Coronavirus Disease 2019-Associated Thrombotic Microangiopathy

Abstract

Coronavirus disease 2019 (COVID-19) has spread tremendously since its first appearance in December 2019. Infected individuals can experience a wide range of systemic complications, including thrombotic microangiopathy (TMA). Like the other forms of TMA, COVID-19-associated TMA is characterized by thrombocytopenia, hemolytic anemia, and organ failure (such as acute kidney injury). The role of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in COVID-19-associated TMA is most probably dual: it can act either as a trigger to an underlying condition or as a cause of TMA. As opposed to the majority of other reported cases, it may be that in our case COVID-19 was the only cause of TMA. We present a case of a 32-year-old previously healthy man who was treated for acute kidney injury associated with TMA, which we believe was caused by COVID-19. Thrombotic thrombocytopenic purpura, as well as other possible known causes of typical and atypical hemolytic-uremic syndrome, was excluded. During his hospitalization, three negative nasopharyngeal swabs for SARS-CoV-2 were obtained, but serological tests showed the presence of IgG and IgA antibodies. After initial treatment known to be helpful in other forms of TMA (therapeutic plasma exchange and methylprednisolone), his renal function and platelet count recovered completely. Our case illustrates the importance of quickly recognizing this life-threatening complication of COVID-19 and using treatment that has been shown to be beneficial in other forms of TMA. Future studies of the pathophysiology and subsequent targeted treatment of this novel disease are needed.

Coronavirus disease 2019-associated thrombotic microangiopathy treated with plasma exchange and antihypertensive therapy in a patient with HIV: A case report with literature review

“…A total of 63 patients were identified as having TMA associated with COVID-19. Of these, 24 were reported as COVID-19-related TMA (Table 2) [21–39] , 23 as TTP (Table 3) [40–61] , and 16 as aHUS (Table 4). [62–73]…”

“…A total of 63 patients were identified as having TMA associated with COVID-19. Of these, 24 were reported as COVID-19related TMA (Table 2) [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] , 23 as TTP (Table 3) , and 16 as aHUS (Table 4). [62][63][64][65][66][67][68][69][70][71][72][73] [40] The cases of COVID-19-related TMA had a male predominance (58.3%) with a mean age of 44.5 years (interquartile range: 34.75-57.75 years).…”

Neuroimaging of COVID-19

“…43,44,54 Prominent microvascular thrombosis in COVIDÀ19 has been proposed to represent thrombotic microangiopathy (TMA) in cases demonstrating thrombocytopenia, hemolytic anemia, acute kidney injury, or other organ failure. 55,56 TMA is a spectrum of microvascular occlusive diseases thought to be caused by endothelial injury and thrombogenic plasma triggering platelet aggregation and thrombus formation. TMA includes thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome, disseminated intravascular coagulation (DIC), and similar disorders related to autoimmune disease, drug/toxin exposure, and malignant hypertension.…”

Efficacy and Safety of Reparixin in Patients with Severe COVID-19 Pneumonia: A Phase 3, Randomized, Double-Blind Placebo-Controlled Study

“…These are vital innate immune responses against SARS-CoV-2, as they appear to be the most activated cellular immune responses in COVID-19 [ 5 , 6 ]. However, these same processes may contribute to lung tissue damage and systemic complications such as thrombosis, acute respiratory distress syndrome, and multisystem inflammatory disease in children [ 7 , 8 ]. Interleukin-8 [IL-8, also known as chemokine ligand 8 (CXCL8)] is the principal chemoattractant of neutrophils in the lung, with elevated systemic levels associated with poor outcomes in COVID-19 [ 9 , 10 ].…”