Anemia in patients with Covid-19: pathogenesis and clinical significance

High- vs regular-dose recombinant human thrombopoietin plus cyclosporine A in patients with newly diagnosed non-severe aplastic anemia: a retrospective cohort study

BACKGROUND

Cyclosporine A (CsA) and regular doses of recombinant human thrombopoietin (rhTPO) can accelerate platelet recovery in patients with non-severe aplastic anemia (NSAA). However, it is unclear whether CsA plus rhTPO at a higher dose can further increase the efficacy.

METHODS

Data from patients with newly diagnosed NSAA, who had been treated with CsA in combination with different doses of rhTPO between February 2021 and August 2021 at Peking Union Medical College Hospital, were reviewed. All the enrolled patients had been treated with CsA at 3-5 mg/(kg/d), and patients were further classified into high-dose (with rhTPO 30000U qd × 14 days for 2 months) group or regular-dose (with rhTPO 15000U qd × 7days for 3 months) group. The treatment response and therapy-related adverse events were compared.

RESULTS

36 patients including 16 (44.4%) in the high-dose and 20 (55.6%) in the regular-dose group were enrolled. The baseline characteristics were compatible between the two groups. The platelet counts were significantly higher at 1/3/6 months in the high-dose group (p = 0.028, 0.0063 and p = 0.040, respectively). The high-dose group had a significantly shorter time to platelet transfusion independence ([1 (0.5-6) months vs 2.5 (1-12) months, p = 0.040]). There was no significant difference in overall response and complete response rate between the two groups at 1/3/6/12 months (p > 0.05). Treatment-related morbidities were similar between the two groups (p > 0.05).

CONCLUSIONS

Adding a higher dose of rhTPO can further accelerate platelet recovery and platelet transfusion independence in patients with newly diagnosed NSAA.

COVID-19 and β-thalassemia: in lieu of evidence and vague nexus

Coronavirus disease 19 (COVID-19) is an infectious disease caused by severe acute respiratory coronavirus 2 (SARS-CoV-2) causing acute systemic disorders and multi-organ damage. β-thalassemia (β-T) is an autosomal recessive disorder leading to the development of anemia. β-T may lead to complications such as immunological disorders, iron overload, oxidative stress, and endocrinopathy. β-T and associated complications may increase the risk of SARS-CoV-2, as inflammatory disturbances and oxidative stress disorders are linked with COVID-19. Therefore, the objective of the present review was to elucidate the potential link between β-T and COVID-19 regarding the underlying comorbidities. The present review showed that most of the β-T patients with COVID-19 revealed mild to moderate clinical features, and β-T may not be linked with Covid-19 severity. Though patients with transfusion-dependent β-T (TDT) develop less COVID-19 severity compared to non-transfusion-depend β-T(NTDT), preclinical and clinical studies are recommended in this regard.

Assessing the Diagnostic Values of the Neutrophil-to-Lymphocyte Ratio (NLR) and Systematic Immunoinflammatory Index (SII) as Biomarkers in Predicting COVID-19 Severity: A Multicentre Comparative Study

COVID-19 has been notoriously unpredictable in its clinical course. Such unpredictability poses a challenge to clinicians in predicting patients who will develop severe cases and possibly die from the infection. This study aims to assess and compare the diagnostic value of the NLR and SII as biomarkers in predicting COVID-19 severity, represented by mortality, with a multicentre comparative study including 855 patients in Saudi Arabia. Descriptive and analytical statistics were used to compare haematological indices between survivors and non-survivors. The median age of patients included was 41 years old, with an almost equal ratio of men to women. Most participants were Saudis, and the mortality rate in the study cohort was 13.22%. Non-survivors, as compared to survivors, were significantly older, had lower RBC counts, haemoglobin and haematocrit levels, as well as significantly higher WBC and neutrophil counts. Both the NLR and SII were capable of differentiating between survivors and non-survivors, with the latter having significantly higher values. However, the NLR was superior to the SII in such differentiation, as it had a larger area under the curve. This study further confirms the diagnostic values of the NLR and SII as biomarkers in predicting COVID-19 severity and mortality, with the NLR being more sensitive and specific. Clinical guidelines on managing COVID-19 cases should benefit from these findings by harnessing the value of the NLR in COVID-19 management.

Precision nutrition to reset virus-induced human metabolic reprogramming and dysregulation (HMRD) in long-COVID

SARS-CoV-2, the etiological agent of COVID-19, is devoid of any metabolic capacity; therefore, it is critical for the viral pathogen to hijack host cellular metabolic machinery for its replication and propagation. This single-stranded RNA virus with a 29.9 kb genome encodes 14 open reading frames (ORFs) and initiates a plethora of virus-host protein-protein interactions in the human body. These extensive viral protein interactions with host-specific cellular targets could trigger severe human metabolic reprogramming/dysregulation (HMRD), a rewiring of sugar-, amino acid-, lipid-, and nucleotide-metabolism(s), as well as altered or impaired bioenergetics, immune dysfunction, and redox imbalance in the body. In the infectious process, the viral pathogen hijacks two major human receptors, angiotensin-converting enzyme (ACE)-2 and/or neuropilin (NRP)-1, for initial adhesion to cell surface; then utilizes two major host proteases, TMPRSS2 and/or furin, to gain cellular entry; and finally employs an endosomal enzyme, cathepsin L (CTSL) for fusogenic release of its viral genome. The virus-induced HMRD results in 5 possible infectious outcomes: asymptomatic, mild, moderate, severe to fatal episodes; while the symptomatic acute COVID-19 condition could manifest into 3 clinical phases: (i) hypoxia and hypoxemia (Warburg effect), (ii) hyperferritinemia ('cytokine storm'), and (iii) thrombocytosis (coagulopathy). The mean incubation period for COVID-19 onset was estimated to be 5.1 days, and most cases develop symptoms after 14 days. The mean viral clearance times were 24, 30, and 39 days for acute, severe, and ICU-admitted COVID-19 patients, respectively. However, about 25-70% of virus-free COVID-19 survivors continue to sustain virus-induced HMRD and exhibit a wide range of symptoms that are persistent, exacerbated, or new 'onset' clinical incidents, collectively termed as post-acute sequelae of COVID-19 (PASC) or long COVID. PASC patients experience several debilitating clinical condition(s) with >200 different and overlapping symptoms that may last for weeks to months. Chronic PASC is a cumulative outcome of at least 10 different HMRD-related pathophysiological mechanisms involving both virus-derived virulence factors and a multitude of innate host responses. Based on HMRD and virus-free clinical impairments of different human organs/systems, PASC patients can be categorized into 4 different clusters or sub-phenotypes: sub-phenotype-1 (33.8%) with cardiac and renal manifestations; sub-phenotype-2 (32.8%) with respiratory, sleep and anxiety disorders; sub-phenotype-3 (23.4%) with skeleto-muscular and nervous disorders; and sub-phenotype-4 (10.1%) with digestive and pulmonary dysfunctions. This narrative review elucidates the effects of viral hijack on host cellular machinery during SARS-CoV-2 infection, ensuing detrimental effect(s) of virus-induced HMRD on human metabolism, consequential symptomatic clinical implications, and damage to multiple organ systems; as well as chronic pathophysiological sequelae in virus-free PASC patients. We have also provided a few evidence-based, human randomized controlled trial (RCT)-tested, precision nutrients to reset HMRD for health recovery of PASC patients.

Peripheral blood indicators and COVID-19: an observational and bidirectional Mendelian randomization study

Blood is critical for health, supporting key functions like immunity and oxygen transport. While studies have found links between common blood clinical indicators and COVID-19, they cannot provide causal inference due to residual confounding and reverse causality. To identify indicators affecting COVID-19, we analyzed clinical data (n = 2,293, aged 18-65 years) from Guangzhou Medical University's first affiliated hospital (2022-present), identifying 34 significant indicators differentiating COVID-19 patients from healthy controls. Utilizing bidirectional Mendelian randomization analyses, integrating data from over 2.46 million participants from various large-scale studies, we established causal links for six blood indicators with COVID-19 risk, five of which is consistent with our observational findings. Specifically, elevated Troponin I and Platelet Distribution Width levels are linked with increased COVID-19 susceptibility, whereas higher Hematocrit, Hemoglobin, and Neutrophil counts confer a protective effect. Reverse MR analysis confirmed four blood biomarkers influenced by COVID-19, aligning with our observational data for three of them. Notably, COVID-19 exhibited a positive causal relationship with Troponin I (Tnl) and Serum Amyloid Protein A, while a negative association was observed with Plateletcrit. These findings may help identify high-risk individuals and provide further direction on the management of COVID-19.

Glycated albumin in the detection of diabetes during COVID-19 hospitalization

BACKGROUND

Diabetes has emerged as an important risk factor for COVID-19 adverse outcomes during hospitalization. We investigated whether the measurement of glycated albumin (GA) may be useful in detecting newly diagnosed diabetes during COVID-19 hospitalization.

METHODS

In this cross-sectional test accuracy study we evaluated HCPA Biobank data and samples from consecutive in-patients, from 30 March 2020 to 20 December 2020. ROC curves were used to analyse the performance of GA to detect newly diagnosed diabetes (patients without a previous diagnosis of diabetes and admission HbA1c ≥6.5%).

RESULTS

A total of 184 adults (age 58.6 ± 16.6years) were enrolled, including 31 with newly diagnosed diabetes. GA presented AUCs of 0.739 (95% CI 0.642-0.948) to detect newly diagnosed diabetes. The GA cut-offs of 19.0% was adequate to identify newly diagnosed diabetes with high specificity (85.0%) but low sensitivity (48.4%).

CONCLUSIONS

GA showed good performance to identify newly diagnosed diabetes and may be useful for identifying adults with the condition in COVID-19-related hospitalization.

Iron dysregulation and inflammatory stress erythropoiesis associates with long-term outcome of COVID-19

Persistent symptoms following SARS-CoV-2 infection are increasingly reported, although the drivers of post-acute sequelae (PASC) of COVID-19 are unclear. Here we assessed 214 individuals infected with SARS-CoV-2, with varying disease severity, for one year from COVID-19 symptom onset to determine the early correlates of PASC. A multivariate signature detected beyond two weeks of disease, encompassing unresolving inflammation, anemia, low serum iron, altered iron-homeostasis gene expression and emerging stress erythropoiesis; differentiated those who reported PASC months later, irrespective of COVID-19 severity. A whole-blood heme-metabolism signature, enriched in hospitalized patients at month 1-3 post onset, coincided with pronounced iron-deficient reticulocytosis. Lymphopenia and low numbers of dendritic cells persisted in those with PASC, and single-cell analysis reported iron maldistribution, suggesting monocyte iron loading and increased iron demand in proliferating lymphocytes. Thus, defects in iron homeostasis, dysregulated erythropoiesis and immune dysfunction due to COVID-19 possibly contribute to inefficient oxygen transport, inflammatory disequilibrium and persisting symptomatology, and may be therapeutically tractable.

COVID-19 in patients with anemia and haematological malignancies: risk factors, clinical guidelines, and emerging therapeutic approaches

Extensive research in countries with high sociodemographic indices (SDIs) to date has shown that coronavirus disease 2019 (COVID-19) may be directly associated with more severe outcomes among patients living with haematological disorders and malignancies (HDMs). Because individuals with moderate to severe immunodeficiency are likely to undergo persistent infections, shed virus particles for prolonged periods, and lack an inflammatory or abortive phase, this represents an overall risk of morbidity and mortality from COVID-19. In cases suffering from HDMs, further investigation is needed to achieve a better understanding of triviruses and a group of related variants in patients with anemia and HDMs, as well as their treatment through vaccines, drugs, and other methods. Against this background, the present study aimed to delineate the relationship between HDMs and the novel COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Besides, effective treatment options for HDM cases were further explored to address this epidemic and its variants. Therefore, learning about how COVID-19 manifests in these patients, along with exploiting the most appropriate treatments, may lead to the development of treatment and care strategies by clinicians and researchers to help patients recover faster. Video Abstract.

COVID-19 impairs oxygen delivery by altering red blood cell hematological, hemorheological, and oxygen transport properties

Introduction: Coronavirus disease 2019 (COVID-19) is characterized by impaired oxygen (O2) homeostasis, including O2 sensing, uptake, transport/delivery, and consumption. Red blood cells (RBCs) are central to maintaining O2 homeostasis and undergo direct exposure to coronavirus in vivo. We thus hypothesized that COVID-19 alters RBC properties relevant to O2 homeostasis, including the hematological profile, Hb O2 transport characteristics, rheology, and the hypoxic vasodilatory (HVD) reflex. Methods: RBCs from 18 hospitalized COVID-19 subjects and 20 healthy controls were analyzed as follows: (i) clinical hematological parameters (complete blood count; hematology analyzer); (ii) O2 dissociation curves (p50, Hill number, and Bohr plot; Hemox-Analyzer); (iii) rheological properties (osmotic fragility, deformability, and aggregation; laser-assisted optical rotational cell analyzer (LORRCA) ektacytometry); and (iv) vasoactivity (the RBC HVD; vascular ring bioassay). Results: Compared to age- and gender-matched healthy controls, COVID-19 subjects demonstrated 1) significant hematological differences (increased WBC count-with a higher percentage of neutrophils); RBC distribution width (RDW); and reduced hematocrit (HCT), Hb concentration, mean corpuscular volume (MCV), and mean corpuscular hemoglobin concentration (MCHC); 2) impaired O2-carrying capacity and O2 capacitance (resulting from anemia) without difference in p50 or Hb-O2 cooperativity; 3) compromised regulation of RBC volume (altered osmotic fragility); 4) reduced RBC deformability; 5) accelerated RBC aggregation kinetics; and (6) no change in the RBC HVD reflex. Discussion: When considered collectively, homeostatic compensation for these RBC impairments requires that the cardiac output in the COVID cohort would need to increase by ∼135% to maintain O2 delivery similar to that in the control cohort. Additionally, the COVID-19 disease RBC properties were found to be exaggerated in blood-type O hospitalized COVID-19 subjects compared to blood-type A. These data indicate that altered RBC features in hospitalized COVID-19 subjects burden the cardiovascular system to maintain O2 delivery homeostasis, which appears exaggerated by blood type (more pronounced with blood-type O) and likely plays a role in disease pathogenesis.

Haematological sequelae in the post-acute phase of symptomatic SARS-CoV-2 infection

Many patients surviving SARS-CoV-2 infection suffer from long-term symptoms (long COVID or post COVID) such as shortness of breath, fatigue, loss of taste or smell and cognitive deterioration. However, few data are available concerning blood cell counts and haematological parameters during the post-COVID period. We analysed haematological data from 83 patients previously admitted to the internal medicine unit of our institution because of symptomatic SARS-CoV-2 infection; all data were obtained within 1-12 months from disease onset. A control group of 70 apparently healthy, age- and sex-matched COVID-19 negative individuals was assessed for comparison. Blood cell counts improved in the post-COVID period, but 81% of patients had persistent abnormalities, compared with 50% in the control group, p < 0.001. Most common haematological findings included anaemia (40%), reduced lymphocyte (43%) or eosinophil counts (38%) and low IgM memory B cells and correlated with advanced age, number of chronic comorbidities, female gender, altered renal function, reduced baseline Hb and procalcitonin concentrations and increased RDW. Data on lymphocytes and IgM memory B cells show that impaired immune responses may persist for up to one year in the post-COVID period, possibly contributing to long-term symptoms, especially in female patients.

Factors related to serum levels of intercellular adhesion molecule-1 in probable COVID-19 patients in surgical treatment: an observational study

Introduction

COVID-19 causes a systemic inflammatory response, involving dysregulation and misexpression of many inflammatory cytokines. The recruitment and activation of inflammatory cells depend on the expression of many classes of inflammatory mediators, with increased expression of endothelial cell adhesion molecules being related to COVID-19 disease severity. With the World Health Organization having recently updated case definitions to suspect, probable, and confirmed, this study aimed to measure the mean value of intercellular adhesion molecule 1 (ICAM-1) and its relation to suspected COVID-19.

Methods

all suspected patients (n=20) were hospitalized and treated following the Indonesian National Guidelines for COVID-19 management. ICAM-1 levels were measured on days 1 and 7, demographic data were recorded, and routine blood count values were measured and additionally considered.

Results

the results showed that the levels of ICAM-1 in the 1st-day group (mean 271.3 ng/ml) were higher than those in the 7th-day group (mean 253.9 ng/ml). This difference was statistically significant (p = 0.00, p ≤ 0.05). All of the patients with suspected COVID-19 were included in this study and tested for COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) testing. A total of 10 patients were confirmed positive with a COVID-19 infection, with elevated ICAM-1 levels compared to the confirmed negative patients (with a mean 1st day 296.8 versus a mean 7th day 279.0 ng/ml). ICAM-1 levels of all patients decreased by the seventh day.

Conclusion

the mean value of ICAM-1 levels for patients with confirmed positive COVID-19 cases was higher than those with suspected COVID-19 cases.

Online COVID-19 diagnosis prediction using complete blood count: an innovative tool for public health

BACKGROUND

COVID-19, caused by SARS-CoV-2, presents distinct diagnostic challenges due to its wide range of clinical manifestations and the overlapping symptoms with other common respiratory diseases. This study focuses on addressing these difficulties by employing machine learning (ML) methodologies, particularly the XGBoost algorithm, to utilize Complete Blood Count (CBC) parameters for predictive analysis.

METHODS

We performed a retrospective study involving 2114 COVID-19 patients treated between December 2022 and January 2023 at our healthcare facility. These patients were classified into fever (1057 patients) and pneumonia groups (1057 patients), based on their clinical symptoms. The CBC data were utilized to create predictive models, with model performance evaluated through metrics like Area Under the Receiver Operating Characteristics Curve (AUC), accuracy, sensitivity, specificity, and precision. We selected the top 10 predictive variables based on their significance in disease prediction. The data were then split into a training set (70% of patients) and a validation set (30% of patients) for model validation.

RESULTS

We identified 31 indicators with significant disparities. The XGBoost model outperformed others, with an AUC of 0.920 and high precision, sensitivity, specificity, and accuracy. The top 10 features (Age, Monocyte%, Mean Platelet Volume, Lymphocyte%, SIRI, Eosinophil count, Platelet count, Hemoglobin, Platelet Distribution Width, and Neutrophil count.) were crucial in constructing a more precise predictive model. The model demonstrated strong performance on both training (AUC = 0.977) and validation (AUC = 0.912) datasets, validated by decision curve analysis and calibration curve.

CONCLUSION

ML models that incorporate CBC parameters offer an innovative and effective tool for data analysis in COVID-19. They potentially enhance diagnostic accuracy and the efficacy of therapeutic interventions, ultimately contributing to a reduction in the mortality rate of this infectious disease.

SARS-CoV-2 infection induces expression and secretion of lipocalin-2 and regulates iron in a human lung cancer xenograft model

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection leads to various clinical symptoms including anemia. Lipocalin-2 has various biological functions, including defense against bacterial infections through iron sequestration, and it serves as a biomarker for kidney injury. In a human protein array, we observed increased lipocalin-2 expression due to parental SARS-CoV-2 infection in the Calu-3 human lung cancer cell line. The secretion of lipocalin-2 was also elevated in response to parental SARS-CoV-2 infection, and the SARS-CoV-2 Alpha, Beta, and Delta variants similarly induced this phenomenon. In a Calu-3 implanted mouse xenograft model, parental SARSCoV- 2 and Delta variant induced lipocalin-2 expression and secretion. Additionally, the iron concentration increased in the Calu-3 tumor tissues and decreased in the serum due to infection. In conclusion, SARS-CoV-2 infection induces the production and secretion of lipocalin-2, potentially resulting in a decrease in iron concentration in serum. Because the concentration of iron ions in the blood is associated with anemia, this phenomenon could contribute to developing anemia in COVID-19 patients. [BMB Reports 2023; 56(12): 669-674].

Role of Metals on SARS-CoV-2 Infection: a Review of Recent Epidemiological Studies

PURPOSE OF REVIEW

Metals and metalloids are known for their nutritional as well as toxic effects in humans. In the context of the SARS-CoV-2 pandemic, understanding the role of metals on COVID-19 infection is becoming important due to their role in infectious diseases. During the past 2 years, a significant number of studies have examined the impact of metals and metalloids on COVID-19 morbidity and mortality. We conducted a systematic review of peer-reviewed manuscripts on the association of metals and metalloids with SARS-CoV-2 infection and COVID-19 severity published since the onset of the pandemic.

RECENT FINDINGS

We searched for epidemiological studies available through the PubMed database published from January 2020 to December 2022. Of 92 studies identified, 20 met our inclusion criteria. These articles investigated the association of zinc (Zn), iron (Fe), selenium (Se), manganese (Mn), cadmium (Cd), arsenic (As), copper (Cu), magnesium (Mg), chromium (Cr), and/or lead (Pb) levels on SARS-CoV-2 infection and/or COVID-19 severity. Of the ten metals and metalloids of interest that reported either positive, negative, or no associations, Zn yielded the highest number of articles (n = 13), followed by epidemiological studies on Se (n = 7) and Fe (n = 5). Elevated serum Zn and Se were associated with reduced COVID-19 severity and mortality. Similarly, higher levels of serum Fe were associated with lower levels of cellular damage and symptoms of SARS-CoV-2 infection and with faster recovery from COVID-19. On the other hand, higher serum and urinary Cu and serum Mg levels were associated with higher COVID-19 severity and mortality. Along with the positive or negative effects, some studies reported no impact of metals on SARS-CoV-2 infection. This systematic review suggests that metals, particularly Zn, Fe, and Se, may help reduce the severity of COVID-19, while Cu and Mg may aggravate it. Our review suggests that future pandemic mitigation strategies may evaluate the role of Zn, Se, and Fe as potential therapeutic interventions.

It's in the blood: a review of the hematological system in SARS-CoV-2-associated COVID-19

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented global healthcare crisis. While SARS-CoV-2-associated COVID-19 affects primarily the respiratory system, patients with COVID-19 frequently develop extrapulmonary manifestations. Notably, changes in the hematological system, including lymphocytopenia, neutrophilia and significant abnormalities of hemostatic markers, were observed early in the pandemic. Hematological manifestations have since been recognized as important parameters in the pathophysiology of SARS-CoV-2 and in the management of patients with COVID-19. In this narrative review, we summarize the state-of-the-art regarding the hematological and hemostatic abnormalities observed in patients with SARS-CoV-2-associated COVID-19, as well as the current understanding of the hematological system in the pathophysiology of acute and chronic SARS-CoV-2-associated COVID-19.

Adverse Drug Events Associated With Remdesivir in Real-World Hospitalized Patients With COVID-19, Including Vulnerable Populations: A Retrospective Multicenter Study

BACKGROUND

Remdesivir is a US Food and Drug Administration-approved drug for coronavirus disease 2019 (COVID-19). Clinical trials were conducted under strictly controlled situations for a selected population, and their reported adverse events may not fully represent conditions in real-world patients. We aimed to estimate the incidence of adverse drug events (ADEs) associated with remdesivir in hospitalized patients with COVID-19, including vulnerable subpopulations, such as those with impaired renal or hepatic function and pregnant women.

METHODS

This retrospective observational study included hospitalized patients with confirmed COVID-19 treated with remdesivir between January and December 2021 at ten hospitals. ADEs and severe ADEs (Common Toxicity Criteria for Adverse Events grade ≥ 3) were operationally defined and analyzed through laboratory investigations. The incidence of ADEs was compared with that of each matched control in subpopulations with renal or hepatic impairment and pregnant women.

RESULTS

Among 2,140 patients, 1,416 (66.2%) and 295 (13.8%) experienced at least one ADE and severe ADE, respectively. The most frequent ADE was 'hepatic injury' (42.9%), followed by anemia (27.6%). The most common severe ADEs were 'hypokalemia' (5.3%), 'hepatic injury' (2.9%), and 'anemia' (3.6%). There was no significant difference in the incidence of ADEs in patients relative to their respective matched-control groups, including those with renal impairment (80.0% vs. control 71.8%, P = 0.063), hepatic impairment (70.4% vs. control 75.0%, P = 0.623) and pregnant women (78.6% vs. control 63.7%, P = 0.067). However, severe ADE incidence was significantly higher in patients with renal impairment (40.8% vs. 16.0%, P < 0.001). The most common severe ADEs in those were 'anemia' (15.3%), 'hypokalemia' (10.5%), and 'thrombocytopenia' (8.9%). There was no statistically significant difference in the incidence of severe ADEs in patients with hepatic impairment or in pregnancy (P = 0.230; P = 0.085).

CONCLUSION

A significant proportion of patients with COVID-19 treated with remdesivir experienced ADEs and severe ADEs. Given the high incidence of severe ADEs, caution is required in patients with renal impairment. Further studies are needed to investigate ADEs in pregnant women and patients with hepatic impairment.

Nutritional deficiency anemia and post-acute sequelae in patients with severe acute respiratory syndrome coronavirus 2 infection: A six-month retrospective cohort analysis of 30 892 patients

The effect of anemia on the post-acute outcome of patients with severe acute respiratory syndrome coronavirus 2 infection was unclear. This study aimed to investigate the potential association between nutritional deficiency anemia (NDA) status and post-acute sequelae of patients with SARS-CoV-2 infection. This retrospective cohort study included patients with coronavirus disease (COVID-19) from January 1, 2022 to November 30, 2022 using the TriNetX research network. The patients were grouped into the NDA group comprising patients diagnosed with NDA and the control group comprising patients without NDA, and propensity score matching (PSM) was performed to balance the two groups. The primary outcome was a composite of post-COVID-19 condition, all-cause hospitalization, and all-cause death. The secondary outcomes were any individual outcomes of the primary composite. The follow-up period was set at 90-180 days after COVID-19 diagnosis. Two cohorts comprising 15 446 nonhospitalized patients with COVID-19 in each group with balanced baseline characteristics were created using PSM. During the follow-up period, the NDA group demonstrated a higher risk of the composite primary outcome, including post-COVID-19 condition, all-cause hospitalization, or all-cause death (hazard ratio [HR], 1.896; 95% confidence interval [CI] =  1.757-2.045). Regarding secondary outcomes, the NDA group was associated with worse outcomes, including post-COVID-19 condition (HR, 1.992; 95% CI = 1.403-2.828), all-cause hospitalization (HR, 1.856; 95% CI = 1.714-2.009), and all-cause death (HR, 3.922; 95% CI = 2.910-5.285) compared to the control group. Among nonhospitalized patients with COVID-19, NDA was associated with a higher risk of post-COVID-19 condition, all-cause hospitalization, and all-cause death during the 90-180-day follow-up period.

A Review of Hematological Complications and Treatment in COVID-19

COVID-19, caused by SARS-CoV-2, and its variants have spread rapidly across the globe in the past few years, resulting in millions of deaths worldwide. Hematological diseases and complications associated with COVID-19 severely impact the mortality and morbidity rates of patients; therefore, there is a need for oversight on what pharmaceutical therapies are prescribed to hematologically at-risk patients. Thrombocytopenia, hemoglobinemia, leukopenia, and leukocytosis are all seen at increased rates in patients infected with COVID-19 and become more prominent in patients with severe COVID-19. Further, COVID-19 therapeutics may be associated with hematological complications, and this became more important in immunocompromised patients with hematological conditions as they are at higher risk of hematological complications after treatment. Thus, it is important to understand and treat COVID-19 patients with underlying hematological conditions with caution. Hematological changes during COVID-19 infection and treatment are important because they may serve as biomarkers as well as to evaluate the treatment response, which will help in changing treatment strategies. In this literature review, we discuss the hematological complications associated with COVID-19, the mechanisms, treatment groups, and adverse effects of commonly used COVID-19 therapies, followed by the hematological adverse events that could arise due to therapeutic agents used in COVID-19.

Alterations of erythropoiesis in Covid-19 patients: prevalence of positive Coombs tests and iron metabolism

Background

For more than 2 years medical practice has been dealing with the Covid-19 pandemic. Atypical symptoms, such as frostbites and acrosyndromes, have appeared, and autoimmune anemias (some of which with cold agglutinins) have been described.

Objectives

We planned to study the prevalence of positive direct Coombs tests (DCTs) and hemolytic autoimmune anemia in patients infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and its correlation with complications, and then investigate the impact of the infection on iron metabolism.

Design

This is an observational, cross-sectional, single-center, exploratory study.

Methods

We obtained Coombs tests in a population of 179 infected patients at the CHU of Liège. We then studied iron metabolism in some of these patients, by measuring serum ferritin, erythropoietin (EPO), erythroferrone and hepcidin.

Results

We did not identify any case of autoimmune hemolysis. However, there was a 20.3% prevalence of positive DCT, mainly with IgG (91.7%). These patients, compared to DCT-negative patients, were not only more anemic and transfused, but also required more transfers to intensive care units and had longer hospital stays and mechanical ventilation. The pattern of anemia was consistent with the anemia of inflammation, showing elevated hepcidin and ferritin levels, while EPO and erythroferrone values were lower than expected at this degree of anemia. Erythroferrone was higher and Hb was lower in DCT-positive patients. Finally, we identified a correlation between iron parameters and complicated forms of infection.

Conclusion

Covid-19 patients suffered from inflammatory anemia with more severe forms of infection correlated to positive DCT status. This could potentially be of interest for future clinical practice.

Confounding role of comorbidities and COVID-19 vaccination uptake in clinical utility of hematological biomarkers in Cameroonian patients infected with SARS-CoV-2

Objectives

To analyze variations in blood profile, the extent of hematological disorders, and the impact of comorbidities and COVID-19 vaccination on blood profile parameters and their clinical value for prognostic of SARS-CoV-2 infection.

Methods

This cross-sectional study took place in Douala, Cameroon. A complete blood count and molecular detection of SARS-CoV-2 were performed on patients. Clinical value was appraised using area under the curve (AUC) analysis.

Results

In total, 420 participants were included. A significant reduction of hematological parameters such as lymphocytes (p < 0.0001), red blood cells (P = 0.0025), mean corpuscular hemoglobin count (P < 0.0001), and platelets (P = 0.02) was seen in SARS-CoV-2 (+) patients. Anisocytosis was the main hematological disorder (95.5%). Normocytic normochromic anemia was predominant in SARS-CoV-2 (+) (35.3%) while microcytic normochromic anemia was more frequently seen in SARS-CoV-2 (-) (16.5%). Neutrophil-to-lymphocyte (NLR) consistently showed statistically significant AUC ∼0.75 upon stratification for age, gender, and comorbidities, with the exception of COVID-19 vaccination uptake.

Conclusion

In a context where molecular detection methods are difficultly affordable in health facilities in developing countries such as Cameroon, NLR could be clinically interesting for identifying SARS-CoV-2 infected individuals, especially those with comorbidities.

Why Is Iron Deficiency/Anemia Linked to Alzheimer's Disease and Its Comorbidities, and How Is It Prevented?

Impaired iron metabolism has been increasingly observed in many diseases, but a deeper, mechanistic understanding of the cellular impact of altered iron metabolism is still lacking. In addition, deficits in neuronal energy metabolism due to reduced glucose import were described for Alzheimer's disease (AD) and its comorbidities like obesity, depression, cardiovascular disease, and type 2 diabetes mellitus. The aim of this review is to present the molecular link between both observations. Insufficient cellular glucose uptake triggers increased ferritin expression, leading to depletion of the cellular free iron pool and stabilization of the hypoxia-induced factor (HIF) 1α. This transcription factor induces the expression of the glucose transporters (Glut) 1 and 3 and shifts the cellular metabolism towards glycolysis. If this first line of defense is not adequate for sufficient glucose supply, further reduction of the intracellular iron pool affects the enzymes of the mitochondrial electron transport chain and activates the AMP-activated kinase (AMPK). This enzyme triggers the translocation of Glut4 to the plasma membrane as well as the autophagic recycling of cell components in order to mobilize energy resources. Moreover, AMPK activates the autophagic process of ferritinophagy, which provides free iron urgently needed as a cofactor for the synthesis of heme- and iron-sulfur proteins. Excessive activation of this pathway ends in ferroptosis, a special iron-dependent form of cell death, while hampered AMPK activation steadily reduces the iron pools, leading to hypoferremia with iron sequestration in the spleen and liver. Long-lasting iron depletion affects erythropoiesis and results in anemia of chronic disease, a common condition in patients with AD and its comorbidities. Instead of iron supplementation, drugs, diet, or phytochemicals that improve energy supply and cellular glucose uptake should be administered to counteract hypoferremia and anemia of chronic disease.

Comparative Analysis of Hematological and Biochemical Changes in Neonates among Women with and without COVID-19 Infection during Pregnancy

The aim of this study is to evaluate the test results of neonates delivered by COVID-19-positive mothers during pregnancy with those of neonates born to unvaccinated mothers who are COVID-19-free. A cohort study was conducted on 367 pregnant women who gave birth at Premiere Hospital, Timisoara, Romania, between May 2021 and February 2022. Two groups were established: Group 1, with 167 pregnant women infected with COVID-19, and Group 2, with 200 pregnant women who were not affected by COVID-19 during pregnancy. Maternal laboratory examination did not exhibit significant variations except for platelet count. In neonatal blood tests, WBC had a significantly lower median value in the group born to COVID-19-free mothers. Neonatal anemia and leukocytosis showed slightly higher prevalence in Group 1, but the differences were not statistically significant. This study suggests that maternal COVID-19 infection during pregnancy does not have significant associations with most maternal and neonatal characteristics.

Evaluation of safety and effectiveness of remdesivir in treating COVID-19 patients after emergency use authorization study

Background: This study aimed to determine the real-world safety and effectiveness of remdesivir in hospitalized adult COVID-19 patients with moderate-to-critical disease in Indonesia. Methods: A multicenter, retrospective cohort study was conducted at four COVID-19 referral hospitals in Jakarta. A total of 587 patients were included, of whom 243 received remdesivir within 72 h of admission. The safety endpoints were the proportions of patients with any adverse event (AE), any grade 3 AE, and AE of each system organ class. The effectiveness endpoints were ICU admission >24 h from baseline, live discharge and mortality at day 14, live discharge and mortality at day 28, and virologic conversion. Patients who received remdesivir within 72 h of admission were considered the treatment group, and those who did not were the control group. Multivariate adjustments were performed using a modified Poisson regression. Results: The study found no significant differences in safety endpoints between the two groups. However, the effectiveness endpoints showed that remdesivir was associated with a decreased risk of ICU admission >24 h from baseline (RR 0.71, 95% CI 0.52-0.96), an increased probability of live discharge at day 14 (RR 1.37, 95% CI 1.08-1.74), and an increased probability of live discharge at day 28 (RR 1.28, 95% CI 1.05-1.57). The rate of virologic conversion was not significantly different between the two groups. Conclusion: The study concludes that remdesivir is safe and effective in the treatment of moderate-to-critical COVID-19 in a real-world setting in Indonesia.

Effects of COVID-19 disease on PAI-1 antigen and haematological parameters during disease management: A prospective cross-sectional study in a regional Hospital in Ghana

BACKGROUND

Individuals with COVID-19 experience thrombotic events probably due to the associated hypofibrinolysis resulting from the upregulation of plasminogen activator inhibitor-1 (PAI-1) antigen. This study evaluated plasma PAI-1 antigen levels and haematological parameters before treatment and after recovery from severe COVID-19 in Ghana.

MATERIALS AND METHODS

This cross-sectional study was conducted at Sunyani Regional Hospital, and recruited 51 patients who had RT-PCR-confirmed SARS-CoV-2. Participants' sociodemographic data and clinical characteristics were taken from the hospital records. Venous blood was taken before COVID-19 treatment commenced for FBC, PAI-1 and ferritin assays. FBC was assessed using an automated haematology analyzer, whilst plasma PAI-1 Ag and serum ferritin levels were assessed with sandwich ELISA. All the tests were repeated immediately after participants recovered from COVID-19.

RESULTS

Of the 51 participants recruited into the study, 78.4% (40) had non-severe COVID-19 whiles 21.6% (11) experienced a severe form of the disease. Severe COVID-19 participants had significantly lower haemoglobin (g/dL): 8.1 (7.3-8.4) vs 11.8 (11.0-12.5), p<0.001; RBC x 1012/L: 2.9 (2.6-3.1) vs 3.4 (3.1-4.3), p = 0.001; HCT%: 24.8 ± 2.6 vs 35.3 ± 6.7, p<0.001 and platelet x 109/L: 86.4 (62.2-91.8) vs 165.5 (115.1-210.3), p<0.001, compared with the non-severe COVID-19 group. But WBC x 109/L: 11.6 (9.9-14.2) vs 5.4 (3.7-6.6), p<0.001 and ferritin (ng/mL): 473.1 (428.3-496.0) vs 336.2 (249.9-386.5), p<0.001, were relatively higher in the participants with severe COVID-19 than the non-severe COVID-19 counterparts. Also, the severely ill SARS-CoV-2-infected participants had relatively higher plasma PAI-1 Ag levels (ng/mL): 131.1 (128.7-131.9) vs 101.3 (92.0-116.8), p<0.001, than those with the non-severe form of the disease. Participants had lower haemoglobin (g/dL): 11.4 (8.8-12.3 vs 12.4 (11.5-13.6), p<0.001; RBC x 1012/L: 3.3 (2.9-4.0) vs 4.3 (3.4-4.6), p = 0.001; absolute granulocyte count x 109/L: 2.3 ± 1.0 vs 4.6 ± 1.8, p<0.001, and platelet x 109/L: 135.0 (107.0-193.0) vs 229.0 (166.0-270.0), p<0.001 values at admission before treatment commenced, compared to when they recovered from the disease. Additionally, the median PAI-1 Ag (ng/mL): 89.6 (74.9-100.8) vs 103.1 (93.2-128.7), p<0.001 and ferritin (ng/mL): 242.2 (197.1-302.1) vs 362.3 (273.1-399.9), p<0.001 levels were reduced after a successful recovery from COVID-19 compared to the values at admission.

CONCLUSION

Plasma PAI-1 Ag level was higher among severe COVID-19 participants. The COVID-19-associated inflammation could affect red blood cell parameters and platelets. Successful recovery from COVID-19, with reduced inflammatory response as observed in the decline of serum ferritin levels restores the haematological parameters. Plasma levels of PAI-1 should be assessed during the management of severe COVID-19 in Ghana. This will enhance the early detection of probable thrombotic events and prompts Physicians to provide interventions to prevent thrombotic complications associated with COVID-19.

Anemia as a risk factor for disease progression in patients admitted for COVID-19: data from a large, multicenter cohort study

In respiratory infections, anemia is both a consequence of acute inflammation and a predictor of poor clinical outcomes. There are few studies investigating the role of anemia in COVID-19, suggesting a potential role in predicting disease severity. In this study, we aimed to assess the association between the presence of anemia at admission and incidence of severe disease and death in patients hospitalized for COVID-19. Data from all adult patients admitted for COVID-19 in University Hospital "P. Giaccone" Palermo, and University Hospital of Bari, Italy, were retrospectively collected from 1st of September 2020 to 31 August 2022. The association between anemia (defined as Hb < 13 g/dl and < 12 g/dl in males and females, respectively), in-hospital mortality and severe COVID-19 was tested using a Cox's regression analysis. Severe COVID-19 forms were defined as admission to intensive or sub-intensive care unit or a qSOFAscore ≥ 2 or CURB65scores ≥ 3. p values were calculated using the Student's t test for continuous variables and the Mantel-Haenszel Chi-square test for categorical ones. The association between anemia and the mortality was made using a Cox's regression analysis, adjusted, in two models, for the potential confounders and using a propensity score. Among the 1562 patients included in the analysis, prevalence of anemia was 45.1% (95% CI 43-48%). Patients with anemia were significantly older (p < 0.0001), reported more co-morbidities, and presented higher baseline levels of procalcitonin, CRP, ferritin and IL-6. Overall, the crude incidence of mortality was about four times higher in patients with anemia compared to those without. After adjusting for 17 potential confounders, the presence of anemia significantly increased the risk of death (HR = 2.68; 95% CI: 1.59-4.52) and of risk of severe COVID-19 (OR = 2.31; 95% CI: 1.65-3.24). The propensity score analysis substantially confirmed these analyses. Our study provides evidence that, in patients hospitalized for COVID-19, anemia is both associated with a more pronounced baseline pro-inflammatory profile and higher incidence of in-hospital mortality and severe disease.

Raman and fourier transform infrared spectroscopy techniques for detection of coronavirus (COVID-19): a mini review

Coronavirus pandemic has been a huge jeopardy to human health in various systems since it outbroke, early detection and prevention of further escalation has become a priority. The current popular approach is to collect samples using the nasopharyngeal swab method and then test for RNA using the real-time polymerase chain reaction, which suffers from false-positive results and a longer diagnostic time scale. Alternatively, various optical techniques, namely, optical sensing, spectroscopy, and imaging shows a great promise in virus detection. In this mini review, we briefly summarize the development progress of vibrational spectroscopy techniques and its applications in the detection of SARS-CoV family. Vibrational spectroscopy techniques such as Raman spectroscopy and infrared spectroscopy received increasing appreciation in bio-analysis for their speediness, accuracy and cost-effectiveness in detection of SARS-CoV. Further, an account of emerging photonics technologies of SARS-CoV-2 detection and future possibilities is also explained. The progress in the field of vibrational spectroscopy techniques for virus detection unambiguously show a great promise in the development of rapid photonics-based devices for COVID-19 detection.

Thirty-Day Outcomes of Young and Middle-Aged Adults Admitted with Severe COVID-19 in Uganda: A Retrospective Cohort Study

Background

There is scarcity of data regarding young and middle-aged adults hospitalized with severe Corona Virus Disease 2019 (COVID-19) in Africa. In this study, we describe the clinical characteristics and 30-day survival among adults aged 18 to 49 years admitted with severe COVID-19 in Uganda.

Methods

We reviewed treatment records of patients admitted with severe COVID-19 across five COVID-19 treatment units (CTU) in Uganda. We included individuals aged 18 to 49 years, who had a positive test or met the clinical criteria for COVID-19. We defined severe COVID-19 as having an oxygen saturation <94%, lung infiltrates >50% on imaging and presence of a co-morbidity that required admission in the CTU. Our main outcome was the 30-day survival from the time of admission. We used a Cox proportional hazards model to determine the factors associated with 30-day survival at a 5% level of significance.

Results

Of the 246 patient files reviewed, 50.8% (n = 125) were male, the mean ± (standard deviation) age was 39 ± 8 years, majority presented with cough, 85.8% (n = 211) and median C-reactive protein (interquartile range) was 48 (47.5, 178.8) mg/L. The 30-day mortality was 23.9% (59/246). At admission, anemia (hazard ratio (HR): 3.00, 95% confidence interval (CI), 1.32-6.82; p = 0.009) and altered mental state (GCS <15) (HR: 6.89, 95% CI: 1.48-32.08, p = 0.014) were significant predictors of 30-day mortality.

Conclusion

There was a high 30-day mortality among young and middle-aged adults with severe COVID-19 in Uganda. Early recognition and targeted management of anemia and altered consciousness are needed to improve clinical outcomes.

Vaccination and Factors Related to the Clinical Outcome of COVID-19 in Healthcare Workers-A Romanian Front-Line Hospital's Experience

The study aims to describe the frequency of COVID-19 in healthcare workers (HCWs) in a designated hospital for COVID-19 treatment in Bucharest, Romania, and to explore COVID-19 vaccination and other factors associated with the clinical outcome. We actively surveyed all HCWs from 26 February 2020 to 31 December 2021. Cases were laboratory-confirmed with RT-PCR or rapid test antigen. Epidemiological, demographic, clinical outcomes, vaccination status, and co-morbidities data were collected. Data were analyzed using Microsoft Excel, SPSS, and MedCalc. A total of 490 cases of COVID-19 in HCWs were diagnosed. The comparison groups were related to the severity of the clinical outcome: the non-severe group (279, 64.65%) included mild and asymptomatic cases, and the potentially severe group included moderate and severe cases. Significant differences between groups were registered for high-risk departments (p = 0.0003), exposure to COVID-19 patients (p = 0.0003, vaccination (p = 0.0003), and the presence of co-morbidities (p < 0.0001). Age, obesity, anemia, and exposure to COVID-19 patients predicted the severity of the clinical outcomes (χ² (4, n = 425) = 65.69, p < 0.001). The strongest predictors were anemia and obesity (OR 5.82 and 4.94, respectively). In HCWs, mild COVID-19 cases were more frequent than severe cases. Vaccination history, exposure, and individual risk influenced the clinical outcome suggesting that measures to protect HCWs and occupational medicine are important for pandemic preparedness.

Severe COVID-19 Pneumonia in a Three-Year-Old with Congenital Iron and B12 Deficiency Anemia of Unknown Etiology: A Case Report

Since COVID-19 first emerged in Wuhan, China, and was declared a global pandemic by the WHO, researchers have been meticulously studying the disease and its complications. Studies of severe COVID-19 disease among pediatric populations are scarce, leading to difficulty in establishing a comprehensive management approach. Case presentation: This report outlines a case of a long-standing combined iron and vitamin B12 deficiency anemia in a three-year-old treated at the Children's Clinical University Hospital due to severe COVID-19 disease. The patient's clinical condition coincided with the derangement of biomarkers described in the literature, including lymphopenia, increased neutrophil/lymphocyte ratio (NLR), decreased lymphocyte/C-reactive protein ratio (LCR), as well as elevated inflammatory markers such as CRP and D-dimers. The patient developed severe bilateral pneumonia requiring invasive ventilation, high-flow oxygen, immunosuppressive therapy with dexamethasone and tocilizumab, and supplementation of anemia deficits with blood transfusion and vitamin B12 administration. Conclusions: Our findings are consistent with the most important biomarkers reported in the literature indicative of severe disease progression. Additionally, poorly controlled anemia may be suggested as a potentially important risk factor for severe COVID-19 disease among children. However, additional quantitative research is required to establish the nature and severity of the risk.

Associations of anemia and blood transfusions with mortality in old, critically ill COVID-19 patients - Results from the prospective COVIP Study

AIMS

Anemia is common in the old and often observed in critically ill patients. Increased age is associated with higher mortality following a COVID-19 infection, making old patients prone to poor outcomes. We investigated whether anemia at admission to the ICU or the need for blood transfusion was associated with 90-day mortality in older, critically ill COVID-19 patients.

METHODS

In this prospective multicenter study, the 90-day mortality of COVID-19 patients≥70 years treated in 138 intensive care units (ICU) was analyzed. Associations between anemia (WHO definition) at admission and discharge from ICU and the use of red blood cell (RBC) transfusions with mortality were assessed. Hemoglobin thresholds of RBC transfusions in old, critically ill COVID-19 patients were recorded.

RESULTS

In 493 patients (350 anemic, 143 non-anemic), anemia (WHO definition) at the time of ICU admission was not associated with impaired overall survival. Transfusion and severe anemia (hemoglobin≤10 g/dL) at ICU discharge were independently associated with a higher risk of 90-day mortality.

CONCLUSION

The need for red blood cell transfusions and severe anemia at ICU discharge, but not at the timepoint of admission, were independently associated with 90-day mortality in critically-ill old COVID-19 patients.

Parameters and Morphological Changes of Erythrocytes and Platelets of COVID-19 Subjects: A Longitudinal Cohort Study

Purpose

Information about dynamic changes occurring in the parameters and morphology of erythrocytes and platelets during the coronavirus disease 2019 (COVID-19) infection and convalescence is scarce. To explore potential associations between dynamic erythrocyte and platelet parameters, morphological changes, and the course or severity of the disease is essential.

Patients and Methods

From January 17th, 2020, to February 20th, 2022, we followed up on 35 patients with non-severe and 11 patients with severe COVID-19 following their discharge. We collected clinical features, dynamic complete blood count (CBC), and peripheral blood smears (PBS) and analyzed parameter and morphological changes of erythrocytes and platelets depending on the course or severity of the disease. The course of the disease included four periods, namely onset (T1), discharge (T2), 1-year follow-up (T3), and 2-year follow-up (T4).

Results

Red blood cell (RBC) counts and hemoglobin were the lowest in T2, followed by T1, and lower in T1 and T2 than in T3 and T4. Inversely, the red blood cell distribution width (RDW) was the highest in T2, followed by T1, and higher than in T3 and T4. Compared to non-severe patients, the platelet of severe patients was lower in T1 and T2. In contrast, the mean platelet volume (MPV) and platelet distribution width (PDW) tended to be higher in severe patients. Similarly, anisocytosis was more common in peripheral blood smears at early stages and in severe patients. Finally, large platelets were more common in severe patients.

Conclusion

Anisocytosis of erythrocytes and large platelets are found in patients with severe COVID-19, these changes may help primary hospitals to identify patients with a high risk of severe COVID-19 at an early stage.

SARS-CoV-2 Infection Dysregulates Host Iron (Fe)-Redox Homeostasis (Fe-R-H): Role of Fe-Redox Regulators, Ferroptosis Inhibitors, Anticoagulants, and Iron-Chelators in COVID-19 Control

Severe imbalance in iron metabolism among SARS-CoV-2 infected patients is prominent in every symptomatic (mild, moderate to severe) clinical phase of COVID-19. Phase-I - Hypoxia correlates with reduced O₂ transport by erythrocytes, overexpression of HIF-1α, altered mitochondrial bioenergetics with host metabolic reprogramming (HMR). Phase-II - Hyperferritinemia results from an increased iron overload, which triggers a fulminant proinflammatory response - the acute cytokine release syndrome (CRS). Elevated cytokine levels (i.e. IL6, TNFα and CRP) strongly correlates with altered ferritin/TF ratios in COVID-19 patients. Phase-III - Thromboembolism is consequential to erythrocyte dysfunction with heme release, increased prothrombin time and elevated D-dimers, cumulatively linked to severe coagulopathies with life-threatening outcomes such as ARDS, and multi-organ failure. Taken together, Fe-R-H dysregulation is implicated in every symptomatic phase of COVID-19. Fe-R-H regulators such as lactoferrin (LF), hemoxygenase-1 (HO-1), erythropoietin (EPO) and hepcidin modulators are innate bio-replenishments that sequester iron, neutralize iron-mediated free radicals, reduce oxidative stress, and improve host defense by optimizing iron metabolism. Due to its pivotal role in 'cytokine storm', ferroptosis is a potential intervention target. Ferroptosis inhibitors such as ferrostatin-1, liproxstatin-1, quercetin, and melatonin could prevent mitochondrial lipid peroxidation, up-regulate antioxidant/GSH levels and abrogate iron overload-induced apoptosis through activation of Nrf2 and HO-1 signaling pathways. Iron chelators such as heparin, deferoxamine, caffeic acid, curcumin, α-lipoic acid, and phytic acid could protect against ferroptosis and restore mitochondrial function, iron-redox potential, and rebalance Fe-R-H status. Therefore, Fe-R-H restoration is a host biomarker-driven potential combat strategy for an effective clinical and post-recovery management of COVID-19.

Peripheral blood cell anomalies in COVID-19 patients in the United Arab Emirates: A single-centered study

Introduction

In this study, we aimed at exploring the morphologic and quantitative abnormalities in the peripheral blood counts of coronavirus disease 2019 (COVID-19) patients.

Methods

A cohort of 131 COVID-19 patients was recruited at University Hospital Sharjah (UHS), UAE. Their peripheral blood smears were examined for morphological evaluation. Also, their clinical laboratory investigations and radiological findings were retrieved from the medical records. Our cohort consisted of 63 males and 68 females with an age of 63.6 ± 18.6 years.

Results

The presence of atypical lymphocytes was observed in around 80% of the recruited COVID-19 patients. Further, monocytes with toxic cytoplasmic vacuoles were identified in 55% of the cases. Neutrophil-associated changes, including pseudo-Pelger-Huët, bands, and long nuclear endoplasm, were reported in around 25-35% of the patients. RBCs associated changes such as microcytic and hypochromic RBCs, as well as targetoid, dacrocytes, ovalocytes, echinocytes/burr cells, and schistocytes, were described. According to disease severity, RBCs chromicity was found to be significantly different between stable and critical patients. COVID-19 patients with CO-RADS 5 showed a similar change in RBCs as well as a decrease in the neutrophils with hypogranular cytoplasm.

Conclusion

Peripheral blood smear assessment in COVID-19 patients could provide information about the disease state and pulmonary involvement.

Clinical course of patients with severe SARS-CoV-2 infection co-treatment with Jin Si Herbal Tea in Eastern Taiwan: A retrospective cohort study

Introduction

Coronavirus disease-2019 (COVID-19) has affected more than 608 million people and has killed 6.5 million people in the world. A few studies showed traditional Chinese medicine can be beneficial for COVID-19 treatment. An herbal preparation Jin Si Herbal Tea (JS) was formulated with herbal extracts known for their potential to decrease spike protein and ACE2 interaction, 3CL, and TRPMSS2 protease activity, and thus aimed to evaluate the clinical course of JS co-treatment along with the usual treatment schedule given for severe COVID-19 patients.

Methods

This retrospective cohort study included patients with severe COVID-19 admitted to Hualien Tzu Chi Hospital between June and July 2021. All the patients were co-treated with JS and the primary outcome was death. The secondary outcomes included laboratory exam, Ct value, clinical course, and hospital stays. There were 10 patients recruited in this study and divided into < 70 years and ≧ 70 years groups (n = 5 in each group).

Results

Older patients (≧70 years) had a higher Charlson Comorbidity Index, VACO index, and lower hemoglobin levels than < 70 years patients. The trend of lymphocyte count, LDH, D-dimer, and Ct value of non-survivors was not consistent with previous studies. The death rate was 20% and the recovery rate to mild illness in 14 days was 40%.

Conclusion

In conclusion, this is the first clinical study of JS co-treatment in severe COVID-19 patients. JS co-treatment might reduce death rate and recovery time. Further large-scale clinical trials would be expected.

The role of iron in chronic inflammatory diseases: from mechanisms to treatment options in anemia of inflammation

Anemia of inflammation (AI) is a highly prevalent comorbidity in patients affected by chronic inflammatory disorders, such as chronic kidney disease, inflammatory bowel disease, or cancer, that negatively affect disease outcome and quality of life. The pathophysiology of AI is multifactorial, with inflammatory hypoferremia and iron-restricted erythropoiesis playing a major role in the context of disease-specific factors. Here, we review the recent progress in our understanding of the molecular mechanisms contributing to iron dysregulation in AI, the impact of hypoferremia and anemia on the course of the underlying disease, and (novel) therapeutic strategies applied to treat AI.

Hematological Profiles and Clinical Outcome of COVID-19 Among Patients Admitted at Debre Markos Isolation and Treatment Center, 2020: A Prospective Cohort Study

BACKGROUND

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is coronavirus isolated from SARS patients. As far as the researchers' knowledge, there was paucity of studies conducted in Ethiopia, particularly in the study area. As immune protection is arisen from our blood cells, assessing their level will provide a clue for controlling the disease and monitoring the prognosis. This study will also provide additional information for clinical intervention and patient management.

PURPOSE

This study aimed to investigate the hematological profile and clinical outcome of coronavirus disease-19 (COVID-19) among patients admitted to the Debre Markos Isolation and Treatment Center (DMITC).

MATERIAL AND METHODS

A prospective cohort study was conducted among 136 COVID-19 adult patients at DMITC from January 1, 2020 to March 30, 2021. Data related to clinical, hematological profiles and socio-demographic factors were collected, entered into Epi data, and analyzed using STATA 14.2 software. Multivariable logistic regression was applied to determine the predictor variable and a p-value <0.05 was considered significant.

RESULTS

Of 136 COVID-19 patients, 28.68% had died. The mean age of patients was 47.21±1.29 years. The hematological profile of the patients revealed that 28% had abnormal leukocyte, 23% abnormal lymphocyte, 44.85% abnormal granulocyte, 22.06% abnormal monocyte, 30.15% abnormal RBC and 87% abnormal platelet counts. The prevalence of anemia was 13.24%.

CONCLUSION

Leukocytosis (mainly granulocytosis and monocytosis) and lymphopenia, were the predominant abnormal findings of complete blood cell count (CBC) analysis of the patient's blood. Most of the patients had abnormally low platelet counts. RBC count and hematocrit determination were the only significant predictors of death. The clinician could manage cases according to the hematological findings of the patients. Further experimental studies should be conducted to determine hematological parameter changes and the clinical outcome of the disease.

Transient Sideroblastic Anemia Post-COVID-19 Infection

A 57-year-old gentleman presented to the hospital with progressive fatigue and dyspnea on exertion three months after recovering from COVID-19. He was noted to have severe anemia with reticulocytopenia. After excluding vitamin deficiencies and heavy metal toxicities, a bone marrow aspirate and biopsy were performed, which showed erythroid predominant trilineage maturing hematopoiesis with 79% ring sideroblasts and no dysplasia. SF3B1 mutation was negative. He was diagnosed with sideroblastic anemia and became transfusion-dependent. He was treated with an erythropoiesis-stimulating agent and luspatercept with transient improvement in anemia. After 12 months of treatment, anemia spontaneously improved. Repeat bone marrow biopsy showed hypercellular marrow with 39% ringed sideroblasts. We suspect that this possibly was a delayed manifestation of COVID-19 infection.

On-Admission Anemia and Survival Rate in COVID-19 Patients

Anemia often worsens the severity of respiratory illnesses, and few studies have so far elucidated the impact of anemia on COVID-19 infection. This study aimed to evaluate the effect of anemia at admission on the overall survival of COVID-19 patients using accelerated failure time (AFT) models.

This registry-based, single-center retrospective cohort study was conducted in a university hospital in Ilam, the southwest of Iran, between March 2020 and September 2021. AFT models were applied to set the data of 2,441 COVID-19 patients. Performance of AFT models was assessed using Akaike’s information criterion (AIC) and Cox-Snell residual. On-admission anemia was defined as hemoglobin (Hb) concentration <120 g/l in men, <110 g/l in women, and <100 g/l in pregnant women.

The median in-hospital survival times for anemic and non-anemic patients were 27 and 31 days, respectively. Based on the AIC and Cox-Snell residual graph, the Weibull model had the lowest AIC and it was the best fitted model to the data set among AFT models. In the adjusted model, the results of the Weibull model suggested that the anemia (adjusted time ratio: 1.04; 95% CI: 1.00-1.08; p = 0.03) was the accelerated factor for progression to death in COVID-19 patients. Each unit of increase in hemoglobin in COVID-19 patients enhanced the survival rate by 4%.

Anemia is an independent risk factor associated with the risk of mortality from COVID-19 infection. Therefore, healthcare professionals should be more sensitive to the Hb level of COVID-19 patients upon admission.

The role of hypoxia and inflammation in the regulation of iron metabolism and erythropoiesis in COVID-19: The IRONCOVID study

Coronavirus Disease (COVID-19) can be considered as a human pathological model of inflammation combined with hypoxia. In this setting, both erythropoiesis and iron metabolism appear to be profoundly affected by inflammatory and hypoxic stimuli, which act in the opposite direction on hepcidin regulation. The impact of low blood oxygen levels on erythropoiesis and iron metabolism in the context of human hypoxic disease (e.g., pneumonia) has not been fully elucidated. This multicentric observational study was aimed at investigating the prevalence of anemia, the alterations of iron homeostasis, and the relationship between inflammation, hypoxia, and erythropoietic parameters in a cohort of 481 COVID-19 patients admitted both to medical wards and intensive care units (ICU). Data were collected on admission and after 7 days of hospitalization. On admission, nearly half of the patients were anemic, displaying mild-to-moderate anemia. We found that hepcidin levels were increased during the whole period of observation. The patients with a higher burden of disease (i.e., those who needed intensive care treatment or had a more severe degree of hypoxia) showed lower hepcidin levels, despite having a more marked inflammatory pattern. Erythropoietin (EPO) levels were also lower in the ICU group on admission. After 7 days, EPO levels rose in the ICU group while they remained stable in the non-ICU group, reflecting that the initial hypoxic stimulus was stronger in the first group. These findings strengthen the hypothesis that, at least in the early phases, hypoxia-driven stimuli prevail over inflammation in the regulation of hepcidin and, finally, of erythropoiesis.

Detection of erythroid progenitors and erythrocytopathies in patients with severe COVID-19 disease

OBJECTIVES

To assess the effect of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection on erythropoiesis and red blood cells (RBC) surface markers by evaluating erythroid progenitor cells (CD [cluster of differentiation]71⁺/CD235a⁺) and RBC surface markers (CD235a and CD36), together with various hematological parameters.

METHODS

This case-control study includes 47 participants recruited in the study: 30 patients with coronavirus disease 2019 (COVID-19) and 17 healthy individuals. The COVID-19 patients were recruited from the intensive care unit (ICU) of various hospitals in Makkah, Saudi Arabia. Blood samples were collected during July and September 2021. Red blood cells indices were measured using a CBC analyzer. The expression of CD235a, CD71, and CD36 was obtained using flow cytometry technique. The unpaired t-test was conducted to evaluate the differences in these markers in COVID-19 patients and healthy individuals.

RESULTS

The data showed that more than half of the COVID-19 patients were anemic (64%). Expansion of erythroid progenitors (CD71⁺/CD235a⁺) was detected in the COVID-19 patients. Analysis of the expression of RBC surface markers, such as CD235a and CD36, showed that SARS-CoV-2 was associated with significantly higher expression of these markers in COVID-19 patients.

CONCLUSION

Severe acute respiratory syndrome coronavirus-2 promoted the expansion of erythroid progenitors in the peripheral blood of COVID-19 patients. In addition, the expression of RBC surface markers was higher in COVID-19 patients. The expansion of erythroid progenitors and alteration of RBC surface markers can contribute to erythrocytopathies observed in severe COVID-19 patients and can therefore be used as prognostic factors.

Iron Deficiency Anemia: Efficacy and Limitations of Nutritional and Comprehensive Mitigation Strategies

Iron deficiency anemia (IDA) has reached epidemic proportions in developing countries and has become a major global public health problem, affecting mainly 0–5-year-old children and young women of childbearing age, especially during pregnancy. Iron deficiency can lead to life-threatening loss of red blood cells, muscle function, and energy production. Therefore, the pathogenic features associated with IDA are weakness and impaired growth, motor, and cognitive performance. IDA affects the well-being of the young generation and the economic advancement of developing countries, such as India. The imbalance between iron intake/absorption/storage and iron utilization/loss culminates into IDA. However, numerous strategic programs aimed to increase iron intake have shown that improvement of iron intake alone has not been sufficient to mitigate IDA. Emerging critical risk factors for IDA include a composition of cultural diets, infections, genetics, inflammatory conditions, metabolic diseases, dysbiosis, and socioeconomic parameters. In this review, we discuss numerous IDA mitigation programs in India and their limitations. The new multifactorial mechanism of IDA pathogenesis opens perspectives for the improvement of mitigation programs and relief of IDA in India and worldwide.

Red Blood Cell Morphologic Abnormalities in Patients Hospitalized for COVID-19

Peripheral blood smear is a simple laboratory tool, which remains of invaluable help for diagnosing primary and secondary abnormalities of blood cells despite advances in automated and molecular techniques. Red blood cells (RBCs) abnormalities are known to occur in many viral infections, typically in the form of mild normo-microcytic anemia. While several hematological alterations at automated complete blood count (including neutrophilia, lymphopenia, and increased red cell distribution width—RDW) have been consistently associated with severity of COVID-19, there is scarce information on RBCs morphological abnormalities, mainly as case-reports or small series of patients, which are hardly comparable due to heterogeneity in sampling times and definition of illness severity. We report here a systematic evaluation of RBCs morphology at peripheral blood smear in COVID-19 patients within the first 72 h from hospital admission. One hundred and fifteen patients were included, with detailed collection of other clinical variables and follow-up. A certain degree of abnormalities in RBCs morphology was observed in 75 (65%) patients. Heterogenous alterations were noted, with spiculated cells being the more frequent morphology. The group with &gt;10% RBCs abnormalities had more consistent lymphopenia and thrombocytopenia compared to those without abnormalities or &lt;10% RBCs abnormalities (p &lt; 0.018, and p &lt; 0.021, respectively), thus underpinning a possible association with an overall more sustained immune-inflammatory “stress” hematopoiesis. Follow-up analysis showed a different mortality rate across groups, with the highest rate in those with more frequent RBCs morphological alterations compared to those with &lt;10% or no abnormalities (41.9%, vs. 20.5%, vs. 12.5%, respectively, p = 0.012). Despite the inherent limitations of such simple association, our results point out towards further studies on erythropoiesis alterations in the pathophysiology of COVID-19.

The significance of antiglobulin (Coombs) test reactivity in patients with COVID-19

Previous case reports have described patients with COVID-19-associated autoimmune hemolytic anemia (AIHA), and cold agglutinin disease (CAD) which is characterized by a positive direct antiglobulin (DAT) or "Coombs" test, yet the mechanism is not well understood. To investigate the significance of Coombs test reactivity among COVID-19 patients, we conducted a retrospective study on hospitalized COVID-19 patients treated at NMC Royal Hospital between 15 April and 30 May 2020. There were 27 (20%) patients in the Coombs-positive group and 108 (80%) in the Coombs-negative group. The cold agglutinin titer was examined in 22 patients due to symptoms suggestive of cold agglutinin disease, and all tested negative. We demonstrated a significant association with reactive Coombs test results in univariate analysis through clinical findings such as ICU admission rate, the severity of COVID-19, and several laboratory findings such as CRP, D-dimer, and hemoglobin levels lactate dehydrogenase, and RDW-CV. However, only hemoglobin levels and disease severity had a statistically significant association in multivariate analysis. A possible explanation of COVID-19-associated positive Coombs is cytokine storm-induced hyperinflammation, complement system activation, alterations of RBCs, binding of SARS-CoV-2 proteins to hemoglobin or its metabolites, and autoantibody production. Coombs-positive patients were tested for hemolysis using indirect bilirubin, consumed haptoglobin, and/or peripheral smear that ruled out any evidence of hemolysis. Understanding this etiology sheds new light on RBC involvement as a pathophysiological target for SARS-CoV-2 by interfering with their function; consequently, therapies capable of restoring RBC function, such as erythrocytapheresis, could be repurposed for the treatment of worsening severe and critical COVID-19.

COVID-19 Infection After Total Joint Arthroplasty Is Associated With Increased Complications

BACKGROUND

The impact of a postoperative diagnosis of COVID-19 in patients undergoing total joint arthroplasty (TJA) remains unknown. The objective of this study is to characterize the effect of COVID-19 infection following TJA on perioperative complication rates.

METHODS

The Mariner database was queried for patients undergoing total hip and total knee arthroplasty from January 2018 to April 2020. TJA patients who were diagnosed with COVID-19 within 90 days postoperatively were matched in a 1:3 fashion based on age, gender, iron deficiency anemia, payer status, and Charlson Comorbidity Index with patients who were not diagnosed with COVID-19. Preoperative comorbidity profiles and complications within 3 months of surgery were compared. Statistical analysis included chi-squared tests and multivariate logistic regression with outcomes considered significant at P < .05.

RESULTS

Of the 239 COVID-19 positive patients, 132 (55.2%) underwent total hip arthroplasty. On multivariate analysis, COVID-19 diagnosis was associated with increased odds of deep vein thrombosis (odds ratio [OR] 4.86, 95% confidence interval [CI] 2.10-11.81, P < .001), pulmonary embolism (OR 6.27, 95% CI 2.57-16.71, P < .001), and all complications (OR 3.36, 95% CI 2.47-4.59, P < .001). Incidence of deep vein thrombosis/pulmonary embolism was greater the closer in time the COVID-19 diagnosis was to the surgical procedure (10.24 times at 1 month, 7.87 times at 2 months, and 1.42 times at 3 months; P < .001). A similar relationship was observed with all complications.

CONCLUSION

Postoperative COVID-19 infection is associated with higher rates of cardiopulmonary complications, thromboembolic disease, renal injury, and urinary tract infections in patients undergoing hip and knee arthroplasty. COVID-19 infection earlier in the postoperative period is associated with a higher risk of complications.

The Impact of Iron Dyshomeostasis and Anaemia on Long-Term Pulmonary Recovery and Persisting Symptom Burden after COVID-19: A Prospective Observational Cohort Study

Coronavirus disease 2019 (COVID-19) is frequently associated with iron dyshomeostasis. The latter is related to acute disease severity and COVID-19 convalescence. We herein describe iron dyshomeostasis at COVID-19 follow-up and its association with long-term pulmonary and symptomatic recovery. The prospective, multicentre, observational cohort study “Development of Interstitial Lung Disease (ILD) in Patients With Severe SARS-CoV-2 Infection (CovILD)” encompasses serial extensive clinical, laboratory, functional and imaging evaluations at 60, 100, 180 and 360 days after COVID-19 onset. We included 108 individuals with mild-to-critical acute COVID-19, whereas 75% presented with severe acute disease. At 60 days post-COVID-19 follow-up, hyperferritinaemia (35% of patients), iron deficiency (24% of the cohort) and anaemia (9% of the patients) were frequently found. Anaemia of inflammation (AI) was the predominant feature at early post-acute follow-up, whereas the anaemia phenotype shifted towards iron deficiency anaemia (IDA) and combinations of IDA and AI until the 360 days follow-up. The prevalence of anaemia significantly decreased over time, but iron dyshomeostasis remained a frequent finding throughout the study. Neither iron dyshomeostasis nor anaemia were related to persisting structural lung impairment, but both were associated with impaired stress resilience at long-term COVID-19 follow-up. To conclude, iron dyshomeostasis and anaemia are frequent findings after COVID-19 and may contribute to its long-term symptomatic outcome.

Emergency Hematopoiesis in the Pathobiology of COVID-19: The Dark Side of an Early Innate Protective Mechanism

The recognition of pathogens to which we are constantly exposed induces the immediate replenishment of innate immune cells from the most primitive stages of their development through emergency hematopoiesis, a central mechanism contributing to early infection control. However, as with other protective mechanisms, its functional success is at risk when the excess of inducing signals accelerates immunological catastrophes. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection exhibits a clinical spectrum that ranges from completely asymptomatic states to fatal outcomes, with the amplification of inflammatory components being the critical point that determine the progress, complication, and severity of the disease. This review focuses on the most relevant findings that entail emergency hematopoiesis to SARS-CoV-2 infection response and revolutionize our understanding of the mechanisms governing the clinical prognosis of COVID-19. Of special interest are the metabolic or hyperinflammatory conditions in aging that exacerbate the phenomenon and favor the uncontrolled emergency myelopoiesis leading to the evolution of severe disease.

Clinical Characteristics and Outcome of Pediatric COVID-19 Patients in Ethiopia During the Early COVID-19 Pandemic: A Prospective Cohort Study

Introduction

Setting

Methods

Results

Conclusion

Extensive Study on Hematological, Immunological, Inflammatory Markers, and Biochemical Profile to Identify the Risk Factors in COVID-19 Patients

Background

Tissue damage caused by COVID-19 could be detected by several clinical indicators including hematological, immunological, biochemical, and inflammatory markers. This study was to detect these clinical parameters to reveal the correlation between the factors and their roles in the development of COVID-19, to explore the hazard factors in severe cases.

Materials and Methods

A total of 200 participants of both sexes were included in the study, with an age range of (25–72) years, categorized into three main groups: 50 healthy individuals, 62 mild infected patients, and 88 severe infected patients with pneumonia. Different hematological and clinical parameters were included in the analysis (Basrah city, Iraq). Serum levels of interleukin-6 (IL-6), ferritin, and high-sensitivity C-reactive protein (hs-CRP) were assessed for all participants using an enzyme-linked immunosorbent assay (ELISA). The liver, renal, and cardiac functions were assessed by clinical chemistry testing.

Results

COVID-19 patients had leukocytosis, with an increased number of neutrophils and a decreased lymphocyte count, according to our findings. In regard to inflammatory parameters, both ESR and hs-CRP showed significant differences between the two groups, whereas IL-6 was significantly higher in the total severe group compared to the other two groups. Biochemical results revealed that each lactate dehydrogenase (LDH), ferritin, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) had significant changes in the total severe group. Among pneumonic with an O2 requirement and pneumonic without an O2 requirement, there were significant differences in immunological and inflammatory markers (p > 0.05). The neutrophils-lymphocytes ratio (NLR) was highly elevated in severe who required O2. Moreover, IL-6, lymphocytes, and neutrophils were possible risk factors for COVID-19 infection, with the strongest influence of IL-6 with a high odds ratio (OR: 24.138, 95% CI: 8.437–30.65, p < 0.01). Furthermore, there were significant correlations among the indicators.

Conclusion

Each of IL-6, lymphocytes, and neutrophils might represent major factors in the severity of COVID-19 and IL-6 plays the main role in inducing the inflammatory and pathophysiology process that is known as the cytokine storm.

COVID-19-Related Brain Injury: The Potential Role of Ferroptosis

The COVID-19 pandemic has caused devastating loss of life and a healthcare crisis worldwide. SARS-CoV-2 is the causative pathogen of COVID-19 and is transmitted mainly through the respiratory tract, where the virus infects host cells by binding to the ACE2 receptor. SARS-CoV-2 infection is associated with acute pneumonia, but neuropsychiatric symptoms and different brain injuries are also present. The possible routes by which SARS-CoV-2 invades the brain are unclear, as are the mechanisms underlying brain injuries with the resultant neuropsychiatric symptoms in patients with COVID-19. Ferroptosis is a unique iron-dependent form of non-apoptotic cell death, characterized by lipid peroxidation with high levels of glutathione consumption. Ferroptosis plays a primary role in various acute and chronic brain diseases, but to date, ferroptosis in COVID-19-related brain injuries has not been explored. This review discusses the mechanisms of ferroptosis and recent evidence suggesting a potential pathogenic role for ferroptosis in COVID-19-related brain injury. Furthermore, the possible routes through which SARS-CoV-2 could invade the brain are also discussed. Discoveries in these areas will open possibilities for treatment strategies to prevent or reduce brain-related complications of COVID-19.