1
|
Nguyen TH, Chen LY, Khan NZ, Lindenbauer A, Bui VC, Zipfel PF, Heinrich D. The Binding of the SARS-CoV-2 Spike Protein to Platelet Factor 4: A Proposed Mechanism for the Generation of Pathogenic Antibodies. Biomolecules 2024; 14:245. [PMID: 38540666 PMCID: PMC10967930 DOI: 10.3390/biom14030245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 04/02/2024] Open
Abstract
Pathogenic platelet factor 4 (PF4) antibodies contributed to the abnormal coagulation profiles in COVID-19 and vaccinated patients. However, the mechanism of what triggers the body to produce these antibodies has not yet been clarified. Similar patterns and many comparable features between the COVID-19 virus and heparin-induced thrombocytopenia (HIT) have been reported. Previously, we identified a new mechanism of autoimmunity in HIT in which PF4-antibodies self-clustered PF4 and exposed binding epitopes for other pathogenic PF4/eparin antibodies. Here, we first proved that the SARS-CoV-2 spike protein (SP) also binds to PF4. The binding was evidenced by the increase in mass and optical intensity as observed through quartz crystal microbalance and immunosorbent assay, while the switching of the surface zeta potential caused by protein interactions and binding affinity of PF4-SP were evaluated by dynamic light scattering and isothermal spectral shift analysis. Based on our results, we proposed a mechanism for the generation of PF4 antibodies in COVID-19 patients. We further validated the changes in zeta potential and interaction affinity between PF4 and SP and found that their binding mechanism differs from ACE2-SP binding. Importantly, the PF4/SP complexes facilitate the binding of anti-PF4/Heparin antibodies. Our findings offer a fresh perspective on PF4 engagement with the SARS-CoV-2 SP, illuminating the role of PF4/SP complexes in severe thrombotic events.
Collapse
Affiliation(s)
- Thi-Huong Nguyen
- Institute for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heilbad Heiligenstadt, Germany
- Faculty of Mathematics and Natural Sciences, Technische Universität Ilmenau, 98694 Ilmenau, Germany
| | - Li-Yu Chen
- Institute for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heilbad Heiligenstadt, Germany
- Institute of Miccrobiology, Friedrich-Schiller-University, 07745 Jena, Germany
| | - Nida Zaman Khan
- Institute for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heilbad Heiligenstadt, Germany
- Faculty of Mathematics and Natural Sciences, Technische Universität Ilmenau, 98694 Ilmenau, Germany
| | - Annerose Lindenbauer
- Institute for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heilbad Heiligenstadt, Germany
| | - Van-Chien Bui
- Department of Water Supply and Wastewater Treatment, Eichsfeldwerke GmbH, 37308 Heilbad Heiligenstadt, Germany
| | - Peter F. Zipfel
- Institute of Miccrobiology, Friedrich-Schiller-University, 07745 Jena, Germany
| | - Doris Heinrich
- Institute for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heilbad Heiligenstadt, Germany
- Faculty of Mathematics and Natural Sciences, Technische Universität Ilmenau, 98694 Ilmenau, Germany
- Fraunhofer Institut für Silicatforschung, Neunerplatz, 97082 Würzburg, Germany
| |
Collapse
|
2
|
Abdelouahed M, Yateem D, Fredericks S. Fc γRIIa - dependent platelet activation identified in COVID-19 vaccine-induced immune thrombotic thrombocytopenia-, heparin-induced thrombocytopenia, streptokinase- and anisoylated plasminogen-streptokinase activator complex-induced platelet activation. Front Cardiovasc Med 2023; 10:1282637. [PMID: 38034388 PMCID: PMC10684751 DOI: 10.3389/fcvm.2023.1282637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), which was caused by the coronavirus - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was globally responsible for remarkable morbidity and mortality. Several highly effective vaccines for COVID-19 were developed and disseminated worldwide within an unprecedented timescale. Rare but dangerous clotting and thrombocytopenia events, and subsequent coagulation abnormalities, have been reported after massive vaccination against SARS-CoV-2. Soon after their global rollout, reports of a morbid clinical syndrome following vaccination with adenovirus-DNA-based vaccines appeared. In the spring of 2021, reports of a novel, rare and morbid clinical syndrome, with clinically devastating and fatal complication after vaccination with adenovirus-based coronavirus vaccines (Janssen/Johnson & Johnson and Astra-Zeneca vaccines) led to a brief suspension of their use by several countries. Those complications were associated with unusual cerebral and splanchnic venous thrombosis, and circulating autoantibodies directed against anti-platelet factor 4 (PF4), a protein secreted from platelets, leading to the designation: Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT). The reported VITT incidence remains very low and does not affect the overall benefit of immunization, however, if left untreated, VITT can be debilitating or even fatal. VITT resembled specific adverse drugs' reactions that also involved the production of autoantibodies and subsequent abnormal platelet activation through platelet FcγRIIa. These unusual but well-documented drug reactions were heparin-induced thrombocytopenia (HIT), streptokinase- (SK), and anisoylated plasminogen-streptokinase activator complex- (APSAC) associated with platelet-activating antibodies. There was considerable overlapping of clinical features between VITT, COVID-19 and these adverse drugs' reactions. We review the phenomenon of VITT against the backdrop of shared and common mechanisms that underlie HIT-, SK-, and APSAC-platelet FcγRIIa-dependent platelet activation. An understanding of VITT's pathogenesis may be achieved by comparing and contrasting VITT-, HIT-, SK- and APSAC-induced platelet activation mechanisms, their respective physiopathology and similarities. Discussing these conditions in parallel provides insight into complex immunological disorders and diseases associated with abnormal hemostasis and thrombosis in particular.
Collapse
Affiliation(s)
- Mustapha Abdelouahed
- Department of Medical Sciences and Education, Boston University School of Medicine, Boston, MA, United States
| | - Dana Yateem
- School of Medicine, The Royal College of Surgeons in Ireland, Medical University of Bahrain, Al Sayh, Muharraq Governorate, Bahrain
| | - Salim Fredericks
- School of Medicine, The Royal College of Surgeons in Ireland, Medical University of Bahrain, Al Sayh, Muharraq Governorate, Bahrain
| |
Collapse
|
3
|
Nagano M, Kubota K, Sakata A, Nakamura R, Yoshitomi T, Wakui K, Yoshimoto K. A neutralizable dimeric anti-thrombin aptamer with potent anticoagulant activity in mice. MOLECULAR THERAPY. NUCLEIC ACIDS 2023; 33:762-772. [PMID: 37621412 PMCID: PMC10445101 DOI: 10.1016/j.omtn.2023.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a complication caused by administration of the anticoagulant heparin. Although the number of patients with HIT has drastically increased because of coronavirus disease 2019 (COVID-19), the currently used thrombin inhibitors for HIT therapy do not have antidotes to arrest the severe bleeding that occurs as a side effect; therefore, establishment of safer treatments for HIT patients is imperative. Here, we devised a potent thrombin inhibitor based on bivalent aptamers with a higher safety profile via combination with the antidote. Using an anti-thrombin DNA aptamer M08s-1 as a promising anticoagulant, its homodimer and heterodimer with TBA29 linked by a conformationally flexible linker or a rigid duplex linker were designed. The dimerized M08s-1-based aptamers had about 100-fold increased binding affinity to human and mouse thrombin compared with the monomer counterparts. Administration of these bivalent aptamers into mice revealed that the anticoagulant activity of the dimers significantly surpassed that of an approved drug for HIT treatment, argatroban. Moreover, adding protamine sulfate as an antidote against the most potent bivalent aptamer completely suppressed the anticoagulant activity of the dimer. Emerging potent and neutralizable anticoagulant aptamers will be promising candidates for HIT treatment with a higher safety profile.
Collapse
Affiliation(s)
- Masanobu Nagano
- Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1 Komaba, Meguro, Tokyo 153-8902, Japan
| | - Kazuki Kubota
- Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1 Komaba, Meguro, Tokyo 153-8902, Japan
| | - Asuka Sakata
- Medicinal Biology of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8521, Japan
| | - Rei Nakamura
- Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1 Komaba, Meguro, Tokyo 153-8902, Japan
| | - Toru Yoshitomi
- Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1 Komaba, Meguro, Tokyo 153-8902, Japan
| | - Koji Wakui
- Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1 Komaba, Meguro, Tokyo 153-8902, Japan
| | - Keitaro Yoshimoto
- Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1 Komaba, Meguro, Tokyo 153-8902, Japan
| |
Collapse
|
4
|
Maghrabi KA, AlQahtany FS, AlOtair H, Maghrabi MK, AlSaleh K, Owaidah T. Prognostic markers in patients with COVID-19 requiring intensive critical support. J Taibah Univ Med Sci 2023; 18:1089-1098. [PMID: 36969317 PMCID: PMC9998242 DOI: 10.1016/j.jtumed.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 02/05/2023] [Accepted: 02/27/2023] [Indexed: 03/12/2023] Open
Abstract
Objectives Several hematological and immunological markers, particularly neutrophil count, predict the severity of COVID-19. This study aimed at assessing hematological and coagulation parameters at different time points, to predict the complications or outcomes of patients with COVID-19 admitted to the intensive care unit (ICU). Methods We conducted a prospective observational multicenter study in ICU departments. A total of 118 patients with COVID-19 admitted to the ICU were included. Clinical data and blood samples from routine hematology and coagulation tests were collected at admission, and on days 3, 7, and 14. The main outcome measures were high-flow-O2 requirement, thrombosis, and 30-day mortality. Results The mean length of ICU stay for our cohort was 15.70 ± 19 days, and the median was 9 days. The length of stay was significantly prolonged in recovered patients (28.20 ± 29.90 days; chi-square P = 0.0022) and patients with thrombosis (34.40 ± 39.60 days; P = 0.024). A total of 113 (95.70%) patients received prophylactic anticoagulation after admission with different regimens; thrombosis was observed in four (3.90%) patients (P = 0.430), but none died. The venous thromboembolism score increased from a mean of 5.10 ± 2 on day 0 to 6.40 ± 2.80 on day 14 (P = 0.0002). The disseminated intravascular coagulation (DIC) score significantly correlated with thrombosis (P = 0.031). A total of 41.20% of patients in the ICU had a DIC score ≥4, and 11.40% had a score <4. Mortality was negatively associated with patients on high-flow O2, 9 patients (10.80%) (P = 0.040), and positively associated with patients receiving ventilation, 16 patients (27.50%) (P < 0.001). An increase in white blood cell count (subdistribution hazard ratio (SHR): 0.91; 95% CI: 0.80–1) and neutrophil count (SHR: 1; 95% CI: 1.01–1.05) was associated with greater disease severity and D-dimer level (SHR: 1.60; 95% CI: 1.10–2.5). Conclusion The venous thromboembolism score was significantly higher for patients who died than those who recovered. Furthermore, mechanical ventilation was associated with high mortality, whereas the risk of thrombosis and ICU admission correlated with high D-dimer values and DIC scores. Therefore, D-dimer levels and DIC scores are prognostic markers that may predict disease severity in patients with COVID-19.
Collapse
Affiliation(s)
- Khalid A. Maghrabi
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
| | - Fatmah S. AlQahtany
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, KSA
| | - Hadeel AlOtair
- Department of Medicine, King Saud University, King Saud University Medical City, Riyadh, KSA
| | - Mohannad K. Maghrabi
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
| | - Khalid AlSaleh
- Department of Medicine, College of Medicine, King Saud University, Riyadh, KSA
| | - Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA,Alfaisal University, Riyadh, KSA,Corresponding address: Haematology and Transfusion Medicine, King Faisal Specialist Hospital, Alfaisal University, Centre of Excellence in Thrombosis and Hemostasis, P.O. Box 3354, Riyadh 11211, KSA
| |
Collapse
|
5
|
Sharma S, Tyagi T, Antoniak S. Platelet in thrombo-inflammation: Unraveling new therapeutic targets. Front Immunol 2022; 13:1039843. [PMID: 36451834 PMCID: PMC9702553 DOI: 10.3389/fimmu.2022.1039843] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
In the broad range of human diseases, thrombo-inflammation appears as a clinical manifestation. Clinically, it is well characterized in context of superficial thrombophlebitis that is recognized as thrombosis and inflammation of superficial veins. However, it is more hazardous when developed in the microvasculature of injured/inflamed/infected tissues and organs. Several diseases like sepsis and ischemia-reperfusion can cause formation of microvascular thrombosis subsequently leading to thrombo-inflammation. Thrombo-inflammation can also occur in cases of antiphospholipid syndrome, preeclampsia, sickle cell disease, bacterial and viral infection. One of the major contributors to thrombo-inflammation is the loss of normal anti-thrombotic and anti-inflammatory potential of the endothelial cells of vasculature. This manifest itself in the form of dysregulation of the coagulation pathway and complement system, pathologic platelet activation, and increased recruitment of leukocyte within the microvasculature. The role of platelets in hemostasis and formation of thrombi under pathologic and non-pathologic conditions is well established. Platelets are anucleate cells known for their essential role in primary hemostasis and the coagulation pathway. In recent years, studies provide strong evidence for the critical involvement of platelets in inflammatory processes like acute ischemic stroke, and viral infections like Coronavirus disease 2019 (COVID-19). This has encouraged the researchers to investigate the contribution of platelets in the pathology of various thrombo-inflammatory diseases. The inhibition of platelet surface receptors or their intracellular signaling which mediate initial platelet activation and adhesion might prove to be suitable targets in thrombo-inflammatory disorders. Thus, the present review summarizes the concept and mechanism of platelet signaling and briefly discuss their role in sterile and non-sterile thrombo-inflammation, with the emphasis on role of platelets in COVID-19 induced thrombo-inflammation. The aim of this review is to summarize the recent developments in deciphering the role of the platelets in thrombo-inflammation and discuss their potential as pharmaceutical targets.
Collapse
Affiliation(s)
- Swati Sharma
- UNC Blood Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Tarun Tyagi
- Yale Cardiovascular Research Center, Yale School of Medicine, New Haven, CT, United States
| | - Silvio Antoniak
- UNC Blood Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| |
Collapse
|
6
|
Murakami Y, Okazaki S, Yamamoto M, Sakurai R, Jinno J, Ozono T, Ikenaka K, Gon Y, Todo K, Sasaki T, Hirata H, Uchiyama A, Mochizuki H. Ischemic Stroke Due to Heparin-induced Thrombocytopenia during Severe COVID-19 Infection. Intern Med 2022; 61:2797-2801. [PMID: 35793954 PMCID: PMC9556234 DOI: 10.2169/internalmedicine.9531-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 53-year-old woman with severe coronavirus disease 2019 (COVID-19) pneumonia was admitted and treated with intravenous unfractionated heparin for thromboprophylaxis under general anesthesia with mechanical ventilation. She developed right hemiparesis after hospitalization due to a large hemorrhagic infarction. Her platelet count decreased from 243,000/μL at administration to 121,000/μL. Anti-platelet factor 4-heparin antibody testing was positive according to a latex immunoturbidimetric assay. She was therefore diagnosed with heparin-induced thrombocytopenia. We immediately stopped the heparin and started argatroban; the platelet count recovered, and thrombosis did not relapse. Physicians should consider heparin-induced thrombocytopenia as a cause of ischemic stroke in patients with COVID-19 infection.
Collapse
Affiliation(s)
- Yasutaka Murakami
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Makoto Yamamoto
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Japan
| | - Rei Sakurai
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Jyunki Jinno
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Tatsuhiko Ozono
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Kensuke Ikenaka
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Haruhiko Hirata
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Japan
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| |
Collapse
|
7
|
Shiuan E, Sharma D, Ely EW, Moodabagil N, Tillman BF. Limb ischemia due to spontaneous heparin-induced thrombocytopenia as the primary presentation of acute COVID-19 infection. J Thromb Thrombolysis 2022; 54:367-371. [PMID: 35763168 PMCID: PMC9243831 DOI: 10.1007/s11239-022-02676-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/16/2022] [Indexed: 11/30/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) occurs with the development of IgG antibodies that bind complexes of heparin and platelet factor 4 (PF4), which activate platelets and result in a profoundly prothrombotic condition. In rare instances, this syndrome develops in the absence of proximate heparin administration, referred to as spontaneous HIT, for which less than three dozen cases have been reported. Spontaneous HIT is considered a subtype of "autoimmune HIT" (aHIT), characterized by platelet activation in the serotonin release assay (SRA) without the addition of exogenous heparin. Here, we report spontaneous HIT as the presenting feature in a patient with 2019 coronavirus disease infection (COVID-19).A 66-year-old male presented with progressive leg pain and was found to have a platelet count of 39 × 109/L and multiple lower extremity arterial thromboses requiring fasciotomy and thrombectomy. He had no recent hospitalization, heparin exposure, vaccinations, or known thrombophilia. He had a strongly positive IgG-specific enzyme-linked immunosorbent assay for heparin-PF4 antibodies, and the SRA was strongly positive both with and without the addition of heparin. He was treated successfully with bivalirudin, intravenous immunoglobulin, and apixaban.
Collapse
Affiliation(s)
- Eileen Shiuan
- Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Internal Medicine, UCLA Medical Center, Los Angeles, CA, USA
| | - Deva Sharma
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Division of Transfusion Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Brain Dysfunction, and Survivorship (CIBS) Center, Critical Illness, Nashville, TN, USA
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Nikil Moodabagil
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin F Tillman
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Division of Laboratory Medicine, Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Medicine, VA Tennessee Valley Healthcare System, Nashville, TN, USA.
- Hematology/Oncology Division, Vanderbilt University Medical Center, 777 Preston Research Building, 2220 Pierce Avenue, 37232-5310, Nashville, TN, USA.
| |
Collapse
|
8
|
De Michele M, Kahan J, Berto I, Schiavo OG, Iacobucci M, Toni D, Merkler AE. Cerebrovascular Complications of COVID-19 and COVID-19 Vaccination. Circ Res 2022; 130:1187-1203. [PMID: 35420916 PMCID: PMC9005103 DOI: 10.1161/circresaha.122.319954] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The risk of stroke and cerebrovascular disease complicating infection with SARS-CoV-2 has been extensively reported since the onset of the pandemic. The striking efforts of many scientists in cooperation with regulators and governments worldwide have rapidly brought the development of a large landscape of vaccines against SARS-CoV-2. The novel DNA and mRNA vaccines have offered great flexibility in terms of antigen production and led to an unprecedented rapidity in effective and safe vaccine production. However, as mass vaccination has progressed, rare but catastrophic cases of thrombosis have occurred in association with thrombocytopenia and antibodies against PF4 (platelet factor 4). This catastrophic syndrome has been named vaccine-induced immune thrombotic thrombocytopenia. Rarely, ischemic stroke can be the symptom onset of vaccine-induced immune thrombotic thrombocytopenia or can complicate the course of the disease. In this review, we provide an overview of stroke and cerebrovascular disease as a complication of the SARS-CoV-2 infection and outline the main clinical and radiological characteristics of cerebrovascular complications of vaccinations, with a focus on vaccine-induced immune thrombotic thrombocytopenia. Based on the available data from the literature and from our experience, we propose a therapeutic protocol to manage this challenging condition. Finally, we highlight the overlapping pathophysiologic mechanisms of SARS-CoV-2 infection and vaccination leading to thrombosis.
Collapse
Affiliation(s)
- Manuela De Michele
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Joshua Kahan
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY (J.K., A.E.M.)
| | - Irene Berto
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Oscar G Schiavo
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Marta Iacobucci
- Neuroradiology Unit, Department of Human Neurosciences (M.I.), Sapienza University of Rome, Italy
| | - Danilo Toni
- Stroke Unit, Emergency Department (M.D.M., I.B., O.G.S., D.T.), Sapienza University of Rome, Italy
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY (J.K., A.E.M.)
| |
Collapse
|
9
|
Miller E, Norwood C, Giles JB, Huddart R, Karnes JH, Whirl-Carrillo M, Klein TE. PharmGKB summary: heparin-induced thrombocytopenia pathway, adverse drug reaction. Pharmacogenet Genomics 2022; 32:117-124. [PMID: 35102073 PMCID: PMC8988468 DOI: 10.1097/fpc.0000000000000465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Elise Miller
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Charles Norwood
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Jason B. Giles
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Rachel Huddart
- Department of Biomedical Data Science, Stanford University, Stanford, CA
| | - Jason H. Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA
- Department of Biomedical Informatics Research, Stanford University, Stanford, CA
| |
Collapse
|
10
|
Jevtic SD, Nazy I. The COVID Complex: A Review of Platelet Activation and Immune Complexes in COVID-19. Front Immunol 2022; 13:807934. [PMID: 35371058 PMCID: PMC8965558 DOI: 10.3389/fimmu.2022.807934] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/31/2022] [Indexed: 12/11/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a highly prothrombotic viral infection that primarily manifests as an acute respiratory syndrome. However, critically ill COVID-19 patients will often develop venous thromboembolism with associated increases in morbidity and mortality. The cause for this prothrombotic state is unclear but is likely related to platelet hyperactivation. In this review, we summarize the current evidence surrounding COVID-19 thrombosis and platelet hyperactivation. We highlight the fact that several studies have identified a soluble factor in COVID-19 patient plasma that is capable of altering platelet phenotype in vitro. Furthermore, this soluble factor appears to be an immune complex, which may be composed of COVID-19 Spike protein and related antibodies. We suggest that these Spike-specific immune complexes contribute to COVID-19 platelet activation and thrombosis in a manner similar to heparin-induced thrombocytopenia. Understanding this underlying pathobiology will be critical for advancement of future research and therapeutic options.
Collapse
Affiliation(s)
- Stefan D. Jevtic
- Department of Medicine, McMaster University Medical Centre, McMaster University, Hamilton, ON, Canada
| | - Ishac Nazy
- Department of Medicine, McMaster University Medical Centre, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
11
|
Lázaro-García A, Martínez-Alfonzo I, Vidal-Laso R, Velasco-Rodríguez D, Tomás-Mallebrera M, González-Rodríguez M, Llamas-Sillero P. A journey through anticoagulant therapies in the treatment of left ventricular thrombus in post-COVID-19 heparin-induced thrombocytopenia: a case report. Hematology 2022; 27:318-321. [PMID: 35231200 DOI: 10.1080/16078454.2022.2043572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug reaction associated with thrombosis. Clinical scoring systems and the presence of anti-platelet factor 4 (anti-PF4)/heparin antibodies determine the diagnosis. CASE PRESENTATION A 57-year-old man who was treated with acenocoumarol due to a chronic left ventricular thrombus was admitted to the hospital for severe SARS-CoV-2 pneumonia and pulmonary embolism. The patient was started on bemiparin and discharged. Left lower limb acute arterial ischemia and thrombocytopenia were diagnosed 18 days later. Computed tomography angiography revealed a large left ventricular thrombus and multiple arterial thrombi. Left femoral-popliteal thromboembolectomy was performed. Anti-PF4/heparin antibodies confirmed an HIT diagnosis. Fondaparinux (7.5 mg/24 h) was initiated, but cardiac surgery was necessary. Bivalirudin was used during surgery, with an initial load (1.25 mg/kg) and maintenance infusion (2.5 mg/kg/h). The cardiac thrombus was extracted, but the patient experienced a postsurgical myocardial infarction. Percutaneous cardiovascular intervention (PCI) required a bivalirudin load (0.75 mg/kg) and maintenance infusion (1.75 mg/kg/h). No coronary lesions were detected, and argatroban was started afterwards (0.5 µg/kg/min). When the platelet count exceeded 100 × 109/L, acenocoumarol was initiated. Thereupon, acetylsalicylic acid (100 mg/24 h) was added. No other complications have been reported to date. CONCLUSION The clinical presentation of intraventricular and multiple arterial thrombi is remarkable. SARS-CoV-2 infection likely contributed to a hypercoagulable state. The management of patients with HIT undergoing cardiac surgery is challenging. If surgery cannot be delayed, then treatment with bivalirudin is recommended. Additionally, this drug is recommended for PCI. Bivalirudin is safe and well-tolerated in both procedures.
Collapse
Affiliation(s)
- Alberto Lázaro-García
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Inés Martínez-Alfonzo
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Rosa Vidal-Laso
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Diego Velasco-Rodríguez
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | | | | | - Pilar Llamas-Sillero
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| |
Collapse
|
12
|
Alwaheed A, Alalwan M, Aldakhlan H, Albeladi F. Necrotizing Pancreatitis with Prortal Vein Thrombosis in Young Patient with COVID-19. J Infect Public Health 2022; 15:433-436. [PMID: 35344770 PMCID: PMC8934186 DOI: 10.1016/j.jiph.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 01/08/2023] Open
Abstract
The current pandemic of the novel coronavirus disease 2019 (COVID-19) originated in Wuhan, China in December 2019. The most common clinical manifestations are fever, fatigue, and cough. Other common symptoms include anorexia, chest tightness and shortness of breath. Extrapulmonary manifestations including gastrointestinal symptoms were also reported in patients with COVID-19 infection. It has been found that the ACE2 receptor of SARS-CoV-2 is expressed more in the pancreas than in the lungs. However, only few cases reported with pancreatic injury were caused by COVID-19. In this paper, we report a young patient presenting with acute necrotizing pancreatitis that is complicated with portal vein thrombosis and found to have COVID-19 infection.
Collapse
|
13
|
López-Martínez R, Albaiceta GM, Amado-Rodríguez L, Cuesta-Llavona E, Gómez J, García-Clemente M, Vázquez-Coto D, Alvarez V, Coto E. The FCGR2Ars1801274 polymorphism was associated with the risk of death among COVID-19 patients. Clin Immunol 2022; 236:108954. [PMID: 35149195 PMCID: PMC8824710 DOI: 10.1016/j.clim.2022.108954] [Citation(s) in RCA: 2] [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: 09/27/2021] [Revised: 12/16/2021] [Accepted: 02/07/2022] [Indexed: 12/29/2022]
Abstract
Polymorphisms of Fcγ receptors have been associated with variable responses to infections. We determined the association of functional polymorphisms rs1801274 in the FCGR2A and rs396991 in the FCGR3A with COVID-19 severity. This study involved 453 patients with severe COVID-19, in which the FCGR2A rs1801274 G-allele (131-Arg) was significantly associated with death (p = 0.02, OR = 1.47). This effect was independent of age and increased IL6 and D-Dimer levels. This study suggests that the FCGR2A gene might be associated with the risk of death among COVID-19 patients. Our study has several limitations, mainly the limited number of patients and the inclusion of a single population. It is thus necessary to confirm this result in larger cohorts from different populations.
Collapse
Affiliation(s)
| | - Guillermo M Albaiceta
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado deAsturias, ISPA, Oviedo, Spain; Universidad de Oviedo, Oviedo, Spain; CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Instituto Universitario de Oncología del Principado de Asturias, Oviedo, Spain
| | - Laura Amado-Rodríguez
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado deAsturias, ISPA, Oviedo, Spain; CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Instituto Universitario de Oncología del Principado de Asturias, Oviedo, Spain
| | - Elías Cuesta-Llavona
- Genética Molecular, Hospital Universitario Central Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado deAsturias, ISPA, Oviedo, Spain
| | - Juan Gómez
- Genética Molecular, Hospital Universitario Central Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado deAsturias, ISPA, Oviedo, Spain
| | - Marta García-Clemente
- Neumología, Hospital Universitario Central Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado deAsturias, ISPA, Oviedo, Spain
| | | | - Victoria Alvarez
- Inmunología, Hospital Universitario Central Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado deAsturias, ISPA, Oviedo, Spain
| | - Eliecer Coto
- Genética Molecular, Hospital Universitario Central Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado deAsturias, ISPA, Oviedo, Spain; Universidad de Oviedo, Oviedo, Spain.
| |
Collapse
|
14
|
Calcaterra G, Bassareo PP, De Gregorio C, Barilla F, Romeo F, Mehta JL. COVID-19 Vaccine-Induced Pro-thrombotic Immune Thrombocytopenia (VIPIT): State of the Art. Curr Cardiol Rev 2022; 18:11-17. [PMID: 35319381 PMCID: PMC9896421 DOI: 10.2174/1573403x18666220321105909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/03/2021] [Accepted: 01/07/2022] [Indexed: 11/22/2022] Open
Abstract
In 2020, as the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic spread rapidly throughout the world, scientists worked relentlessly to develop and test the safety and effectiveness of potential vaccines. Usually, the vaccine development process involves years of investigation and testing prior to gaining approval for use in practice. A pathogenic PF4-dependent syndrome, unrelated to the use of heparin therapy, may be manifested following the administration of viral vector vaccines. It leads to severe clot formation at unusual sites approximately in 1 out of 110.000 vaccinated persons. This side effect, although rare, represents a newly devastating clotting phenomenon manifested in otherwise healthy young adults, who are often female. An in-depth description of the specific biological mechanisms implicated in the syndrome is here summarized.
Collapse
Affiliation(s)
| | - Pier Paolo Bassareo
- Address correspondence to this author at the University College of Dublin, School of Medicine, Mater Misericordiae University Hospital, Dublin, Republic of Ireland; E-mail:
| | | | | | | | | |
Collapse
|
15
|
Rostami M, Mansouritorghabeh H, Parsa-Kondelaji M. High levels of Von Willebrand factor markers in COVID-19: a systematic review and meta-analysis. Clin Exp Med 2021; 22:347-357. [PMID: 34741678 PMCID: PMC8571968 DOI: 10.1007/s10238-021-00769-x] [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: 08/31/2021] [Accepted: 10/19/2021] [Indexed: 12/23/2022]
Abstract
The SARS-CoV-2 virus has spread to all corners of the world. Thrombosis is the cause of organ failure and subsequent death in COVID-19. The pathophysiology of thrombosis in COVID-19 needs to be further explored to shed light on its downside. For this reason, this meta-analysis of Von Willebrand Factor profile (VWF: Ag, VWF: activity, VWF: RCo), ADAMTS-13, and factor VIII levels in COVID-19 was performed. To obtain data on the status of the aforementioned hemostatic factors, a systematic literature review and meta-analysis were performed on COVID-19. After reviewing the evaluation of 348 papers, 28 papers included in the meta-analysis, which was performed using STATA. The analysis showed an increase in VWF: Ag levels in COVID‐19 patients. VWF: Ac was higher in all COVID-19 patients, while it was lower in the COVID‐19 ICU patients. The pooled mean of VWF: RCO in all patients with COVID-19 was 307.94%. In subgroup analysis, VWF: RCO was significantly higher in ICU patients than in all COVID-19 patients. The pooled mean of ADAMTS-13 activity was 62.47%, and 58.42% in ICU patients. The pooled mean of factor VIII level was 275.8%, which was significantly higher in ICU patients with COVID-19 than all patients with COVID-19. Levels of VWF: Ag, VWF: activity, VWF: ristocetin, and factor VIII are increased in patients with COVID-19. The elevated levels in ICU patients with COVID-19 suggest that these markers may have prognostic value in determining the severity of COVID-19. New therapeutic programs can be developed as a result.
Collapse
Affiliation(s)
- Mehrdad Rostami
- Hematology and Blood Banking, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Mansouritorghabeh
- Hematology and Blood Banking, Mashhad University of Medical Sciences, Mashhad, Iran. .,Central Diagnostic Laboratories, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
| | | |
Collapse
|
16
|
Mechanisms of Immunothrombosis by SARS-CoV-2. Biomolecules 2021; 11:biom11111550. [PMID: 34827548 PMCID: PMC8615366 DOI: 10.3390/biom11111550] [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: 08/14/2021] [Revised: 10/06/2021] [Accepted: 10/09/2021] [Indexed: 12/20/2022] Open
Abstract
SARS-CoV-2 contains certain molecules that are related to the presence of immunothrombosis. Here, we review the pathogen and damage-associated molecular patterns. We also study the imbalance of different molecules participating in immunothrombosis, such as tissue factor, factors of the contact system, histones, and the role of cells, such as endothelial cells, platelets, and neutrophil extracellular traps. Regarding the pathogenetic mechanism, we discuss clinical trials, case-control studies, comparative and translational studies, and observational studies of regulatory or inhibitory molecules, more specifically, extracellular DNA and RNA, histones, sensors for RNA and DNA, as well as heparin and heparinoids. Overall, it appears that a network of cells and molecules identified in this axis is simultaneously but differentially affecting patients at different stages of COVID-19, and this is characterized by endothelial damage, microthrombosis, and inflammation.
Collapse
|
17
|
Nicolai L, Adornetto R, Bianchini R, Carrer F, Borgo CD, Doro S, Masotti D, Puglisi C, Turini L, Wohlauer M, Galeazzi E. Distal arteriovenous fistula to preserve patency in COVID-19-associated acute limb ischemia. Semin Vasc Surg 2021; 34:96-100. [PMID: 34642042 PMCID: PMC8418698 DOI: 10.1053/j.semvascsurg.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/12/2022]
Abstract
The purpose of this study was to report our institutional experience with patients with COVID-19 who developed acute limb ischemia during hospitalization and to determine the characteristics and clinical outcomes. Between March 2020 and January 2021, we treated 3 patients who were COVID-19–positive and developed acute limb ischemia after they received thromboprophylaxis. We performed an embolectomy by exposing the popliteal artery below the knee to treat an occlusion of the popliteal and tibial arteries. An infusion of unfractionated heparin was initiated immediately after surgery, maintaining a partial thromboplastin time ratio > 2.5 times the normal value and transferred the patients to the intensive care unit. However, after these patients developed recurrent acute limb ischemia in the same leg, we decided to perform an embolectomy of popliteal and tibial arteries at the ankle and created an arteriovenous fistula (AVF) with tibial veins using polypropylene 7-0. The first patient died from pneumonia after 3 weeks in the intensive care unit; at that time, the foot was viable with triphasic flow in the distal posterior tibial artery and the AVF was patent. The second and third patients are doing well, they can walk without any problems, and the tibial arteries and AFV were patent on duplex ultrasound after 6 months. The AVF allowed part of the flow of tibial arteries to divert into the small veins of the foot that have a low resistance to maintain patency of tibial vessels, despite a hypercoagulable state and extensive thrombotic microangiopathy in patients with COVID-19.
Collapse
Affiliation(s)
- Laura Nicolai
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy.
| | - Raffaele Adornetto
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy
| | - Roberta Bianchini
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy
| | - Floriana Carrer
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy
| | - Chiara Dal Borgo
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy
| | - Stefano Doro
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy
| | - Daniele Masotti
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy
| | - Cristina Puglisi
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy
| | - Letizia Turini
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy
| | - Max Wohlauer
- Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Edoardo Galeazzi
- Vascular Surgery Unit, Cardioneurovascular Department, Aulss 2 Marca Trevigiana, Treviso Hospital, Italy
| |
Collapse
|
18
|
Sulakshana S, Nayak SS, Perumal S, Das BP. Heparin-Induced Thrombocytopenia in COVID-19: A Systematic Review. Anesth Essays Res 2021; 15:341-347. [PMID: 35422550 PMCID: PMC9004278 DOI: 10.4103/aer.aer_151_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 12/22/2022] Open
Abstract
Background: It has been more than a year since the whole world is struggling with COVID-19 pandemic and may experience resurgences in the near future. Along with severe pneumonia, this disease is notorious for extensive thromboembolic manifestations. That is why experts advocated aggressive anticoagulation as a part of the therapy since the beginning. However, from May 2020 onwards, cases of heparin-induced thrombocytopenia (HIT) are being reported. HIT in itself is an autoimmune entity leading to life-threatening thrombosis in the setting of thrombocytopenia. Continuation of heparin can have disastrous consequences in case of unrecognized HIT. Hence, timely recognition of HIT is of utmost value to modify the anticoagulation strategy and salvaging lives. We performed a systemic review trying to find all reported cases of HIT in COVID-19. Methods: It involved extensive search of the databases including PubMed, Google Scholar, Scopus, and Embase in an attempt to find all reported literature in the last 1 year (November 1, 2019–December 25, 2020) using keywords in various combinations. Literature search resulted in a total of 27 articles and 12 articles were finally selected based on the study design and their relevance pertaining to the intervention done and the outcome of interest. Results: A total of 35 patients were included (mean age 56.7 ± 12.8 years, male-to-female ratio = 2:1). The most frequent comorbidity was hypertension. Fifty-seven percent of cases were with low-molecular weight heparin and the rest with unfractionated heparin. Confirmatory functional assay was done in 85.7% of cases (67% by serotonin-release assay [SRA] and 33% by heparin-induced platelet aggregation [HIPA]). All cases tested with HIPA were positive, while with SRA, only 30% were positive. The most common alternate anticoagulation used was argatroban infusion. The new arterial thrombotic event was seen in only 5.7% of cases as repeat myocardial infarction, stroke, and splenic infarction, while clinically significant bleeding was seen in 17.1% of cases. Fifty percent of bleeding episodes were seen where conventional doses of argatroban were used, while no mortality was seen with low-dose argatroban infusion. However, only 45.7% of patients were discharged, 31.4% of patients died, while the outcome was pending for 23% of patients. Conclusion: Severe endotheliitis and immune dysregulation giving rise to HIT antibodies and antiphospholipid antibodies have been demonstrated in COVID-19 and modifying our therapy becomes indispensable when it is pathogenic with potentially fatal consequences. In the light of interim results of REMAP-CAP study in severe COVID-19 cases where heparin does not improve the outcome, the present anticoagulation strategy needs re-evaluation. Unrecognized HIT can be catastrophic and close clinical monitoring is required for patients on heparin therapy.
Collapse
Affiliation(s)
- Sulakshana Sulakshana
- Department of Anaesthesiology and Critical Care, Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | | | - Siva Perumal
- Department of Anaesthesiology and Critical Care, SVMCH and RC, Puducherry, India
| | - Badri Prasad Das
- Department of Anaesthesiology and Critical Care, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| |
Collapse
|
19
|
Devreese KMJ. COVID-19-related laboratory coagulation findings. Int J Lab Hematol 2021; 43 Suppl 1:36-42. [PMID: 34288440 PMCID: PMC8444785 DOI: 10.1111/ijlh.13547] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/14/2021] [Accepted: 03/28/2021] [Indexed: 01/16/2023]
Abstract
The alterations in the hemostatic balance in COVID-19 patients are strongly disturbed and contribute to a high prothrombotic status. The high rate of venous thromboembolism in COVID-19 patients goes along with derangements in coagulation laboratory parameters. Hemostasis testing has an important role in diagnosed COVID-19 patients. Elevated D-dimer levels were found to be a crucial laboratory marker in the risk assessment of thrombosis in COVID-19 patients. The diagnostic approach also includes prothrombin time and platelet count. Fibrinogen might give an indication for worsening coagulopathy. Other markers (activated partial thromboplastin time (aPTT), fibrinolysis parameters, coagulation factors, natural anticoagulants, antiphospholipid antibodies and parameters obtained by thromboelastography or thrombin generation assays) have been described as being deranged. These may help to understand the pathophysiology of thrombosis in COVID-19 patients but have currently no place in diagnosis or management in COVID-19 patients. For monitoring the heparin anticoagulant therapy, the anti-Xa assay is suggested, because the severe acute-phase reaction (high fibrinogen and high factor VIII) shortens the aPTT.
Collapse
Affiliation(s)
- Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Department of Diagnostic Sciences, Ghent University Hospital, Ghent University, Ghent, Belgium
| |
Collapse
|
20
|
Sharathkumar AA, Faustino EVS, Takemoto CM. How we approach thrombosis risk in children with COVID-19 infection and MIS-C. Pediatr Blood Cancer 2021; 68:e29049. [PMID: 33955167 PMCID: PMC8206673 DOI: 10.1002/pbc.29049] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/04/2021] [Accepted: 03/22/2021] [Indexed: 01/08/2023]
Abstract
Thrombosis within the microvasculature and medium to large vessels is a serious and common complication among critically ill individuals with coronavirus disease 2019 (COVID-19). While children are markedly less likely to develop severe disease than adults, they remain at risk for thrombosis during acute infection and with the post-acute inflammatory illness termed multisystem inflammatory syndrome in children. Significant knowledge deficits in understanding COVID-19-associated coagulopathy and thrombotic risk pose clinical challenges for pediatric providers who must incorporate expert opinion and personal experience to manage individual patients. We discuss clinical scenarios to provide framework for characterizing thrombosis risk and thromboprophylaxis in children with COVID-19.
Collapse
Affiliation(s)
- Anjali A. Sharathkumar
- Stead Family Department of Pediatrics, Carver College of MedicineUniversity of IowaIowa CityIowaUSA
| | - E. Vincent S. Faustino
- Section of Pediatric Critical Care Medicine, Department of PediatricsYale School of MedicineNew HavenConnecticutUSA
| | - Clifford M. Takemoto
- Division of Clinical HematologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| |
Collapse
|
21
|
Smythe MA, Burns C, Liu Q, Garwood CL. Potential Dexamethasone-Direct Oral Anticoagulant Drug Interaction: Is This a Concern in COVID? Ann Pharmacother 2021; 56:319-329. [PMID: 34137279 DOI: 10.1177/10600280211025042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate the literature on a potential dexamethasone-direct oral anticoagulant (DOAC) drug interaction and provide management considerations with COVID hypercoagulability. DATA SOURCES A search of EMBASE, PubMed, and Google Scholar (January 1990 to May 2021), limited to the English language, using applicable search terms resulted in 137 articles, with 21 relevant articles included. Regulatory agency and clinical guidance documents were also reviewed. STUDY SELECTION AND DATA EXTRACTION Included articles describe in vitro or in vivo animal or human data for dexamethasone induction of cytochrome P450 (CYP) 3A4 or P-glycoprotein (P-gp). DATA SYNTHESIS Dexamethasone has the potential to interact with the DOACs via CYP3A4 and/or P-gp induction. Only apixaban and rivaroxaban have CYP3A4 metabolism. Dexamethasone can increase CYP3A4 activity by up to 70% and reduce the area under the concentration-time curve (AUC) of CYP3A4 substrates by >40%, which is consistent with criteria for a weak CYP inducer. In rodents, dexamethasone P-gp induction is associated with AUC reductions of 20% to 50%. Human data are lacking. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Severe COVID-19 infection is associated with hypercoagulability. Although heparins are the preferred anticoagulants for hospitalized COVID-19 patients, DOACs are being utilized. Dexamethasone is recommended for hospitalized COVID-19 patients requiring supplemental oxygen. The concurrent use of dexamethasone and apixaban or rivaroxaban in such patients carries the potential for reduced anticoagulant effect during a state of heightened thrombotic risk. CONCLUSIONS Concurrent use of dexamethasone and apixaban or rivaroxaban in hospitalized COVID-19 patients with laboratory evidence of COVID coagulopathy should be avoided until higher-quality data are available.
Collapse
Affiliation(s)
- Maureen A Smythe
- Wayne State University, Detroit, MI, USA.,Beaumont Hospital, Royal Oak, MI, USA
| | | | | | - Candice L Garwood
- Wayne State University, Detroit, MI, USA.,Detroit Medical Center, MI, USA
| |
Collapse
|
22
|
Ghosh R, Roy D, Mandal A, Pal SK, Chandra Swaika B, Naga D, Pandit A, Ray BK, Benito-León J. Cerebral venous thrombosis in COVID-19. Diabetes Metab Syndr 2021; 15:1039-1045. [PMID: 34015627 PMCID: PMC8128714 DOI: 10.1016/j.dsx.2021.04.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Initially, novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) was considered primarily a respiratory pathogen. However, with time it has behaved as a virus with the potential to cause multi-system involvement, including neurological manifestations. Cerebral venous sinus thrombosis (CVT) has increasingly been reported in association with coronavirus infectious disease of 2019 (COVID-19). Here, we have shed light upon CVT and its possible mechanisms in the backdrop of the ongoing COVID-19 pandemic. METHODS In this review, data were collected from PubMed, EMBASE and Web of Science, until March 30, 2021, using pre-specified searching strategies. The search strategy consisted of a variation of keywords of relevant medical subject headings and keywords, including "COVID-19", "SARS-CoV-2", "coronavirus", and "cerebral venous sinus thrombosis". RESULTS COVID-19 has a causal association with a plethora of neurological, neuropsychiatric and psychological effects. CVT has gained particular importance in this regard. The known hypercoagulable state in SARS-CoV-2 infection is thought to be the main mechanism in COVID-19 related CVT. Other plausible mechanisms may include vascular endothelial dysfunction and altered flow dynamics. CONCLUSIONS Although there are no specific clinical characteristics, insidious or acute onset headache, seizures, stroke-like, or encephalopathy symptoms in a patient with, or who has suffered COVID-19, should prompt the attending physician to investigate for CVT. The treatment of COVID-19 associated CVT does not differ radically from the therapy of CVT without the infection, i.e. urgent initiation of parenteral unfractionated heparin or low molecular weight heparin followed by conventional or mostly newer oral anticoagulants.
Collapse
Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Dipayan Roy
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Arpan Mandal
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Shyamal Kanti Pal
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Bikash Chandra Swaika
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Dinabandhu Naga
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Alak Pandit
- Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Biman Kanti Ray
- Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Universidad Complutense, Madrid, Spain.
| |
Collapse
|
23
|
Nazy I, Jevtic SD, Moore JC, Huynh A, Smith JW, Kelton JG, Arnold DM. Platelet-activating immune complexes identified in critically ill COVID-19 patients suspected of heparin-induced thrombocytopenia. J Thromb Haemost 2021; 19:1342-1347. [PMID: 33639037 PMCID: PMC8014456 DOI: 10.1111/jth.15283] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Thrombocytopenia and thrombosis are prominent in coronavirus disease 2019 (COVID-19), particularly among critically ill patients; however, the mechanism is unclear. Such critically ill COVID-19 patients may be suspected of heparin-induced thrombocytopenia (HIT), given similar clinical features. OBJECTIVES We investigated the presence of platelet-activating anti-platelet-factor 4 (PF4)/heparin antibodies in critically ill COVID-19 patients suspected of HIT. PATIENTS/METHODS We tested 10 critically ill COVID-19 patients suspected of HIT for anti-PF4/heparin antibodies and functional platelet activation in the serotonin release assay (SRA). Anti-human CD32 antibody (IV.3) was added to the SRA to confirm FcγRIIA involvement. Additionally, SARS-CoV-2 antibodies were measured using an in-house ELISA. Finally, von Willebrand factor (VWF) antigen and activity were measured along with A Disintegrin And Metalloprotease with ThromboSpondin-13 Domain (ADAMTS13) activity and the presence of anti-ADAMTS13 antibodies. RESULTS Heparin-induced thrombocytopenia was excluded in all samples based on anti-PF4/heparin antibody and SRA results. Notably, six COVID-19 patients demonstrated platelet activation by the SRA that was inhibited by FcγRIIA receptor blockade, confirming an immune complex (IC)-mediated reaction. Platelet activation was independent of heparin but inhibited by both therapeutic and high dose heparin. All six samples were positive for antibodies targeting the receptor binding domain (RBD) or the spike protein of the SARS-CoV-2 virus. These samples also featured significantly increased VWF antigen and activity, which was not statistically different from the four COVID-19 samples without platelet activation. ADAMTS13 activity was not severely reduced, and ADAMTS13 inhibitors were not present, thus ruling out a primary thrombotic microangiopathy. CONCLUSIONS Our study identifies platelet-activating ICs as a novel mechanism that contributes to critically ill COVID-19.
Collapse
Affiliation(s)
- Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, Hamilton, ON, Canada
| | - Stefan D Jevtic
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jane C Moore
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Angela Huynh
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - James W Smith
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - John G Kelton
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, Hamilton, ON, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, Hamilton, ON, Canada
- Canadian Blood Services, Hamilton, ON, Canada
| |
Collapse
|
24
|
Zhu W, Zheng Y, Yu M, Wei J, Zhang Y, Topchyan P, Nguyen C, Janecke R, Kreuziger LB, White GC, Hari P, Aster R, Cui W, Jobe S, Graham MB, Wang D, Wen R. SARS-CoV-2 receptor binding domain-specific antibodies activate platelets with features resembling the pathogenic antibodies in heparin-induced thrombocytopenia. RESEARCH SQUARE 2021:rs.3.rs-462080. [PMID: 34013243 PMCID: PMC8132233 DOI: 10.21203/rs.3.rs-462080/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Severe COVID-19 is associated with unprecedented thromboembolic complications. We found that hospitalized COVID-19 patients develop immunoglobulin Gs (IgGs) that recognize a complex consisting of platelet factor 4 and heparin similar to those developed in heparin-induced thrombocytopenia and thrombosis (HIT), however, independent of heparin exposure. These antibodies activate platelets in the presence of TLR9 stimuli, stimuli that are prominent in COVID-19. Strikingly, 4 out of 42 antibodies cloned from IgG1+ RBD-binding B cells could activate platelets. These antibodies possessed, in the heavy-chain complementarity-determining region 3, an RKH or Y5 motif that we recently described among platelet-activating antibodies cloned from HIT patients. RKH and Y5 motifs were prevalent among published RBD-specific antibodies, and 3 out of 6 such antibodies tested could activate platelets. Features of platelet activation by these antibodies resemble those by pathogenic HIT antibodies. B cells with an RKH or Y5 motif were robustly expanded in COVID-19 patients. Our study demonstrates that SARS-CoV-2 infection drives the development of a subset of RBD-specific antibodies that can activate platelets and have activation properties and structural features similar to those of the pathogenic HIT antibodies.
Collapse
|
25
|
Carbone M, Lednicky J, Xiao SY, Venditti M, Bucci E. Coronavirus 2019 Infectious Disease Epidemic: Where We Are, What Can Be Done and Hope For. J Thorac Oncol 2021; 16:546-571. [PMID: 33422679 PMCID: PMC7832772 DOI: 10.1016/j.jtho.2020.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/15/2020] [Accepted: 12/29/2020] [Indexed: 12/18/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads mainly by means of aerosols (microdroplets) in enclosed environments, especially those in which temperature and humidity are regulated by means of air-conditioning. About 30% of individuals infected with SARS-CoV-2 develop coronavirus disease 2019 (COVID-19) disease. Among them, approximately 25% require hospitalization. In medicine, cases are identified as those who become ill. During this pandemic, cases have been identified as those with a positive SARS-CoV-2 polymerase chain reaction test, including approximately 70% who were asymptomatic-this has caused unnecessary anxiety. Individuals more than 65 years old, those affected by obesity, diabetes, asthma, or are immune-depressed owing to cancer and other conditions, are at a higher risk of hospitalization and of dying of COVID-19. Healthy individuals younger than 40 years very rarely die of COVID-19. Estimates of the COVID-19 mortality rate vary because the definition of COVID-19-related deaths varies. Belgium has the highest death rate at 154.9 per 100,000 persons, because it includes anyone who died with symptoms compatible with COVID-19, even those never tested for SARS-CoV-2. The United States includes all patients who died with a positive test, whether they died because of, or with, SARS-CoV-2. Countries that include only patients in which COVID-19 was the main cause of death, rather than a cofactor, have lower death rates. Numerous therapies are being developed, and rapid improvements are anticipated. Because of disinformation, only approximately 50% of the U.S. population plans to receive a COVID-19 vaccine. By sharing accurate information, physicians, health professionals, and scientists play a key role in addressing myths and anxiety, help public health officials enact measures to decrease infections, and provide the best care for those who become sick. In this article, we discuss these issues.
Collapse
Affiliation(s)
- Michele Carbone
- Thoracic Oncology, University of Hawaii Cancer Center, Honolulu, Hawaii; Department of Pathology, John A. Burns School of Medicine, Hawaii, Honolulu, Hawaii.
| | - John Lednicky
- Department of Environmental and Global Health, College of Public Health and Health Professions, Emerging Pathogens Institute, University of Florida, Gainesville, Florida
| | - Shu-Yuan Xiao
- Department of Pathology, University of Chicago Medicine, Chicago, llinois
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Universita` La Sapienza, Roma, Italy
| | - Enrico Bucci
- Sbarro Institute for Cancer Research and Molecular Medicine, College for Science and technology, Temple University, Philadelphia, Pennsylvania; Department of Biology, College for Science and Technology, Temple University, Philadelphia, Pennsylvania
| |
Collapse
|
26
|
Cerebral Sinus Thrombosis Secondary to SARS-CoV-2 Infection. Case Rep Neurol Med 2021; 2021:6640368. [PMID: 33763270 PMCID: PMC7952167 DOI: 10.1155/2021/6640368] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/17/2021] [Accepted: 02/13/2021] [Indexed: 01/05/2023] Open
Abstract
Coronavirus disease-19 (COVID-19) is a novel infectious disease and every day we are learning more about its various clinical features and complications. Different studies during the pandemic have shown various neurological manifestations secondary to the infection such as stroke due to cerebral vessel thrombosis. Herein, we presented a 57-year-old man admitted to our hospital with gradual headache, seizure, and decreasing level of consciousness. Three weeks earlier, he was diagnosed with COVID-19 and mild to moderate respiratory problems. Decreased level of consciousness made physicians intubate the patient and initiate mechanical ventilation in the intensive care unit (ICU). Treatment was initiated with phenytoin. Brain CT scan showed right transverse sinus and cortical vein thrombosis with subarachnoid hemorrhage. He received successful anticoagulant therapy, with further improvement in oxygenation, and discharged with a good general condition. This case is important because several neurological complications of COVID-19 should be noticed and managed by appropriate treatment according to the patient's condition.
Collapse
|
27
|
COVID-19 in thrombosis research: An editorial perspective. Thromb Res 2021; 201:147-150. [PMID: 33798826 PMCID: PMC7987507 DOI: 10.1016/j.thromres.2021.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 12/30/2022]
|
28
|
Madala S, Krzyzak M, Dehghani S. Is COVID-19 an Independent Risk Factor for Heparin-Induced Thrombocytopenia? Cureus 2021; 13:e13425. [PMID: 33758713 PMCID: PMC7978146 DOI: 10.7759/cureus.13425] [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] [Indexed: 12/14/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a viral respiratory illness initially described in Wuhan, China, and was declared a pandemic by World Health Organization (WHO) in 2020, and the disease is named coronavirus disease (COVID-19). SARS-CoV2 is known to cause fever, cough, fatigue, and acute respiratory distress syndrome. As more patients become infected, extrapulmonary manifestations came to rise and hypercoagulability is one among those. COVID-19 could predispose patients to both venous and arterial thromboembolic events which are commonly treated with unfractionated heparin or low molecular weight heparin (LMWH). The treatment of patients who develop heparin-induced thrombocytopenia (HIT) while being treated with heparin or LMWH for COVID-induced thromboembolic complications is challenging. We describe a patient admitted to the hospital with COVID-19 pneumonia, found to have a cerebrovascular event treated with unfractionated heparin. She also received therapeutic LMWH for anticoagulation on day 1 of presentation due to atrial fibrillation. She was diagnosed with HIT and was found to have a pulmonary embolism, aortic arch mural thrombus, and arterial thrombi in the lower extremities. As more recent studies showed HIT antibodies in COVID-19 patients who are naive for heparin-based products, COVID-19 may be an independent risk factor for the development of HIT. The role of COVID-19 in the development of HIT is uncertain. High vigilance is required to diagnose and initiate treatment for HIT early in the disease course as it can be life-threatening.
Collapse
Affiliation(s)
| | - Michael Krzyzak
- Medicine, Staten Island University Hospital, Staten Island, USA
| | | |
Collapse
|
29
|
COVID-19-associated coagulopathy and disseminated intravascular coagulation. Int J Hematol 2020; 113:45-57. [PMID: 33161508 PMCID: PMC7648664 DOI: 10.1007/s12185-020-03029-y] [Citation(s) in RCA: 211] [Impact Index Per Article: 52.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/15/2020] [Accepted: 10/22/2020] [Indexed: 01/08/2023]
Abstract
The pathology of coronavirus disease 2019 (COVID-19) is exacerbated by the progression of thrombosis, and disseminated intravascular coagulation (DIC), and cytokine storms. The most frequently reported coagulation/fibrinolytic abnormality in COVID-19 is the increase in d-dimer, and its relationship with prognosis has been discussed. However, limits exist to the utility of evaluation by d-dimer alone. In addition, since the coagulation/fibrinolytic condition sometimes fluctuates within a short period of time, regular examinations in recognition of the significance of the examination are desirable. The pathophysiology of disseminated intravascular coagulation (DIC) associated with COVID-19 is very different from that of septic DIC, and both thrombotic and hemorrhagic pathologies should be noted. COVID-19 thrombosis includes macro- and microthrombosis, with diagnosis of the latter depending on markers of coagulation and fibrinolysis. Treatment of COVID-19 is classified into antiviral treatment, cytokine storm treatment, and thrombosis treatment. Rather than providing uniform treatment, the treatment method most suitable for the severity and stage should be selected. Combination therapy with heparin and nafamostat is expected to develop in the future. Fibrinolytic therapy and adsorption therapy require further study
Collapse
|
30
|
Prothrombotic disturbances of hemostasis of patients with severe COVID-19: A prospective longitudinal observational study. Thromb Res 2020; 197:20-23. [PMID: 33161283 PMCID: PMC7585359 DOI: 10.1016/j.thromres.2020.10.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/11/2020] [Accepted: 10/19/2020] [Indexed: 02/08/2023]
|