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2020-05-22| COVID-19

Links Between COVID-19 and Coagulopathy – A New Direction for COVID-19 Research

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By Rutuja Muthal, Ph.D.

With the steady progress made in COVID-19 research, the scientific community learns about newer symptoms, and treatment strategies are being redefined from time to time. The disease is associated with broad-spectrum manifestations from being asymptomatic to developing mild symptoms such as fever, cough, and diarrhea to severe ones such as respiratory distress, pneumonia, severe lung dysfunction, and in some cases, multiple organ failure [1]. Recent pieces of evidence link hypercoagulability and disseminated intravascular coagulopathy (DIC) with disease severity and mortality [2]. This has paved a new direction for diagnostic and therapeutic research.

 

COVID-19, DIC and Thrombosis

Many critical COVID-19 patients develop coagulopathies such as DIC, which are associated with increased mortality risk [2]. Prolonged prothrombin time and elevated D dimer levels are important indicators of COVID-19-associated coagulopathy (CAC), which differs from DIC in sepsis. Furthermore, it is associated with an increase in inflammation markers like CRP [3]. Several articles report the development of venous, arterial, or novel thromboembolic complications in severe COVID19 patients.

In a recent study conducted by the Irish Centre for Vascular Biology, RCSI, and St James’s Hospital, Dublin suggest that as distinct to DIC, the diffuse bilateral pulmonary inflammation observed in COVID-19 is associated with a novel pulmonary-specific vasculopathy termed as pulmonary intravascular coagulopathy (PIC) [4,5]. Severe COVID-19 disease is found to be associated with an increase in D-dimer levels and being consistent with progressive coagulation activation and parallel activation of fibrinolysis within the lungs.

Additionally, the presence of several small blood clots was observed throughout the lungs, in addition to pneumonia affecting the small air sacs in such patients. This condition is different from other types of lung infections and correlates with a drastic fall in blood oxygen levels in severe patients [6]. From the appearance of harmless skin lesions on feet (COVID toe) to developing life-threatening blockages in blood vessels (causing stroke), doctors have observed numerous clotting related disorders in COVID-19 patients [7].

 

Anticoagulant Therapy

Low Molecular Weight Heparin (LMWH) therapy is being used in managing COVID-19 patients. A study consisting of a majority of COVID-19 patients of Caucasian origin were subjected to LMWH therapy at the time of admission. Even with the evidence of progressive coagulopathy, systemic DIC was absent in these patients [6]. Another article has recommended the use of LMWH, UFH, or fondaparinux at doses indicated for prophylaxis of venous thromboembolism (VTE) in all COVID-19 hospitalized patients; unless any anticoagulant contraindications [8]. A study published in the Journal of Thrombosis and Haemostasis also suggests that the patients meeting SIC criteria or with increased D-dimer may benefit from anticoagulant therapy mainly with LMWH [9].

All these studies necessitate further research on prophylactic anticoagulant therapy in COVID-19 patients. For patients with pre-existing thrombotic conditions, it is essential to follow precautionary measures to avoid COVID infection. Timely monitoring of coagulopathy in patients with severe COVID-19 by measuring prothrombin time, platelet count, and D-dimer concentrations may aid in prognosis [10]. It is thus important to look out for signs of coagulopathy along with other COVID-19 symptoms like fever, respiratory distress. This might aid in early detection and better management of complications from COVID-19 infection.

Related Article: A Review of Neurological Symptoms in COVID-19 Patients

References
  1. https://www.nejm.org/doi/full/10.1056/NEJMoa2004500
  2. https://onlinelibrary.wiley.com/doi/10.1111/jth.14768
  3. https://www.hematology.org/covid-19/covid-19-and-coagulopathy
  4. https://www.sciencedirect.com/science/article/pii/S1568997220300926
  5. https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(20)30121-1/fulltext
  6. https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.16749
  7. https://www.bloomberg.com/news/articles/2020-05-04/coronavirus-causes-blood-clots-harming-organs-from-brain-to-toes
  8. https://pubmed.ncbi.nlm.nih.gov/32281926/
  9. https://onlinelibrary.wiley.com/doi/10.1111/jth.14817
  10. https://onlinelibrary.wiley.com/doi/full/10.1111/jth.14810

 

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