PURPOSE:

• Zhang et al. report on their findings of significant coagulopathy and antiphospholipid antibodies in patients with COVID-19

METHODS:

• Case Series
  • ICU set up on an emergency basis for critically ill COVID-19 in Wuhan, China
• Participants
  • 3 cases with coagulopathy, antiphospholipid antibodies and multiple infarcts

RESULTS:

Case 1

• 69-year-old male
  • Comorbidities: Hypertension | Diabetes |History of stroke
  • Confirmed SARS-CoV-2 based on RT-PCR testing
• Presentation
  • Fever | Cough | Dyspnea | Diarrhea | Headache
• Clinical course
  • Required mechanical ventilation
  • Ischemia in the lower limbs bilaterally and left-hand digits
  • Neuro CT: Bilateral cerebral infarcts
  • Labs: Leukocytosis| Thrombocytopenia | Elevated PT, aPTT, fibrinogen and d-dimer | Anticardiolipin IgA antibodies, anti–β2-glycoprotein I IgA and IgG antibodies

Case 2

• 65-year-old female
  • Comorbidities: Hypertension | Diabetes | CAD
  • No history of thrombosis
• Presentation
  • Fever | Cough | Dyspnea
• Clinical course
  • Required mechanical ventilation
  • Neuro CT: Bilateral cerebral infarcts
  • Labs: Leukocytosis| Thrombocytopenia | Elevated PT, aPTT, fibrinogen and d-dimer | Anticardiolipin IgA antibodies, anti–β2-glycoprotein I IgA and IgG antibodies

Case 3

• 70-year-old male
  • Comorbidities: Hypertension | Nasopharyngeal carcinoma | Emphysema | Stroke
• Presentation
  • Fever | Fatigue | Dyspnea | Headache
• Clinical course
  • Required mechanical ventilation
  • Neuro CT: Bilateral cerebral infarcts
  • Labs: Leukocytosis| Thrombocytopenia | Elevated PT, aPTT, fibrinogen and d-dimer | Anticardiolipin IgA antibodies, anti–β2-glycoprotein I IgA and IgG antibodies

CONCLUSION:

• Antiphospholipid antibodies can appear in critically ill patients with infections
• Thrombotic events can arise in critically ill patients due to
  • Antiphospholipid antibodies
  • DIC
  • Heparin-induced thrombocytopenia
  • Thrombotic microangiopathy
• ISTH has released guidance on the management of coagulopathy in the setting of COVID-19 that include the following key points (see ‘Learn More – Primary Sources’)
  • Along with other key coag labs, monitor fibrinogen | Nonsurvivors may develop DIC around day 4
  • Use prophylactic dose low-molecular-weight heparin unless there is active bleeding or a platelet count of <25×109/L
  • Keep platelet counts >50×109/L in patients with bleeding and >20×109/L in nonbleeding patients | Fibrinogen >2.0 g/L | Prothrombin ratio <1.5

Learn More – Primary Sources:

Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19

ISTH interim guidance on recognition and management of coagulopathy in COVID‐19

Related ObG Topics:

ARDS, Critical Care and COVID-19: ‘Surviving Sepsis Campaign’ Guidelines and Key Points

COVID-19 Guidance: Key Highlights for Healthcare Professionals

COVID-19 and Liver Impairment: How Often Are ALT and AST Elevated?