COVID-19 update: Covid-19-associated coagulopathy

Mandibular mucormycosis following SARS-CoV-2 infection - A case report and review of literature

BACKGROUND

The second wave of COVID-19 pandemic has seen an unprecedented rise in the number of mucormycosis cases worldwide and in India particularly. This otherwise rare fungal infection has become an endemic among patients who have recovered from recent SARS-CoV-2 infection. Among the different types of mucormycosis, rhino-orbital-cerebral involvement has mainly been observed in the recent surge of cases. Very few cases of mucormycosis of mandible have been reported in literature and none in COVID-19 patients. We report a case of isolated mandibular mucormycosis in a COVID- 19 patient, with no other predisposing comorbidities.Case report.A 39 year old patient recently recovered from COVID-19 presented with typical symptoms of osteomyelitis which was confirmed using computed tomography of face. He underwent thorough debridement and curettage and tissue was sent for culture, special staining and biopsy.

RESULT

Diagnosis of mucormycosis was confirmed based on postoperative biopsy and special staining. He was further managed with complete course of appropriate antifungal therapy.

CONCLUSION

Mucormycosis is a fulminant and aggressive infection which requires prompt diagnosis and intervention. Early referral to a maxillofacial surgeon by physicians and general dental practitioners on seeing signs and symptoms of secondary fungal infections involving maxilla or mandible in patients with history of SARS-CoV-19 infection can improve prognosis.

The role of lipoprotein(a) in coronavirus disease 2019 (COVID-19) with relation to development of severe acute kidney injury

Lipoprotein(a) (Lp(a)) is a prothrombotic and anti-fibrinolytic lipoprotein, whose role has not been clearly defined in the pathogenesis of coronavirus disease 2019 (COVID-19). In this prospective observational study, serum Lp(a) as well as outcomes were measured in 50 COVID-19 patients and 30 matched sick controls. Lp(a) was also assessed for correlation with a wide panel of biomarkers. Serum Lp(a) did not significantly differ between COVID-19 patients and sick controls, though its concentration was found to be significantly associated with severity of COVID-19 illness, including acute kidney failure stage (r = 0.380, p = 0.007), admission disease severity (r = 0.355, p = 0.013), and peak severity (r = 0.314; p = 0.03). Lp(a) was also positively correlated with interleukin (IL)-8 (r = 0.308; p = 0.037), fibrinogen (r = 0.344; p = 0.032) and creatinine (r = 0.327; p = 0.027), and negatively correlated with ADAMTS13 activity/VWF:Ag (r = − 0.335; p = 0.021); but not with IL-6 (r = 0.241; p = 0.106). These results would hence suggest that adverse outcomes in patients with COVID-19 may be aggravated by a genetically determined hyper-Lp(a) state rather than any inflammation induced elevations.

Pathogenesis, Symptomatology, and Transmission of SARS-CoV-2 through Analysis of Viral Genomics and Structure

The novel coronavirus SARS-CoV-2, which emerged in late 2019, has since spread around the world and infected hundreds of millions of people with coronavirus disease 2019 (COVID-19). While this viral species was unknown prior to January 2020, its similarity to other coronaviruses that infect humans has allowed for rapid insight into the mechanisms that it uses to infect human hosts, as well as the ways in which the human immune system can respond. Here, we contextualize SARS-CoV-2 among other coronaviruses and identify what is known and what can be inferred about its behavior once inside a human host. Because the genomic content of coronaviruses, which specifies the virus's structure, is highly conserved, early genomic analysis provided a significant head start in predicting viral pathogenesis and in understanding potential differences among variants. The pathogenesis of the virus offers insights into symptomatology, transmission, and individual susceptibility. Additionally, prior research into interactions between the human immune system and coronaviruses has identified how these viruses can evade the immune system's protective mechanisms. We also explore systems-level research into the regulatory and proteomic effects of SARS-CoV-2 infection and the immune response. Understanding the structure and behavior of the virus serves to contextualize the many facets of the COVID-19 pandemic and can influence efforts to control the virus and treat the disease. IMPORTANCE COVID-19 involves a number of organ systems and can present with a wide range of symptoms. From how the virus infects cells to how it spreads between people, the available research suggests that these patterns are very similar to those seen in the closely related viruses SARS-CoV-1 and possibly Middle East respiratory syndrome-related CoV (MERS-CoV). Understanding the pathogenesis of the SARS-CoV-2 virus also contextualizes how the different biological systems affected by COVID-19 connect. Exploring the structure, phylogeny, and pathogenesis of the virus therefore helps to guide interpretation of the broader impacts of the virus on the human body and on human populations. For this reason, an in-depth exploration of viral mechanisms is critical to a robust understanding of SARS-CoV-2 and, potentially, future emergent human CoVs (HCoVs).

Recent Advances of COVID-19 Modeling Based on Regenerative Medicine

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.

A review of ischemic stroke in COVID-19: currently known pathophysiological mechanisms

Coronavirus disease 2019 (COVID-19), the third type of coronavirus pneumonia after severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), is spreading widely worldwide now. This pneumonia causes not only respiratory symptoms but also multiple organ dysfunction, including thrombotic diseases such as ischemic stroke. The purpose of this review is to explore whether COVID-19 is a risk factor for ischemic stroke and its related pathophysiological mechanisms. Based on the high thrombosis rate and frequent strokes of COVID-19 patients, combined with related laboratory indicators and pathological results, the discussion is mainly from two aspects: nerve invasion and endothelial dysfunction. SARS-CoV-2 can directly invade the CNS through blood-borne and neuronal retrograde pathways, causing cerebrovascular diseases. In addition, the endothelial dysfunction in COVID-19 is almost certain. Cytokine storm causes thromboinflammation, and downregulation of ACE2 leads to RAS imbalance, which eventually lead to ischemic stroke.

Ventricular Septal Defect in Delayed Presentation of ST-Elevation Myocardial Infarction (STEMI) Secondary to COVID-19 Pandemic

Like many other countries at the moment, the United Kingdom (UK) is currently under national lockdown due to the coronavirus disease 2019 (COVID-19) pandemic. An unfortunate consequence of such social isolation measures is that patients with genuine acute medical emergencies may not present to a hospital in a timely manner. We present such a scenario, whereby a patient had a delayed presentation of ST-elevation myocardial infarction (STEMI) due to fear of breaching COVID-19 lockdown rules. As a result of the patient presenting well outside the optimal treatment window, her STEMI was complicated by a severe ventricular septal defect (VSD). We discuss how the COVID-19 pandemic has influenced the nature and management of STEMIs and associated issues. 

Pulmonary vascular system: A vulnerable target for COVID-19

The number of coronavirus disease 2019 (COVID‐19) cases has been increasing significantly, and the disease has evolved into a global pandemic, posing an unprecedented challenge to the healthcare community. Angiotensin‐converting enzyme 2, the binding and entry receptor of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in hosts, is also expressed on pulmonary vascular endothelium; thus, pulmonary vasculature is a potential target in COVID‐19. Indeed, pulmonary vascular thickening is observed by early clinical imaging, implying a tropism of SARS‐CoV‐2 for pulmonary vasculature. Recent studies reported that COVID‐19 is associated with vascular endothelial damage and dysfunction along with inflammation, coagulopathy, and microthrombosis; all of these pathologic changes are the hallmarks of pulmonary vascular diseases. Notwithstanding the not fully elucidated effects of COVID‐19 on pulmonary vasculature, the vascular endotheliopathy that occurs after infection is attributed to direct infection and indirect damage mainly caused by renin‐angiotensin‐aldosterone system imbalance, coagulation cascade, oxidative stress, immune dysregulation, and intussusceptive angiogenesis. Degradation of endothelial glycocalyx exposes endothelial cell (EC) surface receptors to the vascular lumen, which renders pulmonary ECs more susceptible to SARS‐CoV‐2 infection. The present article reviews the potential pulmonary vascular pathophysiology and clinical presentations in COVID‐19 to provide a basis for clinicians and scientists, providing insights into the development of therapeutic strategies targeting pulmonary vasculature.

Bioactive Natural Compounds with Antiplatelet and Anticoagulant Activity and Their Potential Role in the Treatment of Thrombotic Disorders

Natural anticoagulant drugs can be obtained from plants, rich in secondary bioactive metabolites which, in addition to being effective antioxidants, also possess anticoagulant and antiplatelet properties and, for this reason, can be excellent candidates for the treatment of thrombotic diseases. This review reports an overview of the hemostatic process and thrombotic disorders together with data on plants, more and less common from around the world, containing bioactive compounds characterized by antiplatelet and anticoagulant activity. The reported literature was obtained from Medline, PubMed, Elsevier, Web of Science, Google Scholar considering only articles in the English language, published in peer-reviewed journals. The number of citations of the articles and the impact factor of the journals were other parameters used to select the scientific papers to be included in the review. The analysis of the literature data selected demonstrates that many plants' bioactive compounds show antiplatelet and anticoagulant activity that make them potential candidates to be used as new natural compounds able to interfere with both primary and secondary hemostasis. Moreover, they could be used together with anticoagulants currently administered in clinical practice to increase their efficacy and to reduce complications in the treatment of thrombotic disorders.

Evaluation of choroidal thickness in patients who have recovered from COVID-19

Purpose

We aimed to evaluate choroidal thickness (CT) in patients who have recovered from COVID-19 by using enhanced depth imaging optical coherence tomography (EDI-OCT).

Methods

We included fifty-eight patients who have recovered from COVID-19 (group 1) and fifty healthy control subjects (group 2) in this prospective study. Best corrected visual acuity, anterior segment and posterior segment examinations of all subjects were performed. CT scan and measurements were taken with the EDI mode of the Spectral Domain OCT device.

Results

Of the 108 subjects included in this study, 57 were female and 51 were male. The mean age was similar in both groups (36.10 ± 7.12 and 35.58 ± 7.29, respectively, p = 0.276). Group 1 had the following characteristics: the mean time since diagnosis was 53.18 ± 2.84; it had been 38.48 ± 4.07 days since the PCR test was negative; and all subjects were outpatients. It was detected that the CT of the patients in group 1 decreased in all areas compared to group 2, and this decrease was significant in subfoveal, temporal and inferior areas (257.48 ± 32.79, 273.62 ± 45.04, p = 0.04; 232.96 ± 41.79, 252.76 ± 46.09, p = 0.02, and 245.22 ± 44.58, 271.54 ± 55.07, p = 0.01, respectively). In the retinal nerve fiber layer analysis for group 1, thickening was detected in all areas, although it was not statistically significant, except in the temporal area where it was (superotemporal, superonasal, nasal, inferonasal, inferotemporal, temporal, and global [p = 0 .08, p = 0.45, p = 0.73, p = 0.64, p = 0.74, p = 0.02, and p = 0.10, respectively]).

Conclusion

For individuals who had recovered from COVID-19, it was found that CT decreased in all areas in these patients. Therefore, this study in which we have demonstrated the decrease in the thickness of the choroidal tissue, a tissue with high blood flow, may contribute to the understanding of the systemic microvascular waste of this disease.

The pathophysiology of sepsis-2021 update: Part 1, immunology and coagulopathy leading to endothelial injury

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

To provide an overview of current literature on the pathophysiology of sepsis, with a focus on mediators of endothelial injury and organ dysfunction.

Summary

Sepsis is a dysregulated response to infection that triggers cascades of interconnected systems. Sepsis has been a significant cause of mortality worldwide, and the recent viral pandemic that may produce severe sepsis and septic shock has been a major contributor to sepsis-related mortality. Understanding of the pathophysiology of sepsis has changed dramatically over the last several decades. Significant insight into the components of the inflammatory response that contribute to endothelial injury and trigger coagulation pathways has been achieved. Similarly, characterization of anti-inflammatory pathways that may lead to secondary infections and poor outcome has illustrated opportunities for improved therapies. Description of an increasing number of important mediators and pathways has occurred and may point the way to novel therapies to address immune dysregulation. Pharmacists will need a fundamental understanding of the overlapping pathways of the immune response to fully prepare for use of novel treatment options. While pharmacists typically understand coagulation cascade how to utilize anticoagulants, the issues in sepsis related coagulopathy and role of mediators such as cytokines and complement and role of activated platelets and neutrophils require a different perspective.

Conclusion

Pharmacists can benefit from understanding both the cellular and organ system issues in sepsis to facilitate assessment of potential therapies for risk and benefit.

Acute limb ischemia in a patient with Covid-19 pneumonia: a case report

Coronavirus disease 2019 (COVID-19) has emerged as a pandemic across the world. Hypercoagulability status in COVID-19 is one of the causes of complication from severe COVID-19 with a high risk of arterial thrombosis. Acute Limb Ischemia is a vascular emergency caused by sudden decrease in the arterial perfusion. We report the case of a 53-year-old male patient with COVID-19 Pneumonia, diagnosed with Acute Limb Ischemia. From clinical examination, which included anamnesis, physical examination, and laboratory results as well as chest X-rays, a suspicion of Acute Limb Ischemia was found in a patient with COVID-19 pneumonia. The SARS-CoV-2 real time PCR examination showed positive results. In this patient, the diagnosis of Acute Limb Ischemia with Covid-19 Pneumonia was established through a multidisciplinary approach covering the fields of pulmonology, cardiology, and thoracic and cardiovascular surgery.

Similarities between COVID-19 and systemic sclerosis early vasculopathy: A "viral" challenge for future research in scleroderma

OBJECTIVE

To review similarities between COVID-19 and systemic sclerosis (SSc) early vasculopathy to provide novel insights into both diseases.

METHODS

A narrative review of the literature supplemented with expert opinion.

RESULTS

There is clear evidence that the endothelium is at the centre stage in SSc and COVID-19, with endothelial cell activation/injury and dysfunction creating the crucial evolving step in the pathogenesis of both diseases. The angiotensin system has also been implicated in the early stages of both COVID-19 and SSc. Autoptic studies provide novel insights into the effects of SARS-CoV-2 on the endothelium. Normal endothelium and endothelial dysfunction in COVID-19 and SSc are discussed. It is debated whether SARS-CoV-2 infection triggers autoimmunity with production of autoantibodies which is of mechanistic interest because other viral illnesses are potentially involved in endothelial dysfunction and in SSc pathogenesis.

CONCLUSION

COVID-19 is due to a direct assault of SARS-CoV-2 on the vascular system as an acute infection, whereas SSc remains a chronic/sub-acute autoimmune disease of largely unknown etiology Further study and exploration of the SARS-CoV-2 pathogenic mechanisms might provide further useful milestones in the understanding of the early SSc pathogenesis.

Von Willebrand factor: A key glycoprotein involved in thrombo-inflammatory complications of COVID-19

COVID-19 is an ongoing public health emergency that has affected millions of people worldwide and is still a threat to many more. One of the pathophysiological features of COVID-19 is associated with the activation of vascular endothelial cells (ECs) leading to the disruption of vascular integrity, coagulation and inflammation. An interlink mechanism between coagulation and inflammatory pathways has been reported in COVID-19. Multiple components are involved in these pathological pathways. Out of all, Von Willebrand Factor (VWF) is one of the primary components of coagulation pathway and also a mediator of vascular inflammation that plays an important role in thrombo-inflammation that further leads to acute respiratory distress syndrome (ARDS). The thrombo-inflammatory co-morbidities such as hyper-coagulation, thrombosis, ARDS etc. have become the major cause of mortality in the patients of COVID-19 admitted to the ICU. Thus, VWF can be explored as a potential target to manage COVID-19 associated co-morbidities. Supporting this hypothesis, there are literature reports which disclose previous attempts to target VWF for the management of thrombo-inflammation in other pathological conditions. The current report summarizes emerging insights into the pathophysiology, mechanism(s), diagnosis, management and foundations for research on this less explored clinically relevant glycoprotein as coagulation biomarker in COVID-19.

Immunothrombotic dysregulation in chagas disease and COVID-19: a comparative study of anticoagulation

Chagas and COVID-19 are diseases caused by Trypanosoma cruzi and SARS-CoV-2, respectively. These diseases present very different etiological agents despite showing similarities such as susceptibility/risk factors, pathogen-associated molecular patterns (PAMPs), recognition of glycosaminoglycans, inflammation, vascular leakage hypercoagulability, microthrombosis, and endotheliopathy; all of which suggest, in part, treatments with similar principles. Here, both diseases are compared, focusing mainly on the characteristics related to dysregulated immunothrombosis. Given the in-depth investigation of molecules and mechanisms related to microthrombosis in COVID-19, it is necessary to reconsider a prompt treatment of Chagas disease with oral anticoagulants.

Rehabilitative management of post-acute COVID-19: clinical pictures and outcomes

This study aimed to detect patients' characteristics who suffered severe and critical COVID-19 pneumonia admitted to the post-acute COVID-19 rehabilitation clinic in Ankara City Hospital, Physical Medicine and Rehabilitation Hospital and to share our experiences and outcomes of rehabilitation programmes applied. This study was designed as a single-centre, retrospective, observational study. Severe and critical COVID-19 patients, admitted to the post-acute COVID-19 rehabilitation clinic, were included in patient-based rehabilitation programmes, targeting neuromuscular and respiratory recovery. Functional status, oxygen (O₂) requirement and daily living activities were assessed before and after rehabilitation. Eighty-five patients, of which 74% were male, were analysed, with the mean age of 58.27 ± 11.13 and mean body mass index of 25.29 ± 4.81 kg/m². The most prevalent comorbidities were hypertension (49.4%) and diabetes mellitus (34.1%). Of the 85 patients, 84 received antiviral drugs, 81 low-molecular-weight heparin, 71 corticosteroids, 11 anakinra, 4 tocilizumab, 16 intravenous immunoglobulin and 6 plasmapheresis. 78.8% of the patients were admitted to the intensive care unit, with a mean length of stay of 19.41 ± 18.99 days, while those who needed O₂ support with mechanic ventilation was 36.1%. Neurological complications, including Guillain-Barré syndrome, critical illness-related myopathy/neuropathy, cerebrovascular disease and steroid myopathy, were observed in 39 patients. On initial functional statuses, 55.3% were bedridden, 22.4% in wheelchair level and 20% mobilised with O₂ support. After rehabilitation, these ratios were 2.4%, 4.7% and 8.2%, respectively. During admission, 71 (83.5%) patients required O₂ support, but decreased to 7 (8.2%) post-rehabilitation. Barthel Index improved statistically from 44.82 ± 27.31 to 88.47 ± 17.56. Patient-based modulated rehabilitation programmes are highly effective in severe and critical COVID-19 complications, providing satisfactory well-being in daily living activities.

Global haemostatic tests demonstrate the absence of parameters of hypercoagulability in non-hypoxic mild COVID-19 patients: a prospective matched study

Severe COVID-19 patients demonstrate hypercoagulability, necessitating thromboprophylaxis. However, less is known about the haemostatic profile in mild COVID-19 patients. We performed an age and gender-matched prospective study of 10 severe and 10 mild COVID-19 patients. Comprehensive coagulation profiling together with Thromboelastography and Clot Waveform Analysis were performed. FBC, PT, APTT, D-dimer, fibrinogen and CWA were repeated every 3 days for both groups and repeat TEG was performed for severe patients up till 15 days. On recruitment, severe patients had markers reflecting hypercoagulability including raised median D-dimer 1.0 μg/mL (IQR 0.6, 1.4) (p = 0.0004), fibrinogen 5.6 g/L (IQR 4.9, 6.6) (p = 0.002), Factor VIII 206% (IQR 171, 203) and vWF levels 265.5% (IQR 206, 321). Mild patients had normal values of PT, aPTT, fibrinogen and D-dimer, and slightly elevated median Factor VIII and von Willebrand factor (vWF) levels. Repeated 3-day assessments for both groups showed declining trends in D-dimer and Fibrinogen. CWA of severe COVID-19 group demonstrated hypercoagulability with an elevated median values of aPTT delta change 78.8% (IQR 69.8, 85.2) (p = 0.001), aPTT clot velocity (min1) 7.8%/s (IQR 6.7, 8.3) (p = 0.001), PT delta change 22.4% (IQR 19.4, 29.5) (p = 0.004), PT min1 7.1%/s (IQR 6.3, 9.0) (p = 0.02), PT clot acceleration (min 2) 3.6%/s² (IQR 3.2, 4.5) (p = 0.02) and PT clot deceleration (max2) 2.9%/s² (IQR 2.5, 3.5) (p = 0.02). TEG of severe patients reflected hypercoagulability with significant increases in the median values of CFF MA 34.6 mm (IQR 27.4,38.6) (p = 0.003), CRT Angle 78.9° (IQR 78.3, 80.0) (p = 0.0006), CRT A10 67.6 mm (IQR 65.8, 69.6) (p = 0.007) and CFF A10 32.0 mm (IQR 26.8, 34.0) (p = 0.003). Mild COVID-19 patients had absent hypercoagulability in both CWA and TEG. 2 severe patients developed thromboembolic events while none occurred in the mild COVID-19 group. Mild COVID-19 patients show absent parameters of hypercoagulability in global haemostatic tests while those with severe COVID-19 demonstrated parameters associated with hypercoagulability on the global haemostatic tests together with raised D-Dimer, fibrinogen, Factor VIII and vWF levels.

Systemic inflammation in COVID‐19 patients may induce various types of venous and arterial thrombosis: A systematic review

COVID‐19 is a global pandemic with a daily increasing number of affected individuals. Thrombosis is a severe complication of COVID‐19 that leads to a worse clinical course with higher rates of mortality. Multiple lines of evidence suggest that hyperinflammation plays a crucial role in disease progression. This review compiles clinical data of COVID‐19 patients who developed thrombotic complications to investigate the possible role of hyperinflammation in inducing hypercoagulation. A systematic literature search was performed using PubMed, Embase, Medline and Scopus to identify relevant clinical studies that investigated thrombotic manifestations and reported inflammatory and coagulation biomarkers in COVID‐19 patients. Only 54 studies met our inclusion criteria, the majority of which demonstrated significantly elevated inflammatory markers. In the cohort studies with control, D‐dimer was significantly higher in COVID‐19 patients with thrombosis as compared to the control. Pulmonary embolism, deep vein thrombosis and strokes were frequently reported which could be attributed to the hyperinflammatory response associated with COVID‐19 and/or to the direct viral activation of platelets and endothelial cells, two mechanisms that are discussed in this review. It is recommended that all admitted COVID‐19 patients should be assessed for hypercoagulation. Furthermore, several studies have suggested that anticoagulation may be beneficial, especially in hospitalized non‐ICU patients. Although vaccines against SARS‐CoV‐2 have been approved and distributed in several countries, research should continue in the field of prevention and treatment of COVID‐19 and its severe complications including thrombosis due to the emergence of new variants against which the efficacy of the vaccines is not yet clear.

COVID-19 and oral diseases: Assessing manifestations of a new pathogen in oral infections

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a recently identified virus responsible for life-threatening coronavirus disease 19 (COVID-19). The SARS-CoV-2 infected subjects can be asymptomatic or symptomatic; the later may present a wide spectrum of clinical manifestations. However, the impact of SARS-CoV-2 on oral diseases remain poorly studied. Detection of SARS-CoV-2 in saliva indicates existence of virus in the oral cavity. Recent studies demonstrating the expression of ACE-2, a SARS-CoV-2 entry receptor, in oral tissues further strengthens this observation. Cytokine storm in severe COVID-19 patients and copious secretion of pro-inflammatory cytokines (IL-6, IL-1β and TNF-α) in multiple symptomatic oral pathologies including periodontitis and periapical periodontitis suggests that inflammatory microenvironment is a hallmark of both COVID-19 and oral diseases. Hyperinflammation may provide conducive microenvironment for the growth of local oral pathogens or opportunistic microbes and exert detrimental impact on the oral tissue integrity. Multiple case reports have indicated uncharacterized oral lesions, symptomatic irreversible pulpitis, higher plaque index, necrotizing/desquamative gingivitis in COVID-19 patients suggesting that SARS-CoV-2 may worsen the manifestations of oral infections. However, the underlying factors and pathways remain elusive. Here we summarize current literature and suggest mechanisms for viral pathogenesis of oral dental pathology derived from oral microbiome and oral mucosa-dental tissue interactions. Longitudinal studies will reveal how the virus impairs disease progression and resolution post-therapy. Some relationships we suggest provide the basis for novel monitoring and treatment of oral viral disease in the era of SARS-CoV-2 pandemic, promoting evidence-based dentistry guidelines to diagnose virus-infected patients to improve oral health.

Histopathologic findings on indication renal allograft biopsies after recovery from acute COVID-19

Current knowledge on histopathological changes occurring after COVID‐19 in transplanted kidneys is limited. Herein, we present renal allograft pathology findings in patients recovered from COVID‐19.

Six patients underwent indication biopsy, and one required allograft nephrectomy after acute COVID‐19. Demographic data, clinical characteristics, and laboratory findings were recorded. The histopathological analysis included light microscopy, immunostaining, and electron microscopy.

Five patients were hospitalized for acute COVID‐19, and all were diagnosed with imaging‐confirmed pneumonia, one requiring mechanical ventilation, and two requiring dialysis. Two patients had mild form. Histopathologic examination of renal allograft specimens revealed collapsing, perihilar, tip‐lesion and secondary FSGS in one patient each. One patient had borderline acute cellular rejection, and two had chronic antibody‐mediated rejection. Histopathologic changes of glomerular tufts were accompanied by acute tubular injury in four patients. None of our patients had signs of viral inclusions in kidney cells.

One patient died and one remained dialysis‐dependent after the good initial response to treatment. Patients with collapsing and perihilar FSGS had further progression of their chronic allograft nephropathy still without need for dialysis.

In conclusion, diverse kidney pathology may be found in SARS‐CoV‐2–infected renal transplant patients. It seems that viral infection may affect the immune system with triggering of glomerular diseases, while the acute tubular injury is of multifactorial etiology. Direct viral effect is less likely.

Changes in Hematological, Clinical and Laboratory Parameters for Children with COVID-19: Single-Center Experience

Background

COVID-19 wreaked havoc on the healthcare system, with more than 36 million cases reported globally. Although the pediatric population makes up a lesser proportion of total COVID-19 patients than adults, the clinical status, age and comorbidities warrant identifying possible prognostic factors associated with disease severity in this group. The current study aimed to explore the incidence of thrombosis, overall outcome, and different hematological and coagulation markers in children with COVID-19.

Methods

This is a single-center prospective study of 43 patients (age < 14 years) with confirmed COVID-19 diagnosis recruited from April to August 2020. Data for clinical presentation were collected and analyzed. The samples were tested for different hematological and coagulation markers.

Results

Twenty-nine (67.4%) were symptomatic at presentation, with fever being the most common symptom (n = 23, 53.5%), followed by respiratory (n = 5, 11.6%) and gastrointestinal symptoms (n = 3, 7%). Co-morbid conditions were recorded in 26 (60.5%) patients, with malignancy being the commonest (n = 9, 20.9%). In this cohort of patients with age <14 years, hypertension, respiratory symptoms and ABO group-A were significantly associated with pediatric intensive care unit (PICU) admission during the course of treatment. Patients with elevated FVIII and fibrinogen levels at presentation were more likely to have an extended length of hospital stay (LOS) (P-value =0.036 and 0.032 respectively). No thrombotic event was observed in our cohort. D-dimer values were higher (above 0.5 µg/mL) in 24 (55.8%) patients at admission. We found an association between high D-dimer and PICU admission and LOS.

Conclusion

Although we did not observe thrombosis in our cohort, serial measurements of D-dimer and elevated FVIII bear a prognostic value in predicting the need for critical care in children with COVID-19. Further studies with larger sample size can aid in the establishment of prognostic factors for the pediatric COVID-19 population.

Thrombotic and Hypercoagulability Complications of COVID-19: An Update

The current COVID-19 pandemic emerged in December 2019, in China, affecting millions of people worldwide. COVID-19 is mainly a disease of the respiratory system, yet systematic complications have also been reported among SARS-CoV-2 infected patients. Thrombotic complications are one of the severe clinical outcomes of COVID-19, especially among critically ill patients, and are associated with poor prognosis. To date, many studies have concluded that COVID-19 increases the incidence of thrombotic events and coagulopathies; however, the exact mechanism behind such a disease outcome is not well known. Various pathophysiological mechanisms for thrombotic events in COVID-19 have been proposed, these include virus-induced endothelial cell damage, inflammation, and excess production of pro-inflammatory cytokines. As a result, most critically diseased COVID-19 patients are managed with prophylactic anticoagulant, yet some still develop thrombotic episodes. Therefore, better understanding of the mechanisms behind the thrombotic complications is needed to develop treatments that specifically target such pathways, which may aid in better disease management and improve the prognosis.

The Level of vWF Antigen and Coagulation Markers in Hospitalized Patients with Covid-19

Background

The coagulopathy of COVID-19 still awaits more clarification, and one approach that has not been investigated is to compare the hemostatic changes between COVID-19 and non-COVID-19 infected patients.

Objective

This study aims to study COVID-19 coagulopathy by measuring markers of endothelial injury and coagulation, including anticoagulants (TFPI, protein C, protein S, and AT) in COVID-19 patients and compare them with non-COVID-19 patients early in the course of the disease.

Methodology

This is an observational, prospective cross-sectional study comparing the levels of protein C, protein S, antithrombin (AT) III, clotting factor (F) VIII, von Willebrand factor (vWF) and coagulation screening tests (PT and a PTT), fibrinogen, D-dimer in COVID-19 patients admitted during the same time with non-COVID-19 infections. The demographic and clinical data of the patients were collected from electronic medical records during admission. Blood tests were extracted within 24 hours of admission for both groups.

Results

Fifty-four (66.7% males) consecutive COVID-19 patients and 24 (59% males) non-COVID-19 controls were enrolled in the study from October 2020 till December 2020. COVID-19 patients were significantly older than non-COVID-19 (57.7±14.2 vs 50±19.8 years, p=0.005). Fibrinogen level was significantly higher in COVID-19 patients compared to controls (5.9±1.48 vs 3.9±1.57, p<0.001). There was no statistically significant difference in the level of FVIII, protein C, S, ATIII, and D-dimer between the two groups. The level of vWF Ag was statistically higher in COVID-19 patients (276.7±91.1 vs 184.7±89.4, p=0.0001). There was significant thrombocytopenia and lymphopenia among COVID-19 patients. Inflammatory markers, CRP, ferritin, and LDH, were increased in COVID-19 patients compared to non-COVID-19, but the difference was not statistically significant. High fibrinogen and vWF AG levels were the two independent variables found in COVID-19 patients.

Conclusion

The level of vWF Ag is increased early in the course of COVID-19 infection. This can be used as a biomarker for endothelial injury, which is peculiar to COVID-19 infection.

Thrombosis, an important piece in the COVID-19 puzzle: From pathophysiology to therapy

A lot of data about coronavirus disease 2019 (COVID-19) have been already published; however, these still form only a part of the pandemic puzzle. Once we have all the pieces of the puzzle, we will be able to successfully treat this disease with its multiple challenges. COVID-19 has a high thrombogenic potential. In this study, we aimed to review published data about COVID-19 associated thrombosis from pathophysiology to treatment and the role in patient evolution. We searched for articles and studies published online through MEDLINE/PubMed database, Google Scholar, ScienceDirect, Wiley Online Library, and Nature Public Health Emergency Collection. We found numerous articles regarding COVID-19 infection but selected only those focused on thrombosis. D-dimers have a predictive value in identifying thrombosis and a high level correlates with the severity of the infection and death. Most patients who were on chronic anticoagulant therapy before contracting the virus had a better prognosis. Heparin has other favorable effects such as a direct antiviral and anti-inflammatory effect in addition to its anticoagulant effect. COVID-19 infections are frequently complicated by thrombotic pathology. High plasma level of D-dimers is a predictive factor for severe prognosis, and the recommended anticoagulant, associated with low mortality, is heparin followed by a direct oral anticoagulant. Randomized studies in large groups of patients and therapeutic guidelines are still needed on this subject.

Therapeutic approaches in COVID-19 followed before arrival of any vaccine

In present times covid-19 is spreading and is showing very destructive effects. It does not only affected the physical health but mental health as well as the economy of the major affected countries. Corona viruses are group of related RNA viruses. The first case of this virus was observed in China and then this virus got spread in the many countries and different strategies were made to stop the spread of this virus. Since no particular vaccine was available to cure this so different strategies were made. Due to the emergence of pandemic diseases, drug development and control strategies have been re-examined. One of the most important factors that scientists have to consider is the effectiveness of their drugs. This virus causes the respiratory tract infections which can range from mild to lethal. COVID-19 is a major cause of death in advanced countries. It is due to the absence of any particular vaccine that can effectively treat this condition. So in this review we will discuss about the therapeutic approaches followed to combat this deadly virus. Ayurveda, nitric oxide, nanoparticles and enzymes played a very important role in boosting the immunity and treatment of corona. Many herbs and some tips of using a combination of herbs proved to be very efficient while facing problems in breathing. Giving the dose of nitric oxide at some particular level and chloroquine the drug showed the antiviral activity against the virus. Developing methods to identify and contain COVID-19 is essential to successfully manage the virus. Various strains of the SARS-COV-2 were detected and were found more dangerous. The therapeutic approaches followed actually were efficient and can be used to combat the other variants also. This review focuses on the latest developments in the field of therapeutics and the strategies which were followed before any vaccine.

The ATRIA score is superior to the m-CHA2DS2-Vasc score in predicting in-hospital mortality in COVID-19

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has become a health and social problem all over the world. Most of the deaths occur from embolism and thrombus formation. We aimed to compare the predictive value of the anticoagulation and risk factors in atrial fibrillation (ATRIA) and m-CHA2DS2-Vasc scores in in-hospital mortality in COVID-19.

METHODS

Three-hundred and ninety-four patients who were hospitalized due to COVID-19 between 10 June 2020 and 10 September 2020 were included. Three-hundred and sixty patients who survived were defined as the non-mortality group and the remaining 34 whose hospitalizations resulted in death were defined as the mortality group. The anticoagulation and risk factors in atrial fibrillation and m-CHA2DS2-Vasc scores of the patients were calculated.

RESULTS

A total of 394 patients, mean age 66.2±9.7 (221 male [56.1%]) were included in this retrospective study. The median values of the anticoagulation and risk factors in atrial fibrillation and m-CHA2DS2-Vasc scores were different between the groups (p<0.000 for both). The multivariate logistic regression analysis showed that both the m-CHA2DS2-Vasc and anticoagulation and risk factors in atrial fibrillation scores were independent predictors of in-hospital mortality (p=0.024, 95%CI 1.039-1.704 for anticoagulation and risk factors in atrial fibrillation and p=0.043, 95%CI 1.012-2.088 for m-CHA2DS2-Vasc). In the receiver operating characteristic curve analysis, the anticoagulation and risk factors in atrial fibrillation score was superior to the m-CHA2DS2-Vasc score with an AUC 0.774 and SE:0.037, and p<0.001.

CONCLUSIONS

In our study, we showed that the anticoagulation and risk factors in atrial fibrillation and m-CHA2DS2-Vasc scores can be used as predictors of thrombosis and mortality in COVID-19 patients. In addition, the predictive value of the anticoagulation and risk factors in atrial fibrillation score was higher than that of m-CHA2DS2-Vasc. The use of the anticoagulation and risk factors in atrial fibrillation score to assess high-risk patients in COVID-19 may be recommended.

A Case of Post-COVID-19-Associated Paracentral Acute Middle Maculopathy and Giant Cell Arteritis-Like Vasculitis

ABSTRACT

A 47-year-old man with a history of COVID-19 infection 2 months before presentation, presented with a scotoma of the paracentral visual field of the right eye. After thorough testing and evaluation, a diagnosis of paracentral acute middle maculopathy (PAMM) was established. Two months later, the patient developed temporal headache and jaw claudication. High-dose steroids were initiated, and workup for giant cell arteritis (GCA) was undertaken. The patient experienced resolution of the symptoms within 24 hours of steroid initiation. ESR, CRP, and temporal artery biopsy results were normal, although all were obtained more than 2 weeks after steroid initiation. To the best of our knowledge, our patient represents the first individual to date to potentially implicate COVID-19 in both small and large vessel vasculitis in the ophthalmic setting.

An overview of the COVID-19 complications in paediatric population: A pandemic dilemma

AIM

The primary objective of this article is to understand the various complications caused by the coronavirus in the paediatric population.

METHOD

An electronic search was conducted using PubMed and incorporated forward and backward research methods on clinical trials, case reports, case series, guidelines and reports from the centre for disease control and prevention (CDC), and the keywords included COVID-19, paediatrics, multisystem inflammatory syndrome in children (MIS-C), complications, acute kidney injury and heart failure. Secondary resources included one study from preprint servers (www.preprints.org), last search 8 May 2021, with notion of nonpeer review status. Data were collected and analysed to stay current with the most recent alerts and guidelines for the best care for children during the COVID-19 pandemic.

RESULTS

Evaluation and analysis of literature revealed MIS-C to be the most prevalent followed by neurological complications. Whereas the least prevalent were septic shock and ophthalmic complications.

CONCLUSION

Even though COVID-19 is known to be a less severe in the paediatric population, the complications of the virus have caused a great deal of stress to the paediatric patients' parents and paediatricians worldwide, and hence, emphasis should be given to the management of coronavirus complications in paediatrics.

Two Different Clinical Presentations of Acute Limb Ischemia Caused by Acute Thrombotic Events in COVID-19

Coronavirus disease 2019 (COVID-19) is a global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Coagulopathy is frequently found in severe cases of COVID-19 and is usually manifested as a prothrombotic state. Hyperinflammation, endotheliitis, and immobilization during illness are hypothesized to play a role. Acute limb ischemia (ALI) is one of the presentations of arterial thrombosis in COVID-19. We present two cases of middle-aged men with COVID-19 infection, who developed ALI. The first patient developed ALI after 16 days from the initial COVID-19 diagnosis, and the second patient was admitted to the emergency ward due to sudden discoloration of his right lower limb, and COVID-19 was diagnosed during the evaluation.

ACE2-based decoy receptors for SARS coronavirus 2

SARS coronavirus 2 is neutralized by proteins that block receptor-binding sites on spikes that project from the viral envelope. In particular, substantial research investment has advanced monoclonal antibody therapies to the clinic where they have shown partial efficacy in reducing viral burden and hospitalization. An alternative is to use the host entry receptor, angiotensin-converting enzyme 2 (ACE2), as a soluble decoy that broadly blocks SARS-associated coronaviruses with limited potential for viral escape. Here, we summarize efforts to engineer higher affinity variants of soluble ACE2 that rival the potency of affinity-matured antibodies. Strategies have also been used to increase the valency of ACE2 decoys for avid spike interactions and to improve pharmacokinetics via IgG fusions. Finally, the intrinsic catalytic activity of ACE2 for the turnover of the vasoconstrictor angiotensin II may directly address COVID-19 symptoms and protect against lung and cardiovascular injury, conferring dual mechanisms of action unachievable by monoclonal antibodies. Soluble ACE2 derivatives therefore have the potential to be next generation therapeutics for addressing the immediate needs of the current pandemic and possible future outbreaks.

COVID-19-related coagulopathy: A review of pathophysiology and pharmaceutical management

December 2019 will never be forgotten in the history of medicine when an outbreak of pneumonia of unknown etiology in Wuhan, China sooner or later prompted the World Health Organization to issue a public health warning emergency. This is not the first nor will it be the last time that a member of β-coronaviruses (CoVs) is waging a full-scale war against human health. Notwithstanding the fact that pneumonia is the primary symptom of the novel coronavirus (2019nCoV; designated as SARS-CoV-2), the emergence of severe disease mainly due to the injury of nonpulmonary organs at the shadow of coagulopathy leaves no choice, in some cases, rather than a dreadful death. Multiple casual factors such as inflammation, endothelial dysfunction, platelet and complement activation, renin-angiotensin-aldosterone system derangement, and hypoxemia play a major role in the pathogenesis of coagulopathy in coronavirus disease 2019 (COVID-19) patients. Due to the undeniable role of coagulation dysfunction in the initiation of several complications, assessment of coagulation parameters and the platelet count would be beneficial in early diagnosis and also timely prediction of disease severity. Although low-molecular-weight heparin is considered as the first-line of treatment in COVID-19-associated coagulopathy, several possible therapeutic options have also been proposed for better management of the disease. In conclusion, this review would help us to gain insight into the pathogenesis, clinical manifestation, and laboratory findings associated with COVID-19 coagulopathy and would summarize management strategies to alleviate coagulopathy-related complications.

Treatment Delay and Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction during the COVID-19 Pandemic

Pandemic-specific protocols require additional time to prepare medical staff and catheterization laboratories. Thus, we sought to investigate treatment delay and clinical outcomes in COVID-19 positive and negative patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) during on- and off-hours. All consecutive patients with STEMI treated with PCI between 1 March and 31 December 2020 were enrolled in the analysis. A propensity score match was used to compare COVID-19 positive and negative patients for on- and off-hours. The study group was comprised of 877 paired patients treated during regular hours (every day 7:00 a.m. to 16:59 p.m.) and 418 matched pairs with PCI performed during off-hours (every day 17:00 p.m. to 06:59 a.m.) (ORPKI Polish National Registry). No difference in periprocedural mortality was observed between the two groups (on-hours: COVID-19 negative vs. COVID-19 positive: 17 (1.9%) vs. 11 (1.3%); p = 0.3; off-hours: COVID-19 negative vs. COVID-19 positive: 4 (1.0%) vs. 7 (1.7%); p = 0.5). Additionally, a similar rate of periprocedural complications was reported. Patients diagnosed with COVID-19 were exposed to longer time from first medical contact to angiography (on-hours: 133.8 (±137.1) vs. 117.1 (±135.8) (min); p = 0.001) (off-hours: 148.1 (±201.6) vs. 112.2 (±138.7) (min); p = 0.003). However, there was no influence of COVID-19 diagnosis on mortality and the prevalence of other periprocedural complications irrespective of time of intervention.

Adverse Cardiovascular Effects of Anti-COVID-19 Drugs

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 infection is the cause of the ongoing global pandemic. Mortality from COVID-19 infection is particularly high in patients with cardiovascular diseases. In addition, COVID-19 patients with preexisting cardiovascular comorbidities have a higher risk of death. Main cardiovascular complications of COVID-19 are myocardial infarction, myocarditis, acute myocardial injury, arrhythmias, heart failure, stroke, and venous thromboembolism. Therapeutic interventions in terms of drugs for COVID-19 have many cardiac adverse effects. Here, we review the relative therapeutic efficacy and adverse effects of anti-COVID-19 drugs.

Association Between Novel Coronavirus Disease 2019 (COVID-19) and Idiopathic Intracranial Hypertension

Introduction: Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a rare neurological manifestation of coronavirus disease 2019 (COVID-19) infection. Case Presentation: In this case study, we present a 10-year-old girl with headache, diplopia, bilateral sixth nerve palsy, and papilledema following a history of seven days of fever about two weeks ago. In lumbar puncture, the opening pressure was 56 cmH2O. Cerebrospinal fluid analysis was normal. Brain magnetic resonance imaging (MRI) was suggestive of IIH. Nasopharyngeal reverse transcription-polymerase chain reaction (RT-PCR) was positive for COVID-19. Oral acetazolamide was prescribed, and the patient improved completely after three weeks of continuous medical treatment. Conclusions: Since IIH is a rare neurological complication of COVID-19, we have to suspect COVID-19 infection in any patient with IIH.

Continuous renal replacement therapy in COVID-19-associated AKI: adding heparin to citrate to extend filter life-a retrospective cohort study

BACKGROUND

Coronavirus disease 2019 (COVID-19) may predispose patients to thrombotic events. The best anticoagulation strategy for continuous renal replacement therapy (CRRT) in such patients is still under debate. The purpose of this study was to evaluate the impact that different anticoagulation protocols have on filter clotting risk.

METHODS

This was a retrospective observational study comparing two different anticoagulation strategies (citrate only and citrate plus intravenous infusion of unfractionated heparin) in patients with acute kidney injury (AKI), associated or not with COVID-19 (COV + AKI and COV - AKI, respectively), who were submitted to CRRT. Filter clotting risks were compared among groups.

RESULTS

Between January 2019 and July 2020, 238 patients were evaluated: 188 in the COV + AKI group and 50 in the COV - AKI group. Filter clotting during the first filter use occurred in 111 patients (46.6%). Heparin use conferred protection against filter clotting (HR = 0.37, 95% CI 0.25-0.55), resulting in longer filter survival. Bleeding events and the need for blood transfusion were similar between the citrate only and citrate plus unfractionated heparin strategies. In-hospital mortality was higher among the COV + AKI patients than among the COV - AKI patients, although it was similar between the COV + AKI patients who received heparin and those who did not. Filter clotting was more common in patients with D-dimer levels above the median (5990 ng/ml). In the multivariate analysis, heparin was associated with a lower risk of filter clotting (HR = 0.28, 95% CI 0.18-0.43), whereas an elevated D-dimer level and high hemoglobin were found to be risk factors for circuit clotting. A diagnosis of COVID-19 was marginally associated with an increased risk of circuit clotting (HR = 2.15, 95% CI 0.99-4.68).

CONCLUSIONS

In COV + AKI patients, adding systemic heparin to standard regional citrate anticoagulation may prolong CRRT filter patency by reducing clotting risk with a low risk of complications.

Retinal manifestations in patients with SARS-CoV-2 infection and pathogenetic implications: a systematic review

Introduction

The pandemic of COVID-19 has been caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Apart from respiratory malfunction, COVID-19 causes a system-wide thromboembolic state, leading to serious cardiovascular, cerebrovascular and peripheral vascular manifestations. However, our knowledge regarding retinal manifestations due to systemic COVID-19 is minimal. This systematic review has comprehensively summarized all retinal manifestations secondary to COVID-19 disease recorded till date since the beginning of the pandemic.

Methods

All studies published till November 27, 2020, which have reported retinal manifestations in COVID-19 patients were systematically reviewed using the PRISMA statement.

Results

We included 15 articles: 11 case reports and four cross-sectional case series. The most commonly reported manifestations which did not affect visual acuity were retinal hemorrhages and cotton wool spots. The most common vision threatening manifestation was retinal vein occlusion with associated macular edema. Rarely, patients may also present with retinal arterial occlusions and ocular inflammation. These manifestations may occur from as soon as within a week after the onset of COVID-19 symptoms to more than 6 weeks after.

Conclusion

Mostly causing milder disease, COVID-19 may however lead to severe life-threatening thromboembolic complications, and systemic antithrombotic therapy has been suggested as a prophylactic and therapeutic management strategy for patients affected with serious systemic disease. However, both sick and apparently healthy patients may suffer from various retinal complications which may lead to loss of vision as well. No consensus regarding management of retinal complications with anticoagulants or anti-inflammatory medications have been proposed; however, they may be tackled on individual basis.

COVID-19 and biomarkers of thrombosis: focus on von Willebrand factor and extracellular vesicles

COVID-19, caused by the SARS-CoV-2 virus, is responsible for a pandemic of unparalleled portion over the past century. While the acute phase of infection causes significant morbidity and mortality, post-acute sequelae that can affect essentially any organ system is rapidly taking on an equally large part of the overall impact on human health, quality of life, attempts to return to normalcy and the global economy. Herein, we summarize the potential role of von Willebrand Factor and extracellular vesicles toward understanding the pathophysiology, clinical presentation, duration of illness, diagnostic approach and management of COVID-19 and its sequelae.

Optic Nerve Head Vessel Density Assessment in Recovered COVID-19 Patients: A Prospective Study Using Optical Coherence Tomography Angiography

PRECIS

Vascular diseases have been linked to alterations in optic nerve head perfusion.

PURPOSE

The main objective was to investigate the changes in peripapillary vessel density (VD) in post coronavirus disease (COVID-19) patients.

METHODS

In this prospective pilot exploratory study, patients with COVID-19 that were attended in the Emergency Department of Hospital Clinico San Carlos (Madrid) were included. All patients underwent optic nerve head optical coherence tomography angiography using the Cirrus HD-OCT 500 with AngioPlex OCTA (Zeiss, Dublin, CA) 4 and 12 weeks after diagnosis by positive reverse transcriptase-polymerase chain reaction test from nasopharyngeal swab at the Emergency Department. Sociodemographic data, medical history, disease severity, and laboratory work-up were collected.

RESULTS

One hundred and eighty eyes of 90 patients with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection were included. None of the patients reported visual changes. Severe patients were older, more frequently hispanic, dyslipidemic, and presented lower lymphocytes counts, as well as increased ferritin, D-dimer, fibrinogen, and international normalized ratio levels. No changes in optic nerve head vascularization were observed when both visits were compared. No correlation was found between VD and clinical parameters, disease severity and laboratory work-up.

CONCLUSIONS

Changes to peripapillary VD were not observed in patients with COVID-19 in the early months following diagnosis.

Probiotics in Prevention and Treatment of COVID-19: Current Perspective and Future Prospects

Saving lives and flattening the curve are the foremost priorities during the ongoing pandemic spread of SARS-CoV-2. Developing cutting-edge technology and collating available evidence would support frontline health teams. Nutritional adequacy improves general health and immunity to prevent and assuage infections. This review aims to outline the potential role of probiotics in fighting the COVID-19 by covering recent evidence on the association between microbiota, probiotics, and COVID-19, the role of probiotics as an immune-modulator and antiviral agent. The high basic reproduction number (R0) of SARS-CoV-2, absence of conclusive remedies, and the pleiotropic effect of probiotics in fighting influenza and other coronaviruses together favour probiotics supplements. However, further support from preclinical and clinical studies and reviews outlining the role of probiotics in COVID-19 are critical. Results are awaited from many ongoing clinical trials investigating the benefits of probiotics in COVID-19.

Successful management of T-cell mediated rejection in a recent kidney transplant recipient with COVID-19 associated severe acute respiratory syndrome

COVID-19-associated vasculitis has been reported as a defining feature of systemic disease including acute kidney injury. However, the understanding of COVID-19 kidney transplant-related injuries is still evolving. We report a case of AKI with isolated vasculitis (v2 lesion) in a new kidney transplant recipient with COVID-19 pneumonia.

The COVIDome Explorer researcher portal

COVID-19 pathology involves dysregulation of diverse molecular, cellular, and physiological processes. To expedite integrated and collaborative COVID-19 research, we completed multi-omics analysis of hospitalized COVID-19 patients, including matched analysis of the whole-blood transcriptome, plasma proteomics with two complementary platforms, cytokine profiling, plasma and red blood cell metabolomics, deep immune cell phenotyping by mass cytometry, and clinical data annotation. We refer to this multidimensional dataset as the COVIDome. We then created the COVIDome Explorer, an online researcher portal where the data can be analyzed and visualized in real time. We illustrate herein the use of the COVIDome dataset through a multi-omics analysis of biosignatures associated with C-reactive protein (CRP), an established marker of poor prognosis in COVID-19, revealing associations between CRP levels and damage-associated molecular patterns, depletion of protective serpins, and mitochondrial metabolism dysregulation. We expect that the COVIDome Explorer will rapidly accelerate data sharing, hypothesis testing, and discoveries worldwide.

Posterior Reversible Encephalopathy Syndrome and brain haemorrhage as COVID-19 complication: a review of the available literature

Background

SARS-CoV-2 infection has been associated with various neurological manifestations. Since patients affected by SARS-CoV-2 infection present coagulation and immune system dysregulation, ischemic or haemorragic stroke is not uncommon, irrespective of respiratory distress. However, the occurrence of focal neurological deficits together with other symptoms like headache, cortical blindness, seizure and altered mental status should prompt the diagnosis of Posterior Reversible Encephalopathy Syndrome (PRES). Antithrombotic treatment, the alteration of endothelial function, and coagulopathy due to COVID-19 and PRES leading to the breakdown of blood–brain barrier may then contribute to the occurrence of a brain haemorrhage.

Methods

We describe the case of a COVID-19 patient who developed bilateral occipital lobe haemorrhages suggestive of haemorrhagic PRES. We then reviewed the available literature about haemorrhagic evolution of PRES in COVID-19.

Results

We describe the clinical and radiological features of five COVID-19 patients who developed haemorrhagic PRES.

Conclusions

Coagulopathy and endothelial dysfunction resulting from the massive release of cytokines during the host immune response may be key factors in the pathogenesis of COVID-19-related PRES. Antithrombotic therapy and the leakage of the blood–brain barrier can subsequently increase the risk of haemorrhagic transformation of the lesioned brain tissue. A prompt diagnosis of PRES is mandatory, since the timely interruption/reversal of antithrombotic therapy may be a key determinant for a good prognosis.

Increased Incidence of In-Hospital Ischemic Stroke During SARS-CoV-2 Outbreak: A Single-Center Study

BACKGROUND

Meta-analyses of observational studies report a 1.1-1.7% pooled risk of stroke among patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection requiring hospitalization, but consultations for stroke and reperfusion procedures have decreased during the outbreak that occurred during the first half of the year 2020. It is still unclear whether a true increase in the risk of stroke exists among patients with coronavirus disease 2019 (COVID-19). In-hospital ischemic stroke (IHIS) complicated the 0.04-0.06% of all admissions in the pre-COVID-19 era, but its incidence has not been assessed among inpatients with COVID-19. We aimed to compare IHIS incidence among patients with SARS-CoV-2 infection with that of inpatients with non-COVID-19 illnesses from the same outbreak period and from previous periods.

METHODS

This historical cohort study belongs to the COVID-19@Vallecas cohort. The incidence of IHIS was estimated for patients with SARS-CoV-2 hospitalized during March-April 2020 [COVID-19 cohort (CC)], for patients with non-COVID-19 medical illness hospitalized during the same outbreak period [2020 non-COVID-19 cohort (20NCC)], and for inpatients with non-COVID-19 illness admitted during March-April of the years 2016-2019 [historical non-COVID-19 cohort (HNCC)]. Unadjusted risk of IHIS was compared between the three cohorts, and adjusted incidence rate ratio (IRR) of IHIS between cohorts was obtained by means of Poisson regression.

RESULTS

Overall, 8126 inpatients were included in this study. Patients in the CC were younger and more commonly men than those from the HNCC and 20NCC. Absolute risk of IHIS was 0.05% for HNCC, 0.23% for 20NCC, and 0.36% for CC, (p = 0.004 for HNCC vs. CC). Cumulative incidence for IHIS by day nine after admission, with death as a competing risk, was 0.09% for HNCC, 0.23% for 20NCC, and 0.50% for CC. In an adjusted Poisson regression model with sex, age, needing of intensive care unit admission, and cohort (HNCC as reference) as covariates, COVID-19 was an independent predictor for IHIS (IRR 6.76, 95% confidence interval 1.66-27.54, p = 0.01). A nonsignificant increase in the risk of IHIS was observed for the 20NCC (IRR 5.62, 95% confidence interval 0.93-33.9, p = 0.06).

CONCLUSIONS

SARS-CoV-2 outbreak was associated with an increase in the incidence of IHIS when compared with inpatients from a historical cohort. Viral infection itself may be related to the increased risk of IHIS among patients with COVID-19, but in view of our results from the 20NCC, it is likely that other factors, such as hospital saturation and overwhelming of health systems, may have played a role in the increased frequency of IHIS.

Problems of Pathogenesis and Pathogenetic Therapy of COVID-19 from the Perspective of the General Theory of Pathological Systems (General Pathological Processes)

The COVID-19 pandemic examines not only the state of actual health care but also the state of fundamental medicine in various countries. Pro-inflammatory processes extend far beyond the classical concepts of inflammation. They manifest themselves in a variety of ways, beginning with extreme physiology, then allostasis at low-grade inflammation, and finally the shockogenic phenomenon of "inflammatory systemic microcirculation". The pathogenetic core of critical situations, including COVID-19, is this phenomenon. Microcirculatory abnormalities, on the other hand, lie at the heart of a specific type of general pathological process known as systemic inflammation (SI). Systemic inflammatory response, cytokine release, cytokine storm, and thrombo-inflammatory syndrome are all terms that refer to different aspects of SI. As a result, the metabolic syndrome model does not adequately reflect the pathophysiology of persistent low-grade systemic inflammation (ChSLGI). Diseases associated with ChSLGI, on the other hand, are risk factors for a severe COVID-19 course. The review examines the role of hypoxia, metabolic dysfunction, scavenger receptors, and pattern-recognition receptors, as well as the processes of the hemophagocytic syndrome, in the systemic alteration and development of SI in COVID-19.

Predictors of mortality, ICU hospitalization, and extrapulmonary complications in COVID-19 patients

OBJECTIVE

A major coronavirus disease 2019 (COVID-19) outbreak occurred in Northeastern France in spring 2020. This single-center retrospective observational cohort study aimed to compare patients with severe COVID-19 and those with non-severe COVID-19 (survivors vs. non-survivors, ICU patients vs. non-ICU patients) and to describe extrapulmonary complications.

PATIENTS AND METHODS

We included all patients with a confirmed diagnosis of COVID-19 admitted to Colmar Hospital in March 2020.

RESULTS

We examined 600 patients (median age 71.09 years; median body mass index: 26.9 kg/m²); 57.7% were males, 86.3% had at least one comorbidity, 153 (25.5%) required ICU hospitalization, and 115 (19.1%) died. Baseline independent factors associated with death were older age (>75 vs. ≤75 years), male sex, oxygen supply, chronic neurological, renal, and pulmonary diseases, diabetes, cancer, low platelet and hemoglobin counts, and high levels of C-reactive protein (CRP) and serum creatinine. Factors associated with ICU hospitalization were age <75 years, oxygen supply, chronic pulmonary disease, absence of dementia, and high levels of CRP, hemoglobin, and serum creatinine. Among the 600 patients, 80 (13.3%) had an acute renal injury, 33 (5.5%) had a cardiovascular event, 27 (4.5%) had an acute liver injury, 24 (4%) had venous thromboembolism, eight (1.3%) had a neurological event, five (0.8%) had rhabdomyolysis, and one had acute pancreatitis. Most extrapulmonary complications occurred in ICU patients.

CONCLUSION

This study highlighted the main risk factors for ICU hospitalization and death caused by severe COVID-19 and the frequency of numerous extrapulmonary complications in France.

COVID-19 skin lesions are rarely positive at RT-PCR test: the macrophage activation with vascular impact and SARS-CoV-2-induced cytokine storm

BACKGROUND

Several skin manifestations have been reported since the start of the COVID-19 pandemic: chilblains-like, livedoid lesions, urticaria-like, pseudo-Kawasaki disease, and others. Histopathologic images of these lesions most often show aspects of endothelitis, images similar to autoimmune vasculitis. Cutaneous lesions are often negative at RT-PCR for SARS-CoV-2 virus.

METHOD AND RESULTS

We reviewed recent articles on the mechanisms of COVID-19 and we synthesized main pathways of inflammatory cascade. After the penetration into the cells of the respiratory epithelium, SARS-CoV-2 virus initiates a "cytokine storm" well described in previous publications: the expression of interferon type I (IFN-I) is one of the key elements of the antiviral response in COVID-19 patients, IFN-I expression seems to play an important role in the induction of interleukin 6 (IL-6), chemotactic factors such as Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF) and the consequent activation of monocyte-macrophage system followed by the expression of TNF-alpha, and finally by the induction of coagulation factors by both extrinsic and intrinsic pathways.

CONCLUSIONS

The simplified synthesis of the main pathophysiological mechanisms of COVID-19 could help us to understand at least partially the importance of macrophage activation and its vascular involvement in many skin lesions that remain often negative at in␣situ tests for SARS-CoV-2.

Clinical observations of COVID-19 infection in patients with chronic thromboembolic pulmonary hypertension

Aim    To present clinical observations of the novel coronavirus infection (COVID-19) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) after a surgical intervention in the form of thromobendarterectomy from pulmonary artery branches.Material and methods    The Acad. E.N. Meshalkin National Medical Research Center performed 127 open surgical interventions for CTEPH in the form of thromobendarterectomy from 2016 through 2020. The present study enrolled 113 patients included into the follow-up care group and into the Center Registry who were followed up for more than 6 months after the surgery. Clinical and functional features of COVID-19 were evaluated in the studied group.Results    In the follow-up care group, 5 (4.4%) postoperative CTEPH patients had COVID-19. One patient had asymptomatic disease, and others had typical clinical symptoms and bilateral polysegmental pneumonia. There were no cases requiring artificial ventilation and no lethal outcomes. All patients with COVID-19 received anticoagulants as a basis therapy for CTEPH, and two patients who had residual pulmonary arterial hypertension (PAH) additionally received a PAH-specific therapy. During the treatment of COVID-19, no adjustment of the anticoagulant or PAH-specific therapy was required.Conclusion    The group of patients with CTEPH is a unique pathophysiological model for studying the effect of COVID-19 under the conditions of compromised pulmonary circulation. In the studied follow-up care group, the COVID-19 morbidity was 4.4 % without fatal outcomes. Evaluation of the role of chronic anticoagulant and PAH-specific therapy in COVID-19 postoperative patients as well as evaluation of the role of COVID-19 in CTEPH progression merit further investigation.

The most important biomarker associated with coagulation and inflammation among COVID-19 patients

Coronavirus disease 2019 (COVID-19) induced by SARS-Cov-2 can be related to coagulopathy. Also, the infection-induced inflammatory changes are found in patients with disseminated intravascular coagulopathy (DIC). The lack of previous immunity to COVID-19 has caused infection of a large number of patients worldwide and unpredictability regarding the management of the complications that appear in the course of this viral illness. Lungs are the most important target organ of the SARS-COV-2. In COVID-19 patients, acute lung injury leads to respiratory failure. However, multiorgan failure can also occur in these patients. The primary coagulopathy of COVID-19 is marked by a considerable elevation of D-dimer, ferritin, and fibrinogen degradation products. In comparison, abnormalities in platelet count, prothrombin time, and partial thromboplastin time are partly uncommon in initial presentations. Inflammatory biomarkers including CRP, LDH, and IL-6 are significantly elevated in the early stages of the disease. In this regard, inflammation-associated biomarkers and coagulation test screening, including the assessment of IL-6, CRP, LDH, D-dimer, platelet count, PT&PTT time, ferritin, and fibrinogen levels are suggested for detecting infection by this virus. Overall, COVID-19-associated coagulopathy should be managed like other patients with critical conditions, and supportive care and thromboembolic prophylaxis should be used for severe patients.

Celiac Artery Thrombosis and Splenic Infarction as a Consequence of Mild COVID-19 Infection: Report of an Unusual Case

COVID-19 has been associated with the hypercoagulable state in the literature. Patients who are admitted to the hospital with severe COVID-19 may have some thrombotic complications. These patients have a high risk for venous and arterial thrombosis of large and small vessels. Here, a 42-year-old female with celiac artery thrombosis and splenic infarction after a history of mild COVID-19 was presented.

Phenome-wide and expression quantitative trait locus associations of coronavirus disease 2019 genetic risk loci

While several genes and clinical traits have been associated with higher risk of severe coronavirus disease 2019 (COVID-19), how host genetic variants may interact with these parameters and contribute to severe disease is still unclear. Herein, we performed phenome-wide association study, tissue and immune-cell-specific expression quantitative trait locus (eQTL)/splicing quantitative trait locus, and colocalization analyses for genetic risk loci suggestively associated with severe COVID-19 with respiratory failure. Thirteen phenotypes/traits were associated with the severe COVID-19-associated loci at the genome-wide significance threshold, including monocyte counts, fat metabolism traits, and fibrotic idiopathic interstitial pneumonia. In addition, we identified tissue and immune subtype-specific eQTL associations affecting 48 genes, including several ones that may directly impact host immune responses, colocalized with the severe COVID-19 genome-wide association study associations, and showed altered expression in single-cell transcriptomes. Collectively, our work demonstrates that host genetic variations associated with multiple genes and traits show genetic pleiotropy with severe COVID-19 and may inform disease etiology.

SARS-CoV-2 (COVID-19) as a Predictor of Neuroinflammation and Neurodegeneration: Potential Treatment Strategies

The SARS-CoV-2 (COVID-19) pandemic has attracted attention to the challenge of neuroinflammation as an unavoidable component of viral infections. Acute neuroinflammatory responses include activation of resident tissue macrophages in the CNS followed by release of a variety of cytokines and chemokines associated with activation of oxidative stress and delayed neuron damage. This makes the search for treatments with indirect anti-inflammatory properties relevant. From this point of view, attention is focused on further study of the treatment of patients with COVID-19 with dipyridamole (Curantil) which, having antiviral and anti-inflammatory effects, can inhibit acute inflammatory activity and progression of fibrosis, is a drug with potential, especially among patients with early increases in the D-dimer concentration and severe signs of microangiopathy.