Abstract

Background: Pulmonary embolism (PE) is one of the known sequels of COVID-19 infection We aimed to assess the incidence of PE in patients with COVID-19 infection and to evaluate the relationship between the CT severity of the disease and the laboratory indicators This was a retrospective study conducted on 96 patients with COVID-19 infection proved by positive PCR who underwent CT pulmonary angiography (CTPA) with a calculation of the CT severity of COVID-19 infection Available patients’ complaint and laboratory data at the time of CTPA were correlated with PE presence and disease severity Results: Forty patients (41 7%) showed positive PE with the median time for the incidence of PE which was 12 days after onset of the disease No significant correlation was found between the incidence of PE and the patients’ age, sex, laboratory results, and the CT severity of COVID-19 A statistically significant relation was found between the incidence of PE and the patients’ desaturation, hemoptysis, and chest pain A highly significant correlation was found between the incidence of PE and the rising in the D-dimer level as well as the progressive CT findings when compared to the previous one Conclusion: CT progression and the rising in D-dimer level are considered the most important parameters suggesting underlying PE in patients with positive COVID-19 infection which is commonly seen during the second week of infection and alert the use of CT pulmonary angiography to exclude or confirm PE This is may help in improving the management of COVID-19 infection © 2020, The Author(s)

Abstract

PURPOSE Acute macular neuroretinopathy (AMN) is a visual-deteriorating rare clinical entity with an uncertain etiology. We aimed to report a case of AMN and underlying disease of acute myeloid leukemia (AML). CASE PRESENTATION A thirty-five-year-old female patient with bone marrow biopsy confirmed AML, and bicytopenia, under chemotherapy, complained of sudden paracentral visual field defect in her right eye was referred. Visual acuity was 20/20 in both eyes. Posterior segment evaluation revealed multiple Roth's spots. Optical coherence tomography (OCT) demonstrated hyper-reflectivity band, in the outer nuclear layer and outer plexiform layer, nasal to the fovea of the right eye, and hyperreflective patch in outer retina segmentation en-face OCT, suggestive of the diagnosis of AMN. Nine days after AMN diagnosis, dyspnea, malaise, and cough was initiated. Ground glass opacities in lung CT scan, beside reverse transcription polymerase chain reaction of severe acute respiratory syndrome coronavirus-2, was conclusive of coronavirus disease 2019 (COVID-19). The patient deceased after 6 days. CONCLUSION We report a rare case of AMN following AML. Our findings support the role of ischemia in the outer retina, of which AML may contributed to the pathophysiological process. The patient has deceased less than 2 weeks from AMN initiation.

Abstract

Since the emergence of COVID‐19 in late 2019, our knowledge of the clinical implications of infection with SARS‐CoV‐2 has steadily grown. The clinical spectrum of COVID‐19 is broad, ranging from asymptomatic infection to multi‐organ failure. COVID‐19 induces a proinflammatory state, activating systemic coagulation and resulting in markedly elevated D‐Dimers, fibrinogen and a prolongation of the prothrombin time (PT) (Tang et al, 2020). Initial studies reported the development of Disseminated Intravascular Coagulation (DIC), associated with poorer outcomes (Tang et al, 2020). DIC results from perturbations in the normal haemostatic balance and may produce a clinical phenotype of thrombosis, bleeding or a combination thereof. Subsequently, the International Society on Thrombosis and Haemostasis (ISTH) issued guidance on the management of DIC in this setting (Thachil et al, 2020). This guidance was controversial, recommending admission based on coagulation parameters and more liberal transfusion thresholds (maintaining platelets >25 in non‐bleeding patients). At this time, COVID‐19 represented a particular challenge to transfusion services as concerns existed that transfusion requirements may be increased at a time of limited donor availability. Despite increasing data on thrombotic sequalae of COVID‐19, there remains a paucity of information on transfusion requirements in this clinical setting. This is of importance, not only for physicians, but for clinical transfusion services in order to plan stock management during the pandemic. To address this deficit, we retrospectively analysed the transfusion records and outcomes of a large cohort of patients with COVID‐19.

Abstract

ABSTRACT Objective To determine the incidence, characteristics, and risk factors of pulmonary embolism (PE) among patients hospitalized for COVID-19 Patients and Methods We performed a prospective observational study of a randomly selected cohort of consecutive patients hospitalized for COVID-19 infection between March 8, 2020 through April 25, 2020 All eligible patients underwent a computed tomography pulmonary angiography independently of their PE clinical suspicion and were pre-screened for a baseline elevated D-dimer level Results 119 patients were randomly selected from the 372 admitted to one tertiary hospital in Valencia (Spain) for COVID-19 infection during the period of study Seventy-three patients fulfilled both the inclusion criteria and none of the exclusion criteria and were finally included in the study Despite a high level of pharmacological thromboprophylaxis (89%), the incidence of PE was 35 6% (95% confidence interval [CI], 29 6 to 41 6%), mostly with a peripheral location and low thrombotic load (Qanadli score 18 5%) Multivariate analysis showed that heart rate (Hazard Ratio [HR], 1 04), room-air oxygen saturation (spO2) (HR, 0 87), D-dimer (HR, 1 02), and C-reactive protein (CRP) levels (HR, 1 01) at the time of admission were independent predictors of incident PE during hospitalization A risk score was constructed with these four variables showing a high predictive value of incident PE (AUC-ROC: 0 86;95% CI: 0 80 to 0 93) Conclusions Our findings confirmed a high incidence of PE in hospitalized COVID-19 patients Heart rate, spO2, D-dimer, and CRP levels at admission were associated with higher rates of PE during hospitalization

Abstract

OBJECTIVES The aim of this study was to investigate the impact of concomitant long-term medication-with a focus on ACE inhibitors and oral anticoagulation-on clinical outcomes in patients hospitalized with coronavirus disease 2019. METHODS This is a retrospective cohort study using claims data of the biggest German health insurance company AOK, covering 26.9 million people all over Germany. In particular, patient-related characteristics and co-medication were evaluated. A multivariable logistic regression model was adopted to identify independent predictors for the primary outcome measure of all-cause mortality or need for invasive or non-invasive ventilation or extracorporeal membrane oxygenation. RESULTS 6637 patients in 853 German hospitals were included. The primary outcome occurred in 1826 patients (27.5%). 1372 patients (20.7%) died, 886 patients (13.3%) needed respiratory support, and 53 patients (0.8%) received extracorporeal membrane oxygenation. 34 of these patients survived (64.2%). The multivariable model demonstrated that pre-existing oral anticoagulation therapy with either vitamin-K antagonists OR 0.57 (95% CI 0.40-0.83, p = 0.003) or direct oral anticoagulants OR 0.71 (95% CI 0.56-0.91, p = 0.007)-but not with antiplatelet therapy alone OR 1.10 (95% CI 0.88-1.23, p = 0.66)-was associated with a lower event rate. This finding was confirmed in a propensity match analysis. CONCLUSIONS In a multivariable analysis, a therapy with both direct oral anticoagulants or vitamin-K antagonists-but not with antiplatelet therapy-was associated with improved clinical outcomes. ACE inhibitors did not impact outcomes. Prospective randomized trials are needed to verify this hypothesis.

Abstract

BACKGROUND COVID-19 convalescent plasma (CCP) received an Emergency Use Authorization by the FDA. CCP with a signal-to-cutoff ratio of ≥12 using the Ortho VITROS SARS-CoV-2 IgG test (OVSARS2IgG) is permitted to be labeled "high titer". Little is known about the relationship between OVSARS2IgG ratio and neutralizing capacity of plasma/sera against genuine SARS-CoV-2 virus. METHODS 981 samples from 196 repeat CCP donors 0-119 days post initial donation (DPID) were analyzed. Neutralizing capacity was assessed for 50% (PRNT50) and 90% (PRNT90) reduction of infectious virus using the gold standard plaque reduction neutralization test (PRNT). A subset of 91 donations were evaluated by OVSARS2IgG and compared to PRNT titers for diagnostic accuracy. RESULTS 32.7%/79.5% (PRNT90/PRNT50) of donations met a 1:80 titer initially but only 14.0%/48.8% (PRNT90/PRNT50) met this cut-off ≥85 DPID. Correlation of OVSARS2IgG results to neutralizing capacity allowed extrapolation to CCP therapy results. CCP with OVSARS2IgG ratios equivalent to a therapeutically beneficial group had neutralizing titers of ≥1:640 (PRNT50) and/or ≥1:80 (PRNT90). Specificity and positive predictive value of the OVSARS2IgG for qualifying highly neutralizing CCP was optimal using ratios significantly greater than the FDA cut-off. CONCLUSIONS This information provides a basis for refining the recommended properties of CCP used to treat COVID-19.

Abstract

BACKGROUND Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58-75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723-7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue- plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. CONCLUSIONS While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.