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Karch JL, Okorie CL, Maymone MBC, Laughter M, Vashi NA. Vascular cutaneous manifestations of COVID-19 and RNA viral pathogens: a systematic review. Clin Exp Dermatol 2024; 49:313-324. [PMID: 37936304 DOI: 10.1093/ced/llad377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/27/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND COVID-19, the widely recognized and highly contagious respiratory tract infection, has had a substantial impact on the field of dermatology since its emergence in 2019. SARS-CoV-2, the causative virus of COVID-19, is classified as an RNA virus. Various skin-related symptoms have been reported in patients with COVID-19, most notably the distinctive purple-red acral rash resembling chilblain lesions, commonly referred to as 'COVID toe'; similarly, skin-related symptoms have been observed in connection with other RNA viruses. OBJECTIVES To explore the relationship between RNA viruses and their associated vascular cutaneous manifestations vs. those observed in patients infected with SARS-CoV-2. METHODS A systematic literature review was conducted using PubMed and medical subject heading terms related to RNA viruses and related skin manifestations. RESULTS In total, 3994 patients diagnosed with COVID-19 presenting with skin rashes were included. Chilblain-like lesions were most frequently observed (30.2%), followed by erythematous maculopapular/morbilliform rashes (9.1%) and urticarial rashes (4.7%). Of 8362 patients diagnosed with RNA viruses, more than half of the skin findings reported were erythematous/maculopapular/morbilliform rashes (52.3%), followed by unspecified (11.3%) and purpuric rashes (10.6%). CONCLUSIONS When comparing RNA viral infections with COVID-19 infection, we observed similarities in the reported skin manifestations and their presumed pathways, with many implicated in the proinflammatory response. Owing to the wide range of cutaneous symptoms associated with RNA viruses and our currently limited understanding of the underlying mechanisms, additional research is warranted to investigate the pathology behind viral-induced skin lesions.
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Affiliation(s)
- Jamie L Karch
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Chiamaka L Okorie
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Mayra B C Maymone
- Department of Dermatology, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Melissa Laughter
- Department of Dermatology, New York University, New York, NY, USA
| | - Neelam A Vashi
- Department of Dermatology, Boston University School of Medicine, Boston, MA, USA
- Department of Dermatology, US Department of Veteran Affairs, Boston Health Care System, Boston, MA, USA
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2
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Youness M, Mansour S, Sakr F, Olabi S, Atwi S, Martinez IY, El Khatib S, Hallit S, Salameh P, Malaeb D, Hosseini H. Odds and associated factors for thrombosis development among Lebanese COVID-19 patients: a case-control retrospective study. J Pharm Policy Pract 2024; 17:2319743. [PMID: 38505825 PMCID: PMC10950289 DOI: 10.1080/20523211.2024.2319743] [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] [Indexed: 03/21/2024] Open
Abstract
Background Thromboembolism is reported to be up to 27% in COVID-19 patients due to SARS-CoV-2 infection. Dysregulated systemic inflammation and various patient traits play a vital role in thrombosis progression. Purpose To assess odds and associated factors for thrombosis development among Lebanese COVID-19 patients. Methods This was a case-control retrospective study conducted in January-May 2021. Patients infected with COVID-19 and developed thrombosis were classified as cases and patients who were thrombosis-free identified as control. A questionnaire assessed socio-demographics, clinical parameters, and WHO COVID-19 disease severity. Results Among 267 patients, 26 (9.7%) developed thrombosis and the majority of thrombosis 34.6% was myocardial infarction, and the least (3.8%) was for catheter-related thrombosis. Results showed that the risk of thrombosis development is higher in patients with previous thromboembolic event (OR = 9.160) and previous intake of anti-hypertensive medications at home (OR = 3.116). However, females (OR = 0.330; CI: 0.118-0.925), intake of anticoagulants during hospital admission (OR = 0.126; CI: 0.053-0.300) and non-severe COVID-19 were at lower thrombosis risk (OR = 0.273). Patients who developed thromboembolic events had longer hospital stay (OR = 0.077). Conclusion Patients with COVID-19 and thromboembolism were at higher risk of mortality as compared to patients with COVID-19 but without thromboembolism. The use of anticoagulants significantly reduced the risk for thromboembolism.
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Affiliation(s)
- Mahmoud Youness
- Research Department, Beirut Cardiac Institute, Beirut, Lebanon
| | - Sara Mansour
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Fouad Sakr
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Samer Olabi
- Rafic Hariri University Hospital, Beirut, Lebanon
| | - Sarah Atwi
- Rafic Hariri University Hospital, Beirut, Lebanon
| | | | - Sami El Khatib
- Department of Biomedical Sciences, Lebanese International University, Bekaa, Lebanon
- Center for Applied Mathematics and Bioinformatics (CAMB), Gulf University for Science and Technology, Mubarak Al-Abdullah, Kuwait
| | - Souheil Hallit
- School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
| | - Pascale Salameh
- INSPECT-LB: Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie, Beirut, Lebanon
- Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
- Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
- School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Diana Malaeb
- College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| | - Hassan Hosseini
- Neurology Department, Henri Mondor Hospital, AP-HP, Creteil, France
- UPEC-University Paris-Est, Creteil, France
- RAMSAY SANTÉ, HPPE, Champigny sur Marne, France
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3
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Yang TH, Gao WC, Ma X, Liu Q, Pang PP, Zheng YT, Jia Y, Zheng CB. A Review on The Pathogenesis of Cardiovascular Disease of Flaviviridea Viruses Infection. Viruses 2024; 16:365. [PMID: 38543730 PMCID: PMC10974792 DOI: 10.3390/v16030365] [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: 01/13/2024] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 05/23/2024] Open
Abstract
Members of the Flaviviridae family, encompassing the Flavivirus and Hepacivirus genera, are implicated in a spectrum of severe human pathologies. These diseases span a diverse spectrum, including hepatitis, vascular shock syndrome, encephalitis, acute flaccid paralysis, and adverse fetal outcomes, such as congenital heart defects and increased mortality rates. Notably, infections by Flaviviridae viruses have been associated with substantial cardiovascular compromise, yet the exploration into the attendant cardiovascular sequelae and underlying mechanisms remains relatively underexplored. This review aims to explore the epidemiology of Flaviviridae virus infections and synthesize their cardiovascular morbidities. Leveraging current research trajectories and our investigative contributions, we aspire to construct a cogent theoretical framework elucidating the pathogenesis of Flaviviridae-induced cardiovascular injury and illuminate prospective therapeutic avenues.
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Affiliation(s)
- Tie-Hua Yang
- School of Chinese Materia Medica, Yunnan University of Chinese Medicine, Kunming 650500, China; (T.-H.Y.); (P.-P.P.)
- Key Laboratory of Animal Models and Human Diseases Mechanisms of Chinese Academy of Sciences, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming 650201, China; (X.M.); (Y.-T.Z.)
- Engineering Laboratory of Peptides of Chinese Academy of Sciences, Key Laboratory of Bioactive Peptides of Yunnan Province, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming 650223, China
| | - Wen-Cong Gao
- School of Pharmaceutical Science and Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming 650500, China;
| | - Xin Ma
- Key Laboratory of Animal Models and Human Diseases Mechanisms of Chinese Academy of Sciences, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming 650201, China; (X.M.); (Y.-T.Z.)
- College of Modern Biomedical Industry, Kunming Medical University, Kunming 650500, China
| | - Qian Liu
- School of Pharmacy, Chongqing Medical University, Chongqing 400016, China;
| | - Pan-Pan Pang
- School of Chinese Materia Medica, Yunnan University of Chinese Medicine, Kunming 650500, China; (T.-H.Y.); (P.-P.P.)
- Key Laboratory of Animal Models and Human Diseases Mechanisms of Chinese Academy of Sciences, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming 650201, China; (X.M.); (Y.-T.Z.)
| | - Yong-Tang Zheng
- Key Laboratory of Animal Models and Human Diseases Mechanisms of Chinese Academy of Sciences, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming 650201, China; (X.M.); (Y.-T.Z.)
- Engineering Laboratory of Peptides of Chinese Academy of Sciences, Key Laboratory of Bioactive Peptides of Yunnan Province, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming 650223, China
| | - Yinnong Jia
- School of Pharmaceutical Science and Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming 650500, China;
| | - Chang-Bo Zheng
- School of Pharmaceutical Science and Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming 650500, China;
- College of Modern Biomedical Industry, Kunming Medical University, Kunming 650500, China
- Yunnan Vaccine Laboratory, Kunming 650500, China
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4
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de Oliveira JL, Nogueira IA, Amaral JK, Campos LR, Mendonça MMM, Ricarte MDB, Cavalcanti LPDG, Schoen RT. Extra-articular Manifestations of Chikungunya. Rev Soc Bras Med Trop 2023; 56:0341. [PMID: 38088664 PMCID: PMC10706034 DOI: 10.1590/0037-8682-0341-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
Chikungunya fever (CHIK) is a neglected tropical disease associated with chronic arthritis. CHIK is usually a self-limiting condition; however, extra-articular manifestations present as atypical illness in a minority of patients. These atypical features may mimic other conditions and potentially distract physicians from the true diagnosis. This review analyzes the evidence of many unusual extra-articular manifestations reported in cases of CHIK. Depending on the affected system, these unusual manifestations include encephalitis, myocarditis, acute interstitial nephritis, cutaneous manifestations, acute anterior uveitis, abdominal pain, and depression. In addition, coinfections and comorbidities may cause atypical illness and obscure the diagnosis. Further studies are required to clarify the pathophysiology and natural history of CHIK, as it remains a burdening condition. Exploring its atypical symptoms may be the missing scientific piece of this puzzle.
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Affiliation(s)
- Jobson Lopes de Oliveira
- Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Medicina Clínica, Fortaleza, CE, Brasil
- Centro Universitário Christus, Faculdade de Medicina, Fortaleza, CE, Brasil
| | - Igor Albuquerque Nogueira
- Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Medicina Clínica, Fortaleza, CE, Brasil
| | - J. Kennedy Amaral
- Instituto de Medicina Diagnóstica do Cariri, Juazeiro do Norte, CE, Brasil
| | | | | | | | - Luciano Pamplona de Góes Cavalcanti
- Centro Universitário Christus, Faculdade de Medicina, Fortaleza, CE, Brasil
- Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Saúde Comunitária, Fortaleza, CE, Brasil
| | - Robert T. Schoen
- Yale University School of Medicine, Section of Rheumatology, New Haven, CT, USA
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5
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Vasquez D, Palacio A, Chedraui P, Del Mar Sanchez M, Briones W, Tamariz L, Calle MA. Is Prior Zika Virus Infection Associated With Cardiovascular Disease? Cureus 2023; 15:e47141. [PMID: 38022258 PMCID: PMC10651160 DOI: 10.7759/cureus.47141] [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] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Zika virus (ZIKV) infection is associated with severe complications. Recently, reports have raised the possibility of cardiovascular complications. However, the complications that are reported are in case reports and occur immediately after infection. Our aim is to evaluate the cardiovascular complications of ZIKV infection in a younger patient population. METHODS We conducted a prospective cohort and included patients with a one-year history of prior confirmed ZIKV infection. We performed an echocardiogram, a 24-hour automated blood pressure, and a 24-hour Holter. Our primary outcome included a composite of having diastolic dysfunction, left ventricular hypertrophy, arrhythmias, valvular regurgitation, premature beats, or non-dipper status. RESULTS We included 47 patients with ZIKV and 16 patients without ZIKV. Patients with ZIKV had a similar age as controls (p>0.05). Having had a prior ZIKV infection was associated with diastolic dysfunction, left ventricular hypertrophy, valvular regurgitation, arrhythmias or premature beats, and non-dipper status (p<0.05). The adjusted OR of having the primary outcome was 2.3; 95% CI 1.3-2.7. After one year, IL-10 and C-reactive protein (CRP) were higher in ZIKV-infected patients compared to controls (p<0.05). CONCLUSIONS Our study found that young patients with a prior ZIKV infection have more echocardiographic, arrhythmic, and blood pressure changes when compared to similar-aged controls.
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Affiliation(s)
- Diego Vasquez
- Department of Epidemiology, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | - Ana Palacio
- Population Health and Computational Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Peter Chedraui
- Escuela de Posgrado en Salud, Universidad Espíritu Santo, Samborondón, ECU
| | - Maria Del Mar Sanchez
- Department of Public Health and Epidemiology, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | - Wladimir Briones
- Department of Epidemiology, Ministerio de Salud Publica, Quito, ECU
| | - Leonardo Tamariz
- Population Health and Computational Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Marco A Calle
- Department of Medicine, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
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6
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Zerangian N, Erabi G, Poudineh M, Monajjem K, Diyanati M, Khanlari M, Khalaji A, Allafi D, Faridzadeh A, Amali A, Alizadeh N, Salimi Y, Ghane Ezabadi S, Abdi A, Hasanabadi Z, ShojaeiBaghini M, Deravi N. Venous thromboembolism in viral diseases: A comprehensive literature review. Health Sci Rep 2023; 6:e1085. [PMID: 36778773 PMCID: PMC9900357 DOI: 10.1002/hsr2.1085] [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: 08/30/2022] [Revised: 12/25/2022] [Accepted: 01/19/2023] [Indexed: 02/09/2023] Open
Abstract
Venous thromboembolism (VTE) is known to be a common respiratory and/or cardiovascular complication in hospitalized patients with viral infections. Numerous studies have proven human immunodeficiency virus infection to be a prothrombotic condition. An elevated VTE risk has been observed in critically ill H1N1 influenza patients. VTE risk is remarkably higher in patients infected with the Hepatitis C virus in contrast to uninfected subjects. The elevation of D-dimer levels supported the association between Chikungunya and the Zika virus and the rise of clinical VTE risk. Varicella-zoster virus is a risk factor for both cellulitis and the consequent invasive bacterial disease which may take part in thrombotic initiation. Eventually, hospitalized patients infected with the coronavirus disease of 2019 (COVID-19), the cause of the ongoing worldwide pandemic, could mainly suffer from an anomalous risk of coagulation activation with enhanced venous thrombosis events and poor quality clinical course. Although the risk of VTE in nonhospitalized COVID-19 patients is not known yet, there are a large number of guidelines and studies on thromboprophylaxis administration for COVID-19 cases. This study aims to take a detailed look at the effect of viral diseases on VTE, the epidemiology of VTE in viral diseases, and the diagnosis and treatment of VTE.
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Affiliation(s)
- Nasibeh Zerangian
- Health Education and Health Promotion, Department of Health Education and Health Promotion, School of HealthMashhad University of Medical SciencesMashhadIran
| | - Gisou Erabi
- Student Research CommitteeUrmia University of Medical SciencesUrmiaIran
| | | | - Kosar Monajjem
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Maryam Diyanati
- Student Research CommitteeRafsanjan University of Medical SciencesRafsanjanIran
| | - Maryam Khanlari
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | | | - Diba Allafi
- Student Research CommitteeUrmia University of Medical SciencesUrmiaIran
| | - Arezoo Faridzadeh
- Department of Immunology and Allergy, School of MedicineMashhad University of Medical SciencesMashhadIran,Immunology Research CenterMashhad University of Medical SciencesMashhadIran
| | - Arian Amali
- Student Research Committee, Paramedical DepartmentIslamic Azad University, Mashhad BranchMashhadIran
| | - Nilufar Alizadeh
- Doctor of Medicine (MD), School of MedicineIran University of Medical SciencesTehranIran
| | - Yasaman Salimi
- Student Research CommitteeKermanshah University of Medical SciencesKermanshahIran
| | - Sajjad Ghane Ezabadi
- Student's Scientific Research Center, School of MedicineTehran University of Medical SciencesTehranIran
| | - Amir Abdi
- Student Research Committee, School of Medicine, Tehran Medical SciencesIslamic Azad UniversityTehranIran
| | - Zahra Hasanabadi
- Doctor of Medicine (MD), School of MedicineQazvin University of Medical ScienceQazvinIran
| | - Mahdie ShojaeiBaghini
- Medical Informatics Research Center, Institute for Futures Studies in HealthKerman University of Medical SciencesKermanIran
| | - Niloofar Deravi
- Student Research Committee, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
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7
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Elyaspour Z, Zibaeenezhad MJ, Razmkhah M, Razeghian-Jahromi I. Is It All About Endothelial Dysfunction and Thrombosis Formation? The Secret of COVID-19. Clin Appl Thromb Hemost 2021; 27:10760296211042940. [PMID: 34693754 PMCID: PMC8543709 DOI: 10.1177/10760296211042940] [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] [Indexed: 01/08/2023] Open
Abstract
The world is in a hard battle against COVID-19. Endothelial cells are among the most critical targets of SARS-CoV-2. Dysfunction of endothelium leads to vascular injury following by coagulopathies and thrombotic conditions in the vital organs increasing the risk of life-threatening events. Growing evidences revealed that endothelial dysfunction and consequent thrombotic conditions are associated with the severity of outcomes. It is not yet fully clear that these devastating sequels originate directly from the virus or a side effect of virus-induced cytokine storm. Due to endothelial dysfunction, plasma levels of some biomarkers are changed and relevant clinical manifestations appear as well. Stabilization of endothelial integrity and supporting its function are among the promising therapeutic strategies. Other than respiratory, COVID-19 could be called a systemic vascular disease and this aspect should be scrutinized in more detail in order to reduce related mortality. In the present investigation, the effects of COVID-19 on endothelial function and thrombosis formation are discussed. In this regard, critical players, laboratory findings, clinical manifestation, and suggestive therapies are presented.
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Affiliation(s)
- Zahra Elyaspour
- 48435Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mahboobeh Razmkhah
- 48435Shiraz Institute for Cancer Research, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iman Razeghian-Jahromi
- 48435Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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8
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Massaro G, Lecis D, Martuscelli E, Chiricolo G, Sangiorgi GM. Clinical Features and Management of COVID-19–Associated Hypercoagulability. Card Electrophysiol Clin 2021; 14:41-52. [PMID: 35221084 PMCID: PMC8556574 DOI: 10.1016/j.ccep.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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9
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Cunha MJS, Pinto CAV, Guerra JCDC, Tachibana A, Portugal MFC, Ferraz LJR, Wolosker N. Incidence, diagnosis, treatment methods, and outcomes of clinically suspected venous thromboembolic disease in patients with COVID-19 in a quaternary hospital in Brazil. J Vasc Bras 2021; 20:e20200203. [PMID: 34188671 PMCID: PMC8210641 DOI: 10.1590/1677-5449.200203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/15/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Prothrombotic states have been associated with viral infections and the novel Sars-COV-2 infection has been associated with elevated D-dimer levels, although no causal relation has been clearly established. OBJECTIVES This study presents an epidemiological analysis of manifest VTE episodes in a group of patients hospitalized because of COVID-19. METHODS Medical records of patients who presented symptomatic deep vein thrombosis and/or pulmonary embolism in concomitance with confirmed COVID-19 were retrospectively studied. Demographic characteristics, prevalence of VTE, site of occurrence, D-dimer variation over time, management, and outcomes were analyzed. RESULTS During the study period, 484 confirmed cases of COVID-19 were admitted, 64 of which displayed VTE symptoms and 13 of which had confirmed symptomatic VTE(2.68% of total sample and 20.31% of symptomatic cases). Most cases (76.92%) occurred in intensive care. On the day attributed to VTE onset, D-dimer levels were over 3,000 ng/mL in 8 (80%) patients, a significant increase from baseline admission levels (p < 0.05). A significant decrease was also observed in D-dimer values at hospital discharge (p < 0.05). All patients received pharmacological thromboprophylaxis and/or anticoagulation as indicated. Two deaths occurred during the study, both patients with severe comorbidities. At the end of our study protocol, nine patients had been discharged and two remained hospitalized, but had no signs of VTE worsening. CONCLUSIONS VTE prevalence in hospitalized COVID-19 patients was 2.7%, and higher in intensive care units. Early institution of prophylaxis and immediate full anticoagulation when VTE is diagnosed should be the goals of those who treat this kind of patient.
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Affiliation(s)
| | | | | | | | | | | | - Nelson Wolosker
- Hospital Israelita Albert Einstein – HIAE, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
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10
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de Oliveira JCP, Araujo WJB, Belczak SQ, Erzinger FL, de Oliveira LMP, Marques MA, Sarquis LM, Gutfilen B. Limb ischemia in patients with COVID-19. J Vasc Bras 2021; 20:e20210004. [PMID: 34211543 PMCID: PMC8218822 DOI: 10.1590/1677-5449.210004] [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: 01/14/2023] Open
Abstract
This narrative review covers the life-threatening thromboembolic events associated with SARS-CoV-2 infection/COVID-19. It addresses the physical changes that cause vascular and arterial damage to limbs, laboratory management of coagulation, and management of anticoagulation. COVID-19’s relationship with deep venous thrombosis and arterial thrombosis is also emphasized. The main thromboembolic events described in the literature are illustrated with examples from our experience with COVID-19 patients.
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Affiliation(s)
| | | | - Sergio Quilici Belczak
- Instituto de Aprimoramento e Pesquisa em Angiorradiologia e Cirurgia Endovascular - IAPACE, São Paulo, SP, Brasil
| | | | | | - Marcos Arêas Marques
- Universidade Federal do Estado do Rio de Janeiro - UNIRIO, Rio de Janeiro, RJ, Brasil.,Universidade do Estado do Rio de Janeiro - UERJ, Rio de Janeiro, RJ, Brasil
| | | | - Bianca Gutfilen
- Universidade Federal do Rio de Janeiro - UFRJ, Rio de Janeiro, RJ, Brasil
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11
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Nappi F, Iervolino A, Avtaar Singh SS. Thromboembolic Complications of SARS-CoV-2 and Metabolic Derangements: Suggestions from Clinical Practice Evidence to Causative Agents. Metabolites 2021; 11:341. [PMID: 34070672 PMCID: PMC8229698 DOI: 10.3390/metabo11060341] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 01/08/2023] Open
Abstract
Severe Acute Respiratory Syndrome (SARS) Coronavirus (CoV)-2 is a recently identified positive sense single-strand RNA (ssRNA) β-coronavirus. The viral spike proteins infect human hosts by binding to the cellular receptor angiotensin-converting enzyme 2 (ACE2). The infection causes a systemic illness involving cell metabolism. This widespread involvement is implicated in the pathophysiology of the illness which ranges from mild to severe, requiring multi organ support, ranging from oxygen supplementation to full cardiovascular and respiratory support. Patients with multiple co-existing comorbidities are also at a higher risk. The aim of this review is to explore the exact mechanisms by which COVID-19 affects patients systemically with a primary focus on the bleeding and thrombotic complications linked with the disease. Issues surrounding the thrombotic complications following administration of the ChAdOx1 nCoV-19 (Astra-Zeneca-Oxford) vaccine have also been illustrated. Risk stratification and treatment options in these patients should be tailored according to clinical severity with input from a multidisciplinary team.
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Affiliation(s)
- Francesco Nappi
- Centre Cardiologique du Nord de Saint-Denis, Department of Cardiac Surgery, 93200 Saint-Denis, France
| | - Adelaide Iervolino
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy;
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank G81 4DY, UK;
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12
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Affiliation(s)
- Sarah K Adie
- Department of Clinical Pharmacy, University of Michigan, Victor Vaughan Bldg, 1111 E Catherine St, Rm 305, Ann Arbor, MI, 48109-2054, USA.
| | - Nicholas Farina
- Department of Clinical Pharmacy, University of Michigan, Victor Vaughan Bldg, 1111 E Catherine St, Rm 305, Ann Arbor, MI, 48109-2054, USA
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13
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Raadsen M, Du Toit J, Langerak T, van Bussel B, van Gorp E, Goeijenbier M. Thrombocytopenia in Virus Infections. J Clin Med 2021; 10:jcm10040877. [PMID: 33672766 PMCID: PMC7924611 DOI: 10.3390/jcm10040877] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/10/2021] [Accepted: 02/17/2021] [Indexed: 02/07/2023] Open
Abstract
Thrombocytopenia, which signifies a low platelet count usually below 150 × 109/L, is a common finding following or during many viral infections. In clinical medicine, mild thrombocytopenia, combined with lymphopenia in a patient with signs and symptoms of an infectious disease, raises the suspicion of a viral infection. This phenomenon is classically attributed to platelet consumption due to inflammation-induced coagulation, sequestration from the circulation by phagocytosis and hypersplenism, and impaired platelet production due to defective megakaryopoiesis or cytokine-induced myelosuppression. All these mechanisms, while plausible and supported by substantial evidence, regard platelets as passive bystanders during viral infection. However, platelets are increasingly recognized as active players in the (antiviral) immune response and have been shown to interact with cells of the innate and adaptive immune system as well as directly with viruses. These findings can be of interest both for understanding the pathogenesis of viral infectious diseases and predicting outcome. In this review, we will summarize and discuss the literature currently available on various mechanisms within the relationship between thrombocytopenia and virus infections.
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Affiliation(s)
- Matthijs Raadsen
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
| | - Justin Du Toit
- Department of Haematology, Wits University Donald Gordon Medical Centre Johannesburg, Johannesburg 2041, South Africa;
| | - Thomas Langerak
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
| | - Bas van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Center Plus, 6229 HX Maastricht, The Netherlands;
- Care and Public Health Research Institute (CAPHRI), Maastricht University, 6229 GT Maastricht, The Netherlands
| | - Eric van Gorp
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
- Department of Internal Medicine, Erasmus MC Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Marco Goeijenbier
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
- Department of Internal Medicine, Erasmus MC Rotterdam, 3000 CA Rotterdam, The Netherlands
- Correspondence:
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14
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Ierardi AM, Gaibazzi N, Tuttolomondo D, Fusco S, La Mura V, Peyvandi F, Aliberti S, Blasi F, Cozzi D, Carrafiello G, De Filippo M. Deep vein thrombosis in COVID-19 patients in general wards: prevalence and association with clinical and laboratory variables. Radiol Med 2021; 126:722-728. [PMID: 33469817 PMCID: PMC7815188 DOI: 10.1007/s11547-020-01312-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/15/2020] [Indexed: 12/21/2022]
Abstract
Background Preliminary reports suggest a hypercoagulable state in COVID-19. Deep vein thrombosis (DVT) is perceived as a frequent finding in hospitalized COVID-19 patients, but data describing the prevalence of DVT are lacking. Objectives We aimed to report the prevalence of DVT in COVID-19 patients in general wards, blinded to symptoms/signs of disease, using lower extremities duplex ultrasound (LEDUS) in random patients. We tested the association of DVT with clinical, laboratory and inflammatory markers and also reported on the secondary endpoint of in-hospital mortality. Patients/Methods n = 263 COVID-19 patients were screened with LEDUS between March 01, 2020 and April 05, 2020 out of the overall n = 1012 admitted with COVID-19. Results DVT was detected in n = 67 screened patients (25.5%), n = 41 patients (15.6%) died during the index hospitalization. Multiple logistic regression demonstrated that only C-reactive protein (odds ratio 1.009, 95% CI 1.004–1.013, p < 0.001) was independently associated with the presence of DVT at LEDUS. Both age (odds ratio 1.101, 95% CI 1.054–1.150, p < 0.001) and C-reactive protein (odds ratio 1.012, 95% CI 1.006–1.018, p < 0.001) were instead significantly independently associated with in-hospital mortality. Conclusions The main study finding is that DVT prevalence in COVID-19 patients admitted to general wards is 25.5%, suggesting it may be reasonable to screen COVID-19 patients for this potentially severe but treatable complication, and that inflammation, measured with serum C-reactive protein, is the main variable associated with the presence of DVT, where all other clinical or laboratory variables, age or D-dimer included, are instead not independently associated with DVT.
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Affiliation(s)
- Anna Maria Ierardi
- Radiology Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Nicola Gaibazzi
- Cardiology Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Stefano Fusco
- School of Radiology, University of Milan, Milan, Italy
| | - Vincenzo La Mura
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, U.O.C. Medicina Generale Emostasi e Trombosi, University of Milan, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, U.O.C. Medicina Generale Emostasi e Trombosi, University of Milan, Milan, Italy
| | - Stefano Aliberti
- UOC Pneumologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Francesco Blasi
- UOC Pneumologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Diletta Cozzi
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gianpaolo Carrafiello
- Cardiology Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.,Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Massimo De Filippo
- Department of Medicine and Surgery (DiMeC), Unit of Radiology, University of Parma, Parma, Italy
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15
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Medina-Enríquez MM, Lopez-León S, Carlos-Escalante JA, Aponte-Torres Z, Cuapio A, Wegman-Ostrosky T. ACE2: the molecular doorway to SARS-CoV-2. Cell Biosci 2020; 10:148. [PMID: 33380340 PMCID: PMC7772801 DOI: 10.1186/s13578-020-00519-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/13/2020] [Indexed: 12/18/2022] Open
Abstract
The angiotensin-converting enzyme 2 (ACE2) is the host functional receptor for the new virus SARS-CoV-2 causing Coronavirus Disease 2019. ACE2 is expressed in 72 different cell types. Some factors that can affect the expression of the ACE2 are: sex, environment, comorbidities, medications (e.g. anti-hypertensives) and its interaction with other genes of the renin-angiotensin system and other pathways. Different factors can affect the risk of infection of SARS-CoV-2 and determine the severity of the symptoms. The ACE2 enzyme is a negative regulator of RAS expressed in various organ systems. It is with immunity, inflammation, increased coagulopathy, and cardiovascular disease. In this review, we describe the genetic and molecular functions of the ACE2 receptor and its relation with the physiological and pathological conditions to better understand how this receptor is involved in the pathogenesis of COVID-19. In addition, it reviews the different comorbidities that interact with SARS-CoV-2 in which also ACE2 plays an important role. It also describes the different factors that interact with the virus that have an influence in the expression and functional activities of the receptor. The goal is to provide the reader with an understanding of the complexity and importance of this receptor.
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Affiliation(s)
| | - Sandra Lopez-León
- Global Drug Development, Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
| | | | | | - Angelica Cuapio
- Center of Infectious Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Talia Wegman-Ostrosky
- Department of Basic Research, Instituto Nacional de Cancerología, 22 San Fernando Avenue, Belisario Domínguez Sección XVI, 14080, Mexico City, Mexico.
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16
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Martínez-Sellés M. Editorial commentary: Cardiovascular events after Zika virus infection. Trends Cardiovasc Med 2020; 32:59-60. [PMID: 33279631 DOI: 10.1016/j.tcm.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV. Universidad Europea. Universidad Complutense. Madrid, Spain.
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17
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Chalela R, Caguana O, Zuccarino F, Khilzi K, Rodríguez-Chiaradía DA. Case Report on a Patient with Steinert Disease Complicated by COVID-19. Vasc Health Risk Manag 2020; 16:463-466. [PMID: 33244235 PMCID: PMC7685363 DOI: 10.2147/vhrm.s266659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/29/2020] [Indexed: 01/19/2023] Open
Abstract
SARS-CoV-2 infection is predominantly a respiratory disease with a diverse clinical spectrum. Pulmonary thromboembolic complications during COVID-19 pneumonia may be associated with a high mortality rate and post-mortem findings confirm the presence of platelet-fibrin thrombi in arterial vessels of patients together with lung tissue alterations. We present a patient transferred to the emergency department due to a syncope with no other associated symptoms, who was diagnosed with an acute pulmonary embolism (PE) concomitant with SARS-CoV-2 infection without lung infiltrates. Presenting with a PE as the only manifestation of this infection, reinforces our conception of COVID-19 as a heterogeneous disease of which we still know very little. We believe that while the virus is still circulating in our environment, we need to consider ruling out COVID-19 in all thrombotic events, even if the patients have no other risk factors.
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Affiliation(s)
- Roberto Chalela
- Respiratory Medicine Department, Hospital del Mar, Barcelona, Spain.,Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias(CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Oswaldo Caguana
- Respiratory Medicine Department, Hospital del Mar, Barcelona, Spain.,Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | - Karys Khilzi
- Respiratory Medicine Department, Hospital del Mar, Barcelona, Spain.,Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Diego A Rodríguez-Chiaradía
- Respiratory Medicine Department, Hospital del Mar, Barcelona, Spain.,Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias(CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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18
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Mukherjee A, Ghosh R, Furment MM. Case Report: COVID-19 Associated Renal Infarction and Ascending Aortic Thrombosis. Am J Trop Med Hyg 2020; 103:1989-1992. [PMID: 32918409 PMCID: PMC7646749 DOI: 10.4269/ajtmh.20-0869] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Following its discovery in Wuhan, China, in December 2019, COVID-19 has attained pandemic status in mere months. It is caused by SARS-CoV-2, an enveloped beta coronavirus. This infection causes a prothrombogenic state by interplay of inflammatory mediators, and endothelial, microvascular, and possible hepatic damage and tissue tropism of the virus. This leads to frequent pulmonary and cerebral thromboembolism as well as occasional involvement of other organs. We present a 71-year-old man who initially presented with 2 weeks of fever, cough, and shortness of breath and was diagnosed with COVID-19 pneumonia. He required readmission due to worsened hypoxia and was later found to have left renal artery thrombosis with left kidney infarction, associated with an ascending aortic thrombus. He was anticoagulated and recovered uneventfully. We suggest that physicians have a high degree of suspicion to diagnose and manage the novel manifestations of this disease.
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Affiliation(s)
- Aveek Mukherjee
- Division of Internal Medicine, Rutgers Robert Wood Johnson Medical School/Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Raisa Ghosh
- Division of Internal Medicine, Rutgers Robert Wood Johnson Medical School/Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Marlene Marte Furment
- Division of Internal Medicine, Rutgers Robert Wood Johnson Medical School/Saint Peter's University Hospital, New Brunswick, New Jersey
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19
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Macedo-da-Silva J, Rosa-Fernandes L, Barbosa RH, Angeli CB, Carvalho FR, de Oliveira Vianna RA, Carvalho PC, Larsen MR, Cardoso CA, Palmisano G. Serum Proteomics Reveals Alterations in Protease Activity, Axon Guidance, and Visual Phototransduction Pathways in Infants With In Utero Exposure to Zika Virus Without Congenital Zika Syndrome. Front Cell Infect Microbiol 2020; 10:577819. [PMID: 33312964 PMCID: PMC7708324 DOI: 10.3389/fcimb.2020.577819] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/20/2020] [Indexed: 12/21/2022] Open
Abstract
In 2015, ZIKV infection attracted international attention during an epidemic in the Americas, when neurological disorders were reported in infants who had their mothers exposed to ZIKV during pregnancy. World Health Organization (WHO) epidemiological data show that 5 to 15% of neonates exposed to ZIKV in the uterus have complications included in abnormalities related to Congenital Zika Syndrome (CZS). The risk of complications after birth is not well documented, however, clinical evidence shows that 6% of infants exposed to ZIKV during pregnancy have complications present at birth, and this rate rises to 14% when medical monitoring is performed in all exposed infants, regardless of birth condition. Thus, the evaluation and monitoring of all exposed infants are of foremost importance as the development of late complications has been increasingly supported by clinical evidence. The identification of changes in protein profile of infants exposed to ZIKV without CZS could provide valuable findings to better understand molecular changes in this cohort. Here, we use a shotgun-proteomics approach to investigate alterations in the serum of infants without CZS symptoms but exposed to intrauterine ZIKV (ZIKV) compared to unexposed controls (CTRL). A complex pattern of differentially expressed proteins was identified, highlighting the dysregulation of proteins involved in axon orientation, visual phototransduction, and global protease activity in children exposed to ZIKV without CZS. These data support the importance of monitoring children exposed to ZIKV during gestation and without early CZS symptoms. Our study is the first to assess molecular evidence of possible late disorders in children victims of the ZIKV outbreak in the Americas. We emphasize the importance of medical monitoring of symptomatic and asymptomatic children, as apparently unexplained late neurological and eye disorders may be due to intrauterine ZIKV exposure.
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Affiliation(s)
- Janaina Macedo-da-Silva
- GlycoProteomics Laboratory, Department of Parasitology, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil
- Laboratory for Structural and Computational Proteomics, Carlos Chagas Institute, Fiocruz, Curitiba, Brazil
| | - Lívia Rosa-Fernandes
- GlycoProteomics Laboratory, Department of Parasitology, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Raquel Hora Barbosa
- Maternal and Child Department, School of Medicine, Universidade Federal Fluminense, Niteroi, Brazil
| | - Claudia B. Angeli
- GlycoProteomics Laboratory, Department of Parasitology, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Fabiana Rabe Carvalho
- Maternal and Child Department, School of Medicine, Universidade Federal Fluminense, Niteroi, Brazil
- Multiuser Laboratory for Research in Nephrology and Medical Sciences (LAMAP), School of Medicine, Universidade Federal Fluminense, Niteroi, Brazil
| | - Renata Artimos de Oliveira Vianna
- Maternal and Child Department, School of Medicine, Universidade Federal Fluminense, Niteroi, Brazil
- Multiuser Laboratory for Research in Nephrology and Medical Sciences (LAMAP), School of Medicine, Universidade Federal Fluminense, Niteroi, Brazil
| | - Paulo C. Carvalho
- Laboratory for Structural and Computational Proteomics, Carlos Chagas Institute, Fiocruz, Curitiba, Brazil
| | - Martin R. Larsen
- Department of Biochemistry and Molecular Biology, University of Southern Denmark, Odense, Denmark
| | - Claudete Araújo Cardoso
- Maternal and Child Department, School of Medicine, Universidade Federal Fluminense, Niteroi, Brazil
- Multiuser Laboratory for Research in Nephrology and Medical Sciences (LAMAP), School of Medicine, Universidade Federal Fluminense, Niteroi, Brazil
| | - Giuseppe Palmisano
- GlycoProteomics Laboratory, Department of Parasitology, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil
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20
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Orsi FA, De Paula EV, Santos FDO, Teruchkin MM, Campêlo DHC, Mello TT, Chindamo MC, Macedo AVS, Rocha AT, Ramacciotti E, Nascimento ACK, Annichino-Bizzacchi J, Lourenco DM, Guerra JCDC, Rezende SM, Cavalheiro Filho C. Guidance on diagnosis, prevention and treatment of thromboembolic complications in COVID-19: a position paper of the Brazilian Society of Thrombosis and Hemostasis and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy. Hematol Transfus Cell Ther 2020; 42:300-308. [PMID: 32565232 PMCID: PMC7293502 DOI: 10.1016/j.htct.2020.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/03/2020] [Indexed: 12/15/2022] Open
Abstract
Hemostatic abnormalities and thrombotic risk associated with coronavirus disease 2019 (COVID-19) are among the most discussed topics in the management of this disease. The aim of this position paper is to provide the opinion of Brazilian experts on the thromboprophylaxis and management of thrombotic events in patients with suspected COVID-19, in the sphere of healthcare in Brazil. To do so, the Brazilian Society of Thrombosis and Hemostasis (BSTH) and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy (ABHH) have constituted a panel of experts to carefully review and discuss the available evidence about this topic. The data discussed in this document was reviewed by May 9, 2020. Recommendations and suggestions reflect the opinion of the panel and should be reviewed periodically as new evidence emerges.
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Affiliation(s)
- Fernanda Andrade Orsi
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil.
| | - Erich V De Paula
- Centro de Hematologia e Hemoterapia da Universidade Estadual de Campinas (Hemocentro-Unicamp), Campinas, SP, Brazil
| | | | | | | | | | - Maria Chiara Chindamo
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil; Barra D'Or Hospital, Rede D'Or São Luiz, Rio de Janeiro, RJ, Brazil
| | | | - Ana Thereza Rocha
- Faculdade de Medicina da Bahia da Universidade Federal da Bahia (FMB-UFBA), Salvador, BA, Brazil; Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brazil
| | - Eduardo Ramacciotti
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil; Hospital Christóvão da Gama, Grupo Leforte, Santo André, SP, Brazil; Loyola University Medical Center, Maywood, IL, United States
| | | | - Joyce Annichino-Bizzacchi
- Centro de Hematologia e Hemoterapia da Universidade Estadual de Campinas (Hemocentro-Unicamp), Campinas, SP, Brazil
| | | | - João Carlos de Campos Guerra
- Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil; Centro de Hematologia de São Paulo (CHSP), São Paulo, SP, Brazil
| | - Suely Meireles Rezende
- Faculdade de Medicina da Universidade Federal de Minas Gerais (FM/UFMG), Belo Horizonte, MG, Brazil
| | - Cyrillo Cavalheiro Filho
- Hospital Sírio-libanês, São Paulo, SP, Brazil; Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor FMUSP), São Paulo, SP, Brazil
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21
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Fragkou PC, Thomas K, Sympardi S, Liatsos GD, Pirounaki M, Sambatakou H, Marantos T, Karofylakis E, Dourakis SP, Tsiodras S, Kavvatha D. Clinical characteristics and outcomes of measles outbreak in adults: A multicenter retrospective observational study of 93 hospitalized adults in Greece. J Clin Virol 2020; 131:104608. [PMID: 32877891 PMCID: PMC7448962 DOI: 10.1016/j.jcv.2020.104608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/03/2020] [Accepted: 08/21/2020] [Indexed: 12/23/2022]
Abstract
Measles is an unresolved issue for unvaccinated or incompletely vaccinated adults. Data for outcomes, complications and risk factors in adults are limited. Pneumonitis and hepatic involvement are the most frequent complications in adults. Older age, low lymphocyte count and male sex are associated with pneumonitis. Case fatality ratio in adults is low despite the high frequency of complications.
Objectives Measles outbreaks are increasingly reported among countries that were close-to-eliminate measles infection. There are few reports of clinical characteristics of measles in adults in the contemporary literature. In this study we aim to describe the clinical characteristics and complications of measles infection in hospitalized adults during the recent epidemic in Greece. Methods A multicentre observational retrospective study was conducted in three tertiary hospitals in Greece. All adult hospitalized patients (≥18 years old) with serologically confirmed and/or clinical features compatible with measles were included. Pediatric patients and patients with missing data were excluded. Results In total, 93 patients, 40 males (43 %) and 53 females (57 %), mostly young patients were included. Most of them (87 %) had no past medical history. Among women, 4 were pregnant. 56 (60.2 %) and 25 (26.9 %) patients reported either unknown or incomplete vaccination for measles. Ribavirin was administered in 8 (8.6 %) patients. Pneumonitis and hepatic involvement were the most common complications, occurring in 43 (46.2 %) and 75 (80.6 %) patients respectively. Pneumonitis was significantly associated with male sex, older age, lower lymphocyte counts and higher C-reactive protein (CRP) on admission. One pregnant woman suffered spontaneous fetal miscarriage and one patient died due to acute respiratory distress syndrome (ARDS) and high-risk pulmonary embolism. Conclusion Considerable proportions of incompletely vaccinated or unvaccinated adults have led to the re-emergence of measles in countries with reported close-to-elimination rates. Pneumonitis is a major complication among adults with measles. More studies are imperative in order to explore the role of immune paresis in measles.
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Affiliation(s)
- Paraskevi C Fragkou
- 4thDepartment of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, 12462, Greece.
| | - Konstantinos Thomas
- 4thDepartment of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, 12462, Greece.
| | - Styliani Sympardi
- 1stDepartment of Internal Medicine, Thriasio General Hospital, Elefsis, 19600, Greece.
| | - George D Liatsos
- 2ndDepartment of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, 11527, Greece.
| | - Maria Pirounaki
- 2ndDepartment of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, 11527, Greece.
| | - Helen Sambatakou
- 2ndDepartment of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, 11527, Greece.
| | - Theodoros Marantos
- 4thDepartment of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, 12462, Greece.
| | - Emmanouil Karofylakis
- 4thDepartment of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, 12462, Greece.
| | - Spyridon P Dourakis
- 2ndDepartment of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, 11527, Greece.
| | - Sotirios Tsiodras
- 4thDepartment of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, 12462, Greece.
| | - Dimitra Kavvatha
- 4thDepartment of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, 12462, Greece.
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22
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Martini R. The compelling arguments for the need of microvascular investigation in COVID-19 critical patients. Clin Hemorheol Microcirc 2020; 75:27-34. [PMID: 32568186 PMCID: PMC7458519 DOI: 10.3233/ch-200895] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The burden of pandemic COVID-19 is growing worldwide, as the continuous increases of contagion. Only 10–15% of the entire infected population has the necessity of intensive care unit (ICU) treatments. But, this relatively low rate of patients has absorbed almost the whole availability of ICU during few days, becoming at least in Italy, an emergency for the national health system. In COVID-19 ICU patients massive aggression of lung with severe pulmonary failure, as well as kidney and liver injuries, heart, brain, bowel and spleen damages with lymph nodes necrosis and even cutaneous manifestations have been observed. Moreover, increased levels of cytokines so-called “cytokines storm (CS), and overt intravascular disseminated coagulation have been also reported. The hypercoagulation and CS would speculate about a microvascular dysfunction. Unfortunately, no specific observations have been performed on microcirculatory dysfunction in COVID-19 patients. Hence the presumed pathophysiological pathways and models about a microvascular involvement can be gathered by sepsis models studies. But despite this lack of evidence, the COVID-19 has emphasized the compelling need for microcirculation monitoring at the bedside in ICU patients.
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Affiliation(s)
- Romeo Martini
- Unità Operativa di Angiologia, Azienda Ospedaliera Universitaria di Padova, Padova, Italy
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23
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Djebara S, Henckaerts L, Vanbrabant P. Bilateral Mondor’s disease in chikungunya virus infection. Oxf Med Case Reports 2020; 2020:omaa065. [PMID: 32793369 PMCID: PMC7416827 DOI: 10.1093/omcr/omaa065] [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: 05/25/2020] [Revised: 06/25/2020] [Accepted: 06/28/2020] [Indexed: 11/14/2022] Open
Abstract
Chikungunya virus (CHIKV) is an arthropod-borne virus that is transmitted by Aedes mosquitoes, and its main features are high fever and (debilitating) arthritis. Infection with CHIKV, as well as other viruses, has been associated with hypercoagulable states and may be linked with the development of venous thrombosis. In fact, the development of deep venous thrombosis has been described in CHIKV infection. We present a case of superficial thrombophlebitis of the thoracic wall, known as Mondor’s disease, associated with CHIKV infection. To our knowledge, this probable association has never been described before.
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Affiliation(s)
- Sarah Djebara
- Center for Infectious Diseases, Polyclinic Department, Queen Astrid Military Hospital, Brussels, Belgium
| | - Liesbet Henckaerts
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Peter Vanbrabant
- Center for Infectious Diseases, Polyclinic Department, Queen Astrid Military Hospital, Brussels, Belgium
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
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24
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Thomson TM, Toscano‐Guerra E, Casis E, Paciucci R. C1 esterase inhibitor and the contact system in COVID-19. Br J Haematol 2020; 190:520-524. [PMID: 32531085 PMCID: PMC7323335 DOI: 10.1111/bjh.16938] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/11/2020] [Indexed: 12/25/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is frequently associated with severe systemic consequences, including vasculitis, a hyperinflammatory state and hypercoagulation. The mechanisms leading to these life-threatening abnormalities are multifactorial. Based on the analysis of publicly available interactomes, we propose that severe acute respiratory syndrome coronavirus-2 infection directly causes a deficiency in C1 esterase inhibitor, a pathogen-specific mechanism that may help explain significant systemic abnormalities in patients with COVID-19.
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Affiliation(s)
- Timothy M. Thomson
- Barcelona Institute for Molecular BiologyNational Science Council (IBMB‐CSIC)BarcelonaSpain
- Networked Center for Hepatic and Digestive Diseases (CIBER‐EHD)Instituto Nacional de la Salud Carlos IIIMadridSpain
| | | | - Ernesto Casis
- Clinical Biochemistry ServiceVall d'Hebrón HospitalBarcelonaSpain
| | - Rosanna Paciucci
- Vall d'Hebrón Institute of ResearchBarcelonaSpain
- Clinical Biochemistry ServiceVall d'Hebrón HospitalBarcelonaSpain
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25
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Ramacciotti E, Macedo AS, Biagioni RB, Caffaro RA, Lopes RD, Guerra JC, Orsi FA, Marques MA, Tafur AJ, Caprini JA, Nicolaides A, Carter CA, Filho CC, Fareed J. Evidence-Based Practical Guidance for the Antithrombotic Management in Patients With Coronavirus Disease (COVID-19) in 2020. Clin Appl Thromb Hemost 2020; 26:1076029620936350. [PMID: 32649232 PMCID: PMC7357049 DOI: 10.1177/1076029620936350] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This practical guidance, endorsed by the Brazilian Society of Thrombosis and Hemostasis and The Brazilian Society of Angiology and Vascular Surgery, the International Union of Angiology and the European Venous Forum, aims to provide physicians with clear guidance, based on current best evidence-based data, on clinical strategies to manage antithrombotic strategies in patients with coronavirus disease 2019.
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Affiliation(s)
- Eduardo Ramacciotti
- Hospital Christóvão da Gama, Grupo Leforte, Santo André, São Paulo, Brazil.,Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, São Paulo, Brazil.,Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | | | | | | | - Renato Delascio Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - João Carlos Guerra
- Hospital Israelita Albert Einstein, São Paulo, Brazil.,Centro de Hematologia de São Paulo, São Paulo, Brazil
| | | | - Marcos Areas Marques
- School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Andrew Nicolaides
- Vascular Screening and Diagnostic Centre and University of Nicosia Medical School, Nicosia, Cyprus
| | - Charles A Carter
- Department of Clinical Research, College of Pharmacy & Health Sciences, Campbell University, NC, USA
| | - Cyrillo Carvalheiro Filho
- Hospital Sirio-Libanês, São Paulo, Brazil.,Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Jawed Fareed
- Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
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26
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Guler N, Siddiqui F, Fareed J. Is the Reason of Increased D-Dimer Levels in COVID-19 Because of ACE-2-Induced Apoptosis in Endothelium? Clin Appl Thromb Hemost 2020; 26:1076029620935526. [PMID: 32659106 PMCID: PMC7359650 DOI: 10.1177/1076029620935526] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Nil Guler
- Department of Hematology, Medical School, Pamukkale University, Denizli, Turkey
| | - Fakiha Siddiqui
- Department of Pathology, Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Jawed Fareed
- Department of Pathology and Laboratory Medicine, Department of Pharmacology and Neuroscience, Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
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27
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 and (select (case when (5705=1121) then null else ctxsys.drithsx.sn(1,5705) end) from dual) is null-- ehdm] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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29
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 and (select (case when (2527=2527) then null else ctxsys.drithsx.sn(1,2527) end) from dual) is null] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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31
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 and 4130=(select upper(xmltype(chr(60)||chr(58)||chr(113)||chr(122)||chr(118)||chr(107)||chr(113)||(select (case when (4130=4130) then 1 else 0 end) from dual)||chr(113)||chr(106)||chr(98)||chr(106)||chr(113)||chr(62))) from dual)-- dlpk] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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32
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 rlike (select (case when (3027=3027) then 0x31302e313033382f7334313539312d3032302d303936382d33 else 0x28 end))-- ezyj] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 and 2832 in (select (char(113)+char(122)+char(118)+char(107)+char(113)+(select (case when (2832=2832) then char(49) else char(48) end))+char(113)+char(106)+char(98)+char(106)+char(113)))-- enfp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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35
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37
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 and 7056=3908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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38
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 and 3729=3729-- zcki] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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42
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 rlike (select (case when (2548=8312) then 0x31302e313033382f7334313539312d3032302d303936382d33 else 0x28 end))-- pcpc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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45
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 and (select 8647 from(select count(*),concat(0x717a766b71,(select (elt(8647=8647,1))),0x716a626a71,floor(rand(0)*2))x from information_schema.plugins group by x)a)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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47
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 and 3417=convert(int,(select char(113)+char(122)+char(118)+char(107)+char(113)+(select (case when (3417=3417) then char(49) else char(48) end))+char(113)+char(106)+char(98)+char(106)+char(113)))] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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48
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49
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Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med 2020. [DOI: 10.1038/s41591-020-0968-3 order by 1-- jhum] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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50
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