected articles reviewing the effect of COVID-19 on neurological conditions, we have documented the relationship between said pre-existing neurological diseases, showing an increased risk of hospitalization, admission length, worsening of symptoms, and even mortality in COVID-19 patients.
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Karim MM, Sultana S, Sultana R, Rahman MT. Possible Benefits of Zinc supplement in CVD and COVID-19 Comorbidity. J Infect Public Health 2021; 14:1686-1692. [PMID: 34649043 PMCID: PMC8489295 DOI: 10.1016/j.jiph.2021.09.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 09/09/2021] [Accepted: 09/29/2021] [Indexed: 12/31/2022] Open
Abstract
As far as comorbidity is concerned, cardiovascular diseases (CVD) appear to be accounted for the highest prevalence, severity, and fatality among COVID 19 patients. A wide array of causal links connecting CVD and COVID-19 baffle the overall prognosis as well as the efficacy of the given therapeutic interventions. At the centre of this puzzle lies ACE2 that works as a receptor for the SARS-CoV-2, and functional expression of which is also needed to minimize vasoconstriction otherwise would lead to high blood pressure. Furthermore, SARS-CoV-2 infection seems to reduce the functional expression of ACE2. Given these circumstances, it might be advisable to consider a treatment plan for COVID-19 patients with CVD in an approach that would neither aggravate the vasodeleterious arm of the renin-angiotensinogen-aldosterone system (RAAS) nor compromise the vasoprotective arm of RAAS but is effective to minimize or if possible, inhibit the viral replication. Given the immune modulatory role of Zn in both CVD and COVID-19 pathogenesis, zinc supplement to the selective treatment plan for CVD and COVID-19 comorbid conditions, to be decided by the clinicians depending on the cardiovascular conditions of the patients, might greatly improve the therapeutic outcome. Notably, ACE2 is a zinc metalloenzyme and zinc is also known to inhibit viral replication.
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Affiliation(s)
| | - Shahnaz Sultana
- Institute of National Analytical Research and Service (INARS), Bangladesh Council of Scientific and Industrial Research (BCSIR), New Elephant Road, Dhaka 1205, Bangladesh
| | - Rokaia Sultana
- Institute of National Analytical Research and Service (INARS), Bangladesh Council of Scientific and Industrial Research (BCSIR), New Elephant Road, Dhaka 1205, Bangladesh
| | - Mohammad Tariqur Rahman
- Faculty of Dentistry, University of Malaya, Kuala Lumpur 50603, Malaysia,Corresponding author
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Larijani B, Foroughi-Heravani N, Abedi M, Tayanloo-Beik A, Rezaei-Tavirani M, Adibi H, Arjmand B. Recent Advances of COVID-19 Modeling Based on Regenerative Medicine. Front Cell Dev Biol 2021; 9:683619. [PMID: 34760882 PMCID: PMC8573217 DOI: 10.3389/fcell.2021.683619] [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: 03/21/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has caused a pandemic since December 2019 that originated in Wuhan, China. Soon after that, the world health organization declared Coronavirus disease-2019 a global health concern. SARS-CoV-2 is responsible for a lethal respiratory infection as well as the involvement of other organs due to its large tropism spectrum such as neurologic, cardiovascular, endocrine, gastrointestinal, and renal systems. Since the behavior of the virus is not fully understood, a new manifestation of the infection is revealed every day. In order to be able to design more efficient drugs and vaccines to treat the infection, finding out the exact mechanism of pathogenicity would be necessary. Although there have been some big steps toward understanding the relevant process, there are still some deficiencies in this field. Accordingly, regenerative medicine (RM), can offer promising opportunities in discovering the exact mechanisms and specific treatments. For instance, since it is not always possible to catch the pathophysiology mechanisms in human beings, several modeling methods have been introduced in this field that can be studied in three main groups: stem cell-based models, organoids, and animal models. Regarding stem cell-based models, induced pluripotent stem cells are the major study subjects, which are generated by reprogramming the somatic stem cells and then directing them into different adult cell populations to study their behavior toward the infection. In organoid models, different cell lines can be guided to produce a 3D structure including liver, heart, and brain-like platforms. Among animal models, mice are the most common species in this field. However, in order for mice models to be permissive to the virus, angiotensin-converting enzyme 2 receptors, the main receptor involved in the pathogenicity of the virus, should be introduced to the host cells through different methods. Here, the current known mechanism of SARS-CoV-2 infection, different suggested models, the specific response toward different manipulation as well as challenges and shortcomings in each case have been reviewed. Finally, we have tried to provide a quick summary of the present available RM-based models for SARS-CoV-2 infection, as an essential part of developing drugs, for future therapeutic goals.
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Affiliation(s)
- Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical sciences, Tehran, Iran
| | - Najmeh Foroughi-Heravani
- Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Abedi
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Tayanloo-Beik
- Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hossein Adibi
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Arjmand
- Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Iqubal A, Iqubal MK, Hoda F, Najmi AK, Haque SE. COVID-19 and cardiovascular complications: an update from the underlying mechanism to consequences and possible clinical intervention. Expert Rev Anti Infect Ther 2021; 19:1083-1092. [PMID: 33618607 PMCID: PMC7938651 DOI: 10.1080/14787210.2021.1893692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 02/18/2021] [Indexed: 01/08/2023]
Abstract
Introduction: The novel coronavirus has caused significant mortality worldwide and is primarily associated with severe acute respiratory distress syndrome (ARDS). Apart from ARDS, clinical reports have shown noticeable cardiovascular complications among the patients of COVID-19. Infection from virus, stimulation of cytokine storm, altered immune response, and damage to myocardial tissue are some of the proposed mechanisms of cardiovascular complications in COVID-19.Areas covered: Based on the clinical reports of CVDs among COVID-19 patients, we have discussed the molecular mechanisms involved in cardiovascular pathogenesis, its prevalence, and association with COVID-19, and various available therapeutic modality for the treatment.Expert opinion: Seeing the cardiovascular complications in COVID-19 patients and its association with the existing drug, risk-benefit ratio of treatment paradigm, as well as the level of cardiac injury biomarkers must be monitored regularly. Additionally, a well-designed clinical trial should be conducted where head to head comparison can be made with anti-COVID-19 drugs and cardioprotective anti-inflammatory drugs. Nevertheless, vaccines are the best-suited approach, but until then, sanitization, social distancing, and active lifestyle are the best ways to beat this global pandemic situation.
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Affiliation(s)
- Ashif Iqubal
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Mohammad Kashif Iqubal
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Farazul Hoda
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Abul Kalam Najmi
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Syed Ehtaishamul Haque
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
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ILRUN Downregulates ACE2 Expression and Blocks Infection of Human Cells by SARS-CoV-2. J Virol 2021; 95:e0032721. [PMID: 33963054 DOI: 10.1128/jvi.00327-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The human protein-coding gene ILRUN (inflammation and lipid regulator with UBA-like and NBR1-like domains; previously C6orf106) was identified as a proviral factor for Hendra virus infection and was recently characterized to function as an inhibitor of type I interferon expression. Here, we have utilized transcriptome sequencing (RNA-seq) to define cellular pathways regulated by ILRUN in the context of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection of Caco-2 cells. We find that inhibition of ILRUN expression by RNA interference alters transcription profiles of numerous cellular pathways, including upregulation of the SARS-CoV-2 entry receptor ACE2 and several other members of the renin-angiotensin aldosterone system. In addition, transcripts of the SARS-CoV-2 coreceptors TMPRSS2 and CTSL were also upregulated. Inhibition of ILRUN also resulted in increased SARS-CoV-2 replication, while overexpression of ILRUN had the opposite effect, identifying ILRUN as a novel antiviral factor for SARS-CoV-2 replication. This represents, to our knowledge, the first report of ILRUN as a regulator of the renin-angiotensin-aldosterone system (RAAS). IMPORTANCE There is no doubt that the current rapid global spread of COVID-19 has had significant and far-reaching impacts on our health and economy and will continue to do so. Research in emerging infectious diseases, such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is growing rapidly, with new breakthroughs in the understanding of host-virus interactions to assist with the development of innovative and exciting therapeutic strategies. Here, we present the first evidence that modulation of the human protein-coding gene ILRUN functions as an antiviral factor for SARS-CoV-2 infection, likely through its newly identified role in regulating the expression of SARS-CoV-2 entry receptors ACE2, TMPRSS2, and CTSL. These data improve our understanding of biological pathways that regulate host factors critical to SARS-CoV-2 infection, contributing to the development of antiviral strategies to deal with the current SARS-CoV-2 pandemic.
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Zhan XY, Li L, Hu Y, Li Q, Kong H, Ng MHL, Chen C, He Y, Huang B, Yang M. Elderly Male With Cardiovascular-Related Comorbidities Has a Higher Rate of Fatal Outcomes: A Retrospective Study in 602 Patients With Coronavirus Disease 2019. Front Cardiovasc Med 2021; 8:680604. [PMID: 34164443 PMCID: PMC8215131 DOI: 10.3389/fcvm.2021.680604] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/19/2021] [Indexed: 01/08/2023] Open
Abstract
Elderly with comorbidities have shown a higher rate of fatal outcomes when suffering coronavirus disease 2019 (COVID-19). However, a delineation of clinical significances of hematologic indices and underlying comorbidities in the progression and outcome of COVID-19 remains undefined. Six hundred two COVID-19 patients with established clinical outcomes (discharged or deceased) from Hankou Hospital of Wuhan, China between January 14, 2020 and February 29, 2020 were retrospectively analyzed. Of the 602 patients with COVID-19, 539 were discharged and 63 died in the hospital. The deceased group showed higher leukocyte and neutrophil counts but lower lymphocyte and platelet counts. Longer activated partial thromboplastin time (APTT) and prothrombin time (PT), as well as higher D-dimer and C-reactive protein levels, were found in non-survivors. Our observations suggest that these parameters could serve as potential predictors for the fatal outcome and in the discharged group. A higher neutrophil count and D-dimer level but lower lymphocyte were associated with a longer duration of hospitalization. A multivariable Cox regression analysis showed that higher neutrophil count, prolonged PT, and low lymphocyte count were risk factors for patients with COVID-19. Also, we found an association of lower lymphocyte count and higher C-reactive protein levels with the elderly group and those with cardiovascular-related comorbidities. The significantly different hematologic profiles between survivors and non-survivors support that distinct hematologic signatures in COVID-19 patients will dictate different outcomes as a prognostic marker for recovery or fatality. Lymphopenia and aggressive inflammatory response might be major causes for fatal outcomes in the elderly male and especially those with cardiovascular-related comorbidities.
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Affiliation(s)
- Xiao-Yong Zhan
- The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Liang Li
- The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Yuhai Hu
- Department of Clinical Laboratory, Hankou Hospital, Wuhan, China
| | - Qiang Li
- Department of Clinical Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Huimin Kong
- The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Margaret H L Ng
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong, China
| | - Chun Chen
- The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Yulong He
- The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Bihui Huang
- The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Mo Yang
- The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
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Chang JC. COVID-19 Sepsis: Pathogenesis and Endothelial Molecular Mechanisms Based on "Two-Path Unifying Theory" of Hemostasis and Endotheliopathy-Associated Vascular Microthrombotic Disease, and Proposed Therapeutic Approach with Antimicrothrombotic Therapy. Vasc Health Risk Manag 2021; 17:273-298. [PMID: 34103921 PMCID: PMC8179800 DOI: 10.2147/vhrm.s299357] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/24/2021] [Indexed: 12/15/2022] Open
Abstract
COVID-19 sepsis is characterized by acute respiratory distress syndrome (ARDS) as a consequence of pulmonary tropism of the virus and endothelial heterogeneity of the host. ARDS is a phenotype among patients with multiorgan dysfunction syndrome (MODS) due to disseminated vascular microthrombotic disease (VMTD). In response to the viral septicemia, the host activates the complement system which produces terminal complement complex C5b-9 to neutralize pathogen. C5b-9 causes pore formation on the membrane of host endothelial cells (ECs) if CD59 is underexpressed. Also, viral S protein attraction to endothelial ACE2 receptor damages ECs. Both affect ECs and provoke endotheliopathy. Disseminated endotheliopathy activates two molecular pathways: inflammatory and microthrombotic. The former releases inflammatory cytokines from ECs, which lead to inflammation. The latter initiates endothelial exocytosis of unusually large von Willebrand factor (ULVWF) multimers and FVIII from Weibel–Palade bodies. If ADAMTS13 is insufficient, ULVWF multimers activate intravascular hemostasis of ULVWF path. In activated ULVWF path, ULVWF multimers anchored to damaged endothelial cells recruit circulating platelets and trigger microthrombogenesis. This process produces “microthrombi strings” composed of platelet-ULVWF complexes, leading to endotheliopathy-associated VMTD (EA-VMTD). In COVID-19, microthrombosis initially affects the lungs per tropism causing ARDS, but EA-VMTD may orchestrate more complex clinical phenotypes, including thrombotic thrombocytopenic purpura (TTP)-like syndrome, hepatic coagulopathy, MODS and combined micro-macrothrombotic syndrome. In this pandemic, ARDS and pulmonary thromboembolism (PTE) have often coexisted. The analysis based on two hemostatic theories supports ARDS caused by activated ULVWF path is EA-VMTD and PTE caused by activated ULVWF and TF paths is macrothrombosis. The thrombotic disorder of COVID-19 sepsis is consistent with the notion that ARDS is virus-induced disseminated EA-VMTD and PTE is in-hospital vascular injury-related macrothrombosis which is not directly related to viral pathogenesis. The pathogenesis-based therapeutic approach is discussed for the treatment of EA-VMTD with antimicrothrombotic regimen and the potential need of anticoagulation therapy for coinciding macrothrombosis in comprehensive COVID-19 care.
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Affiliation(s)
- Jae C Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
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Klaourakis K, Vieira JM, Riley PR. The evolving cardiac lymphatic vasculature in development, repair and regeneration. Nat Rev Cardiol 2021; 18:368-379. [PMID: 33462421 PMCID: PMC7812989 DOI: 10.1038/s41569-020-00489-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 02/08/2023]
Abstract
The lymphatic vasculature has an essential role in maintaining normal fluid balance in tissues and modulating the inflammatory response to injury or pathogens. Disruption of normal development or function of lymphatic vessels can have severe consequences. In the heart, reduced lymphatic function can lead to myocardial oedema and persistent inflammation. Macrophages, which are phagocytic cells of the innate immune system, contribute to cardiac development and to fibrotic repair and regeneration of cardiac tissue after myocardial infarction. In this Review, we discuss the cardiac lymphatic vasculature with a focus on developments over the past 5 years arising from the study of mammalian and zebrafish model organisms. In addition, we examine the interplay between the cardiac lymphatics and macrophages during fibrotic repair and regeneration after myocardial infarction. Finally, we discuss the therapeutic potential of targeting the cardiac lymphatic network to regulate immune cell content and alleviate inflammation in patients with ischaemic heart disease.
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Affiliation(s)
- Konstantinos Klaourakis
- Burdon Sanderson Cardiac Science Centre, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
- British Heart Foundation-Oxbridge Centre of Regenerative Medicine, CRM, University of Oxford, Oxford, UK
| | - Joaquim M Vieira
- Burdon Sanderson Cardiac Science Centre, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK.
- British Heart Foundation-Oxbridge Centre of Regenerative Medicine, CRM, University of Oxford, Oxford, UK.
| | - Paul R Riley
- Burdon Sanderson Cardiac Science Centre, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK.
- British Heart Foundation-Oxbridge Centre of Regenerative Medicine, CRM, University of Oxford, Oxford, UK.
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Pharmacological mechanism of immunomodulatory agents for the treatment of severe cases of COVID-19 infection. Inflamm Res 2021; 70:389-405. [PMID: 33608746 PMCID: PMC7894237 DOI: 10.1007/s00011-021-01445-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Coronavirus disease 2019 (COVID-19) is a world-wide pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To date, treatment of severe COVID-19 is far from clear. Therefore, it is urgent to develop an effective option for the treatment of patients with COVID-19. Most patients with severe COVID-19 exhibit markedly increased serum levels of pro-inflammatory cytokines, including interferon (IFN)-α, IFN-γ, and interleukin (IL)-1β. Immunotherapeutic strategies have an important role in the suppression of cytokine storm and respiratory failure in patients with COVID-19. METHODS A systematic search in the literature was performed in PubMed, Scopus, Embase, Cochrane Library, Web of Science, as well as Google Scholar preprint database using all available MeSH terms for Coronavirus, SARS-CoV-2, anti-rheumatoid agents, COVID-19, cytokine storm, immunotherapeutic drugs, IFN, interleukin, JAK/STAT inhibitors, MCP, MIP, TNF. RESULTS Here, we first review common complications of COVID-19 patients, particularly neurological symptoms. We next explain host immune responses against COVID-19 particles. Finally, we summarize the existing experimental and clinical immunotherapeutic strategies, particularly anti-rheumatoid agents and also plasma (with a high level of gamma globulin) therapy for severe COVID-19 patients. We discuss both their therapeutic effects and side effects that should be taken into consideration for their clinical application. CONCLUSION It is suggested that immunosuppressants, such as anti-rheumatoid drugs, could be considered as a potential approach for the treatment of cytokine storm in severe cases of COVID-19. One possible limitation of immunosuppressant therapy is their inhibitory effects on host anti-viral immune response. So, the appropriate timing of administration should be carefully considered.
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Azevedo RB, Botelho BG, Hollanda JVGD, Ferreira LVL, Andrade LZJD, Oei SSML, Mello TDS, Muxfeldt ES. Practical Approach to Acute Coronary Syndrome in Patients with COVID-19. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Brown SA, Zaharova S, Mason P, Thompson J, Thapa B, Ishizawar D, Wilkes E, Ahmed G, Rubenstein J, Sanchez J, Joyce D, Kalyanaraman B, Widlansky M. Pandemic Perspective: Commonalities Between COVID-19 and Cardio-Oncology. Front Cardiovasc Med 2020; 7:568720. [PMID: 33344513 PMCID: PMC7746643 DOI: 10.3389/fcvm.2020.568720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/06/2020] [Indexed: 12/15/2022] Open
Abstract
Overlapping commonalities between coronavirus disease of 2019 (COVID-19) and cardio-oncology regarding cardiovascular toxicities (CVT), pathophysiology, and pharmacology are special topics emerging during the pandemic. In this perspective, we consider an array of CVT common to both COVID-19 and cardio-oncology, including cardiomyopathy, ischemia, conduction abnormalities, myopericarditis, and right ventricular (RV) failure. We also emphasize the higher risk of severe COVID-19 illness in patients with cardiovascular disease (CVD) or its risk factors or cancer. We explore commonalities in the underlying pathophysiology observed in COVID-19 and cardio-oncology, including inflammation, cytokine release, the renin-angiotensin-aldosterone-system, coagulopathy, microthrombosis, and endothelial dysfunction. In addition, we examine common pharmacologic management strategies that have been elucidated for CVT from COVID-19 and various cancer therapies. The use of corticosteroids, as well as antibodies and inhibitors of various molecules mediating inflammation and cytokine release syndrome, are discussed. The impact of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) is also addressed, since these drugs are used in cardio-oncology and have received considerable attention during the COVID-19 pandemic, since the culprit virus enters human cells via the angiotensin converting enzyme 2 (ACE2) receptor. There are therefore several areas of overlap, similarity, and interaction in the toxicity, pathophysiology, and pharmacology profiles in COVID-19 and cardio-oncology syndromes. Learning more about either will likely provide some level of insight into both. We discuss each of these topics in this viewpoint, as well as what we foresee as evolving future directions to consider in cardio-oncology during the pandemic and beyond. Finally, we highlight commonalities in health disparities in COVID-19 and cardio-oncology and encourage continued development and implementation of innovative solutions to improve equity in health and healing.
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Affiliation(s)
- Sherry-Ann Brown
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Svetlana Zaharova
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Peter Mason
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jonathan Thompson
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Bicky Thapa
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - David Ishizawar
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Erin Wilkes
- Department of Pharmacy, Froedtert Health and Medical College of Wisconsin, Milwaukee, WI, United States
| | - Gulrayz Ahmed
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jason Rubenstein
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joyce Sanchez
- Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, WI, United States
| | - David Joyce
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Michael Widlansky
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
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13
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Diaz T, Trachtenberg BH, Abraham SJK, KosagiSharaf R, Durant-Archibold AA. Aspirin Bioactivity for Prevention of Cardiovascular Injury in COVID-19. Front Cardiovasc Med 2020; 7:562708. [PMID: 33330639 PMCID: PMC7734129 DOI: 10.3389/fcvm.2020.562708] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Temistocles Diaz
- Internal Medicine-Interventional Cardiology, Department of Cardiology, Punta Pacifica Hospital, Affiliate of John Hopkins Medicine International, Panama City, Panama.,Biomedicine Research Unit, Center for Biodiversity and Drug Discovery, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT Asociation of Public Interest), Panama City, Panama
| | - Barry H Trachtenberg
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, United States
| | - Samuel J K Abraham
- Department of Surgery & Centre for Advancing Clinical Research (CACR), Yamanashi University, Chuo, Japan.,Edogawa Evolutionary Laboratory of Science (EELS), Edogawa Hospital, Tokyo, Japan.,The Mary-Yoshio Translational Hexagon (MYTH), Nichi-In Centre for Regenerative Medicine (NCRM), Chennai, India
| | - Rao KosagiSharaf
- Biomedicine Research Unit, Center for Biodiversity and Drug Discovery, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT Asociation of Public Interest), Panama City, Panama
| | - Armando A Durant-Archibold
- Biomedicine Research Unit, Center for Biodiversity and Drug Discovery, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT Asociation of Public Interest), Panama City, Panama.,Department of Biochemistry, College of Natural, Exact Science and Technology, Universidad de Panama, Panama City, Panama
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14
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Kumrungsee T, Zhang P, Chartkul M, Yanaka N, Kato N. Potential Role of Vitamin B6 in Ameliorating the Severity of COVID-19 and Its Complications. Front Nutr 2020; 7:562051. [PMID: 33195363 PMCID: PMC7658555 DOI: 10.3389/fnut.2020.562051] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/28/2020] [Indexed: 12/18/2022] Open
Affiliation(s)
| | - Peipei Zhang
- State Key Laboratory of Cellular Stress Biology, School of Medicine and School of Life Science, Xiamen University, Xiamen, China
| | - Maesaya Chartkul
- Emergency Department, Bangkok Chanthaburi Hospital, Chanthaburi, Thailand
- Emergency Department, King Prajadhipok Memorial Hospital, Chanthaburi, Thailand
- Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Noriyuki Yanaka
- Graduate School of Integrated Sciences for Life, Hiroshima University, Higashi-Hiroshima, Japan
| | - Norihisa Kato
- Graduate School of Integrated Sciences for Life, Hiroshima University, Higashi-Hiroshima, Japan
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15
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Therapeutic modalities and novel approaches in regenerative medicine for COVID-19. Int J Antimicrob Agents 2020; 56:106208. [PMID: 33213829 PMCID: PMC7582055 DOI: 10.1016/j.ijantimicag.2020.106208] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/25/2020] [Accepted: 10/17/2020] [Indexed: 02/08/2023]
Abstract
The recent coronavirus disease 2019 outbreak around the world has had an enormous impact on the global health burden, threatening the lives of many individuals, and has had severe socio-economic consequences. Many pharmaceutical and biotechnology companies have commenced intensive research on different therapeutic strategies, from repurposed antiviral drugs to vaccines and monoclonal antibodies to prevent the spread of the disease and treat infected patients. Among the various strategies, advanced therapeutic approaches including cell- and gene-editing-based therapeutics are also being investigated, and initial results in in-vitro and early phase I studies have been promising. However, further assessments are required. This article reviews the underlying mechanisms for the pathogenesis of severe acute respiratory syndrome coronavirus-2, and discusses available therapeutic candidates and advanced modalities that are being evaluated in in-vitro/in-vivo models and are of note in clinical trials.
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16
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Alberca RW, Yendo TM, Leuzzi Ramos YÁ, Fernandes IG, Oliveira LDM, Teixeira FME, Beserra DR, de Oliveira EA, Gozzi-Silva SC, Andrade MMDS, Branco ACCC, Pietrobon AJ, Pereira NZ, de Brito CA, Orfali RL, Aoki V, Duarte AJDS, Benard G, Sato MN. Case Report: COVID-19 and Chagas Disease in Two Coinfected Patients. Am J Trop Med Hyg 2020; 103:2353-2356. [PMID: 33025877 PMCID: PMC7695072 DOI: 10.4269/ajtmh.20-1185] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
American trypanosomiasis, also named Chagas disease (CD), is an anthropozoonosis caused by the protozoan parasite Trypanosoma cruzi. The disease affects millions of people worldwide, leading yearly to approximately 50,000 deaths. COVID-19, generated by SARS-CoV-2, can lead to lymphopenia and death. We hereby describe the first report of two patients with CD and COVID-19 coinfection, from hospitalization until patients' death.
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Affiliation(s)
- Ricardo Wesley Alberca
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Tatiana Mina Yendo
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Yasmim Álefe Leuzzi Ramos
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Iara Grigoletto Fernandes
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luana de Mendonça Oliveira
- Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.,Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Franciane Mouradian Emidio Teixeira
- Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.,Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Danielle Rosa Beserra
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Emily Araujo de Oliveira
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Sarah Cristina Gozzi-Silva
- Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.,Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Milena Mary de Souza Andrade
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Anna Cláudia Calvielli Castelo Branco
- Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.,Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Anna Julia Pietrobon
- Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.,Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Nátalli Zanete Pereira
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Cyro Alves de Brito
- Technical Division of Medical Biology, Adolfo Lutz Institute, Immunology Center, São Paulo, Brazil
| | - Raquel Leão Orfali
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Valéria Aoki
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alberto José da Silva Duarte
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Gil Benard
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Maria Notomi Sato
- Departamento de Dermatologia, Faculdade de Medicina FMUSP, Laboratorio de Dermatologia e Imunodeficiencias (LIM-56), Universidade de Sao Paulo, Sao Paulo, Brazil
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17
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Waleed RM, Sehar I, Iftikhar W, Khan HS. Hematologic parameters in coronavirus infection (COVID-19) and their clinical implications. Discoveries (Craiova) 2020; 8:e117. [PMID: 33110936 PMCID: PMC7585459 DOI: 10.15190/d.2020.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Coronaviruses are a class of enveloped RNA viruses that cause infections of the respiratory tract, characterized by fever, tiredness, dry cough, diarrhea, loss of smell or taste, chest pain and shortness of breath. Many patients with mysterious pneumonia were distinguished in December 2019 in Wuhan. The pneumonia of obscure origin was found to be ascribed to a novel coronavirus and described as novel coronavirus pneumonia (NCP). The Chinese authorities initially reported the wave of mysterious pneumonia on December 31st, 2019 and it was declared as an outbreak of international concern on January 30th, 2020. A systematic search of relevant research was conducted, and a total of 58 primary research articles were identified, analyzed, and debated to better understand the hematologic profile in COVID-19 (Coronavirus disease) infection and its clinical implications. All the findings in this article manifest a true impression of the current interpretation of hematological findings of the SARS-COV-2 disease. Pathophysiology of COVID-19 disease can be better interpreted by taking into consideration the hematologic parameters. Clinical implications of the hematologic profile of COVID-19 patients including cytokine storm, coagulation profile, and thrombophilic complications are under-recognized. Therefore, this review focuses on the coagulation profile, cytokine storm, and its treatment options. The role of pre-existing thrombophilia in COVID-19 patients and how it could result in the poor prognosis of the disease is also debated. The recent data suggests that hypercoagulability could be the potential cause of fatalities due to COVID-19. Potential effects of tocilizumab, metronidazole, and ulinastatin in suppressing cytokine storm may help to treat SARS-COV-2 infection. This review also highlights the significance of thrombophilia testing in SARS-CoV-2 patients depending on the clinical features and especially in pregnant women.
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Affiliation(s)
| | - Inbisat Sehar
- CMH Lahore Medical College and Institute of Dentistry, Lahore, Pakistan
| | - Waleed Iftikhar
- CMH Lahore Medical College and Institute of Dentistry, Lahore, Pakistan.,California Institute of Behavioral Neurosciences & Psychology, Fairfield, CA 94534, USA
| | - Huma Saeed Khan
- CMH Lahore Medical College and Institute of Dentistry, Lahore, Pakistan
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18
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Spence JD, de Freitas GR, Pettigrew LC, Ay H, Liebeskind DS, Kase CS, Del Brutto OH, Hankey GJ, Venketasubramanian N. Mechanisms of Stroke in COVID-19. Cerebrovasc Dis 2020; 49:451-458. [PMID: 32690850 PMCID: PMC7445374 DOI: 10.1159/000509581] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada,
| | - Gabriel R de Freitas
- Department of Neurology, Universidade Federal Fluminense and Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, Brazil
| | - L Creed Pettigrew
- Department of Neurology, University of Kentucky School of Medicine, Lexington, Kentucky, USA
| | - Hakan Ay
- Department of Neurology and Radiology, Harvard School of Medicine and Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts, USA
| | - David S Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center, Department of Neurology, University of California, Los Angeles, California, USA
| | - Carlos S Kase
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | | | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Washington, Australia
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