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He S, Blombäck M, Wallén H. COVID-19: Not a thrombotic disease but a thromboinflammatory disease. Ups J Med Sci 2024; 129:9863. [PMID: 38327640 PMCID: PMC10845889 DOI: 10.48101/ujms.v129.9863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/17/2023] [Accepted: 10/21/2023] [Indexed: 02/09/2024] Open
Abstract
While Coronavirus Disease in 2019 (COVID-19) may no longer be classified as a global public health emergency, it still poses a significant risk at least due to its association with thrombotic events. This study aims to reaffirm our previous hypothesis that COVID-19 is fundamentally a thrombotic disease. To accomplish this, we have undertaken an extensive literature review focused on assessing the comprehensive impact of COVID-19 on the entire hemostatic system. Our analysis revealed that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection significantly enhances the initiation of thrombin generation. However, it is noteworthy that the thrombin generation may be modulated by specific anticoagulants present in patients' plasma. Consequently, higher levels of fibrinogen appear to play a more pivotal role in promoting coagulation in COVID-19, as opposed to thrombin generation. Furthermore, the viral infection can stimulate platelet activation either through widespread dissemination from the lungs to other organs or localized effects on platelets themselves. An imbalance between Von Willebrand Factor (VWF) and ADAMTS-13 also contributes to an exaggerated platelet response in this disease, in addition to elevated D-dimer levels, coupled with a significant increase in fibrin viscoelasticity. This paradoxical phenotype has been identified as 'fibrinolysis shutdown'. To clarify the pathogenesis underlying these hemostatic disorders in COVID-19, we also examined published data, tracing the reaction process of relevant proteins and cells, from ACE2-dependent viral invasion, through induced tissue inflammation, endothelial injury, and innate immune responses, to occurrence of thrombotic events. We therefrom understand that COVID-19 should no longer be viewed as a thrombotic disease solely based on abnormalities in fibrin clot formation and proteolysis. Instead, it should be regarded as a thromboinflammatory disorder, incorporating both classical elements of cellular inflammation and their intricate interactions with the specific coagulopathy.
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Affiliation(s)
- Shu He
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Division of Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Margareta Blombäck
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Division of Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Gheiasi B, Taghinezhad F, Patel DK, Salimi E, Babashahi M, Mozafari A. Thrombocytopenia Secondary to COVID-19: Outcomes Analysis in Terms of Thrombotic Microangiopathy, Acute Kidney Injury, and Mortality. Int J Hematol Oncol Stem Cell Res 2024; 18:7-13. [PMID: 38680710 PMCID: PMC11055419 DOI: 10.18502/ijhoscr.v18i1.14740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/16/2023] [Indexed: 05/01/2024] Open
Abstract
Background: COVID-19 usually complicates respiratory failure; microvascular, macrovascular, and renal complications are common. Both micro and macrovascular complications are associated with multi-organ dysfunction and in-hospital mortality. Thrombotic microangiopathy (TMA) causes microvascular thromboses associated with organ failure, including acute kidney injury (AKI). Materials and Methods: This Retrospective Cohort study included 100 COVID-19 patients with thrombocytopenia, followed up in a university hospital's intensive care unit (ICU). The primary endpoints were in-hospital mortality or discharge from the hospital and assessing the occurrence of TMA and AKI during the hospitalization. The effect of thrombotic microangiopathy and acute kidney injury on mortality was investigated using logistic regression models in Stata software version 12.1. Results: The TMA and AKI were associated with in-hospital mortality in COVID-19 patients presenting with thrombocytopenia in multivariate regression analysis, adjusted for other variables. The effect of AKI on mortality was obtained (adjusted OR 4.09, 95% CI: 1.33-12.53, p = 0.01). Moreover, the odds of mortality due to TMA were ten-fold higher in the patients who had TMA than those who did not (adjusted OR 10.26, 95% CI: 1.26-83.76, p = 0.03). Conclusion: We outlined TMA in COVID-19 patients, which could be responsible for kidney injury and mortality in critically COVID-19 patients.
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Affiliation(s)
- Bahareh Gheiasi
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | | | - Darshik Kumar Patel
- Department of Intensive Care Medicine, Loyola Medicine - Macneal Hospital, Berwyn, IL, USA
| | - Ebrahim Salimi
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Mashallah Babashahi
- Department of Laboratory Sciences, School of Allied Medical Sciences, University of Medical Sciences, Ilam, Iran
| | - Aliashraf Mozafari
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
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Masuda E, Fukushima K, Hebisawa Y, Tanaka M, Ohta A, Imamura A. Coronavirus disease 2019-associated thrombotic microangiopathy treated with plasma exchange and antihypertensive therapy in a patient with HIV: A case report with literature review. Medicine (Baltimore) 2023; 102:e35469. [PMID: 37832064 PMCID: PMC10578717 DOI: 10.1097/md.0000000000035469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/13/2023] [Indexed: 10/15/2023] Open
Abstract
RATIONALE Coronavirus disease 2019 (COVID-19) is an infectious disease that often causes complications in multiple organs and thrombosis due to abnormal blood coagulation. This case report aimed to describe the clinical course of COVID-19-associated thrombotic microangiopathy (TMA) and reviewed the comprehensive information on TMA, thrombotic thrombocytopenic purpura (TTP), and atypical hemolytic uremic syndrome associated with COVID-19 in the past literature. PATIENT CONCERNS A 46-year-old Japanese man was diagnosed with human immunodeficiency virus infection 10 years ago and treated with antiretroviral therapy. The patient presented with fever, malaise, hematuria, and bilateral upper abdominal discomfort for the past 4 days. DIAGNOSES COVID-19-associated TMA was diagnosed based on a positive polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 and laboratory findings such as thrombocytopenia, acute kidney injury, and hemolytic anemia. Malignant hypertension and human immunodeficiency virus infection were also considered as differential diagnoses of TMA. INTERVENTIONS Considering the possibility of TTP, plasma exchange was performed, and glucocorticoids were administered. Hemodialysis was performed for acute kidney injury. Antihypertensive drugs were administered to control the high blood pressure. OUTCOMES Platelet count and renal function improved, and hemodialysis was no longer required. The patient was in good general condition and was discharged from the hospital. LESSONS COVID-19-associated TMA should be considered as a differential diagnosis during the COVID-19 epidemic. Excessive inflammation and severe COVID-19 are not essential for TMA development. Early intervention using conventional TMA treatments, such as plasma exchange and corticosteroids, might be important in improving prognosis while differentiating between TTP and atypical hemolytic uremic syndrome. Antihypertensive therapy may be helpful in the treatment of COVID-19-associated TMA.
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Affiliation(s)
- Eriko Masuda
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kazuaki Fukushima
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Yu Hebisawa
- Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Masayuki Tanaka
- Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Akito Ohta
- Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Akifumi Imamura
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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Schieppati F, Russo L, Gamba S, Galimberti E, Giaccherini C, Tartari CJ, Bolognini S, Verzeroli C, Ticozzi C, Barcella L, Marchetti M, Falanga A. Hemostatic Profile and Serological Response of Patients with Immune Thrombotic Thrombocytopenic Purpura after Receiving BNT162b2 Vaccine: A Prospective Study. Thromb Haemost 2023; 123:945-954. [PMID: 37172940 DOI: 10.1055/s-0043-1768921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Coronavirus disease is a clinical challenge for patients with autoimmune conditions. Patients affected by immune thrombotic thrombocytopenic purpura (iTTP) are particularly vulnerable to SARS-CoV-2 infection. Protecting these patients with vaccination is therefore mandatory, although concerns may exist on a possible increased thrombotic risk or risk of disease relapse after vaccine exposure. So far, there is no information on serological response and hemostatic activation in iTTP patients after SARS-CoV-2 vaccination. MATERIALS AND METHODS In this study, in April 2021, we enrolled iTTP patients in clinical remission and on regular outpatient follow-up to receive the first and second dose BNT162b2 vaccine as a part of a prospective trial aimed at monitoring for 6 months after vaccination the occurrence of subclinical laboratory signs of clotting activation, as well as overt thrombotic complications or disease relapse. The seroconversion response was monitored in parallel. The results were compared with those of control non-iTTP subjects. RESULTS A moderate decrease of ADAMTS-13 activity was recorded at 3 and 6 months in five patients with normal values at baseline, while an ADAMTS-13 relapse occurred at 6 months in one patient. Abnormalities in the endothelium activation biomarkers postvaccination were observed in iTTP patients compared with controls. The immunological response to vaccine was overall positive. No clinical iTTP relapses or thrombotic events manifested in the 6 month-follow-up after vaccination. CONCLUSION The results of this study are in favor of efficacy and safety of mRNA vaccines in patients with iTTP, and highlight the importance of long-term monitoring of iTTP patients.
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Affiliation(s)
- Francesca Schieppati
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Laura Russo
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Sara Gamba
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Elisa Galimberti
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Cinzia Giaccherini
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Carmen J Tartari
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Silvia Bolognini
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Cristina Verzeroli
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Chiara Ticozzi
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Barcella
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Marina Marchetti
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Anna Falanga
- Division of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
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Bruzzese A, Vigna E, Terzi D, Greco S, Martino EA, Vangeli V, Mendicino F, Lucia E, Olivito V, Labanca C, Morelli R, Neri A, Morabito F, Zinno F, Mastroianni A, Gentile M. Safe and Effective Administration of Caplacizumab in COVID-19-Associated Thrombotic Thrombocytopenic Purpura. Hematol Rep 2023; 15:448-453. [PMID: 37489376 PMCID: PMC10366750 DOI: 10.3390/hematolrep15030046] [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: 03/27/2023] [Revised: 04/28/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a potentially life-threatening, rare acute thrombotic microangiopathy (TMA), caused by a severe ADAMTS13 deficiency. As the COVID-19 pandemic rapidly spread around the globe, much data about the pathogenicity of this virus were published. Soon after the detection of the first cases of COVID-19, it was clear that there was a wide range of COVID coagulopathy manifestations, such as deep venous thrombosis, pulmonary thromboembolism, and thrombotic microangiopathies. In the literature, little data have been reported about the association between TTP and COVID-19, and the treatment of COVID-19-associated TTP is still under debate. Here we present the case of a 46-year-old woman who developed a COVID-associated TTP, successfully treated with plasma exchange (PEX), steroids, and caplacizumab.
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Affiliation(s)
| | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
| | - Dario Terzi
- Immunohaematology Section, Annunziata Hospital, 87100 Cosenza, Italy
| | - Sonia Greco
- Infectious & Tropical Diseases Unit, Annunziata Hospital, 87100 Cosenza, Italy
| | | | - Valeria Vangeli
- Infectious & Tropical Diseases Unit, Annunziata Hospital, 87100 Cosenza, Italy
| | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
| | - Virginia Olivito
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
| | - Caterina Labanca
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
| | - Rosellina Morelli
- Medicine Department, "Annunziata" Hospital of Cosenza, 87100 Cosenza, Italy
| | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
| | | | - Francesco Zinno
- Immunohaematology Section, Annunziata Hospital, 87100 Cosenza, Italy
| | - Antonio Mastroianni
- Infectious & Tropical Diseases Unit, Annunziata Hospital, 87100 Cosenza, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, 87036 Rende, Italy
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Muacevic A, Adler JR, Yelne P, Gaidhane SA, Kumar S, Acharya S. Thrombotic Thrombocytopenic Purpura Treated Successfully in a COVID-19 Patient Having a Computed Tomography Severity Score of 22/25. Cureus 2022; 14:e33097. [PMID: 36721550 PMCID: PMC9884125 DOI: 10.7759/cureus.33097] [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: 11/20/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
We present a case of a 50-year-old female who came to us with chief complaints of breathlessness, general weakness, and cough. She tested positive for coronavirus disease 2019 (COVID-19) on testing with Reverse Transcription Polymerase Chain Reaction (RT-PCR). She had high resolution computed tomography (HRCT) thorax score of 22/25. On investigation, she had thrombocytopenia with schistocytosis on the peripheral smear and evidence of acute kidney injury. She was diagnosed with thrombotic thrombocytopenic purpura (TTP) and was treated with oral prednisone, plasma exchange, and remdesivir. There was an improvement in clinical as well as biochemical parameters such as lactate dehydrogenase, haemoglobin, and platelet counts. This case report highlights TTP that may be a serious complication in COVID-19 patients, especially with a CT severity score of 22/25. Early diagnosis and intervention can lead to a positive outcome.
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Melissa N, Adit S, Junaid H, Sean D. The perfect storm: Thrombotic thrombocytopenic purpura (TTP) associated with COVID-19, a clinical case series and review. EJHAEM 2022; 3:1358-1364. [PMID: 36467834 PMCID: PMC9713044 DOI: 10.1002/jha2.577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 06/17/2023]
Abstract
This is a case series of three patients in our hospital system who developed acquired thrombotic thrombocytopenic purpura (aTTP) after testing positive for COVID-19 infection. Two patients had acute COVID-19 infections, and one had COVID-19 IgG antibodies consistent with prior COVID-19 infection. Twelve additional cases of aTTP after COVID-19 infection were found in the literature. COVID-19 creates alterations in the vWF-ADAMTS-13 axis with reduced ADAMTS-13 in acute illness that may lead those patients who are predisposed into fulminant aTTP. Further genetic studies are necessary to uncover why some patients with COVID-19 can have concurrent aTTP. For those with a prior COVID-19 infection, molecular mimicry with autoantibodies to ADAMTS-13 is likely the predominant trigger, but having an underlying predisposition (prior episode of TTP, genetic predisposition to autoimmune conditions, or breast cancer history) creates an environment that could be a possible trigger for aTTP.
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Affiliation(s)
- Neumann Melissa
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellManhassetNew YorkUSA
| | - Singhal Adit
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellManhassetNew YorkUSA
| | - Habibullah Junaid
- Division of Hospital Medicine and Division of PulmonaryCritical Care and Sleep MedicineDonald and Barbara Zucker School of Medicine at Hofstra/NorthwellManhassetNew YorkUSA
| | - Dhar Sean
- Division of Hospital Medicine and Division of PulmonaryCritical Care and Sleep MedicineDonald and Barbara Zucker School of Medicine at Hofstra/NorthwellManhassetNew YorkUSA
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8
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Alhomoud M, Alhobayb T, Armitage K. COVID-19 infection triggering Thrombotic Thrombocytopenic Purpura. IDCases 2021; 26:e01256. [PMID: 34458098 PMCID: PMC8383479 DOI: 10.1016/j.idcr.2021.e01256] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/29/2021] [Accepted: 08/21/2021] [Indexed: 01/22/2023] Open
Abstract
We present a 62-year-old gentleman with history of Crohn’s disease, G6PD deficiency, who presented with immune-mediated thrombotic thrombocytopenia purpura (iTTP) one week after the diagnosis of COVID-19 infection. He was admitted with worsening dyspnea, acute renal failure, and profound thrombocytopenia with marked schistocytosis on peripheral smear. ADAMTS13 level was severely deficient. He was treated with oral prednisone, plasma exchange and rituximab with complete clinical resolution. Given the temporal association of this recurrent episode of iTTP with COVID-19 infection and no other discernible cause, COVID-19 infection was the most likely trigger.
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Affiliation(s)
- Mohammad Alhomoud
- Division of Hematology and Oncology, Weill Cornell Medical College, New York, NY, USA
| | - Tamara Alhobayb
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Keith Armitage
- Division of Infectious Diseases, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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9
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Singh B, Kaur P, Mekheal EM, Fasulo S, Maroules M. COVID-19 and thrombotic thrombocytopenic purpura: a review of literature. Hematol Transfus Cell Ther 2021; 43:529-531. [PMID: 34368627 PMCID: PMC8324406 DOI: 10.1016/j.htct.2021.06.009] [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: 04/07/2021] [Accepted: 06/21/2021] [Indexed: 01/07/2023] Open
Affiliation(s)
- Balraj Singh
- Department of Hematology & Oncology Saint Joseph's University Medical Center Paterson, New Jersey, United States
| | - Parminder Kaur
- Department of Cardiology, Saint Joseph's University Medical Center Paterson, New Jersey, United States
| | - Erinie M Mekheal
- Department of Hematology & Oncology Saint Joseph's University Medical Center Paterson, New Jersey, United States
| | - Sydney Fasulo
- Department of Hematology & Oncology Saint Joseph's University Medical Center Paterson, New Jersey, United States
| | - Michael Maroules
- Department of Hematology & Oncology Saint Joseph's University Medical Center Paterson, New Jersey, United States
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Verma DP, Dandu H, Yadav G, Verma SP. Complicated case of COVID-19 disease with overlapping features of thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis. BMJ Case Rep 2021; 14:14/5/e242202. [PMID: 34011641 PMCID: PMC8137254 DOI: 10.1136/bcr-2021-242202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis has been reported as an uncommon complication of severe COVID-19 disease while thrombotic thrombocytopenic purpura has been rarely reported. Here, we are reporting a 21-year-old man who developed a combination of these complications during the hospital stay in the post-COVID-19 recovery period. He presented with fever and bilateral COVID-19-related pneumonia requiring invasive ventilation. His hospital course was complicated by the development of pneumothorax, ventilator-associated pneumonia, thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis. He received remdesivir, IVIG, steroid, fresh frozen plasma and supportive care but had a fatal outcome.
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Affiliation(s)
- Durga Prasad Verma
- Clinical Hematology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Himanshu Dandu
- Medicine, King Georges Medical University, Lucknow, Uttar Pradesh, India
| | - Geeta Yadav
- Pathology, King Georges Medical University, Lucknow, Uttar Pradesh, India
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Affiliation(s)
- Pathum Sookaromdee
- Private Academic Consultant, Bangkok, Thailand
- * Address for Correspondence: Private Academic Consultant, Bangkok, Thailand E-mail:
| | - Viroj Wiwanitkit
- Adjunct Professor, Joseph Ayobabalola University, Ikeji-Arakeji, Nigeria
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