Plasma Exchange in the Treatment of Thrombotic Microangiopathy Associated With Covid-19 Infection: A Case Report

Abstract

The novel Coronavirus-2019 pandemic brings a largely unfamiliar landscape and continual quest for understanding of the spectrum of presentation for this disease. Recent studies have shown endothelial injury as the trigger for the cytokine storm seen in Covid-19 infection. Hypercoagulability and excessive complement activation can lead to a diffuse thrombotic angiopathy and organ dysfunction CASE PRESENTATION: 40 year old Hispanic male with no past medical history presented to the emergency room with weakness, AMS, recurrent hematemesis. Upon arrival, he was immediately intubated for airway protection. On exam pertinent findings included fever of 102 F, response to noxious stimuli only, and scleral icterus. Laboratory data revealed creatinine 8.08 mg/dL, LDH >2500 IU/L, haptoglobin <10 mg/dL, bilirubin 1.2 mg/dL, hemoglobin 6.8 g/dL, platelets 7,000/L with presence of 3+ schistocytes and positive test for COVID-19. PCR was negative for STEC and shigella. Given a PLASMIC score of 7, a presumptive diagnosis of thrombotic thrombocytopenic purpura (TTP) was made and daily plasma exchange (PEX) with dialysis was urgently initiated. A normal ADAMTS13 level led to discontinuation of PEX after 3 sessions; however, after 4 days hemolysis worsened with low C3 complement, therefore PEX was restarted. A complement panel was suggestive of alternative pathway dysregulation. Patient underwent 15 additional sessions of PEX with resolution of hemolysis, improved renal function and mental status.

Thrombotic microangiopathy (aHUS/iTTP) reported so far in Covid-19 patients: The virus alone or an omnium gatherum of mechanisms and etiologies?

“…Beaulieu et al reported a case of COVID-19 associated cases of iTTP which responded to PEX and caplacizumab ( Beaulieu et al, 2021 ). Two more cases of aHUS and iTTP complicating COVID-19 infection were very recently reported however, exposure to HCQ was not mentioned both responded to PEX ( Logan et al, 2020 ; El-Sawalhy et al, 2021 ). Maharaj et al recently reported a challenging scenario of a case of recalcitrant iTTP with a past history of frequent relapses and thrombotic complications, who was recovering from a recent relapse of TMA.…”

Investigation of plasma exchange and hemoperfusion effects and complications for the treatment of patients with severe COVID‐19 (SARS‐CoV‐2) disease: A systematic scoping review

“…Eventually, after reading the full text of these articles, 21 articles were included for the final data extraction. 13 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 Inter‐rater agreement following the first round of screening between the two investigators was 94.26% (Cohen's k = 0.55). Within the second round of screening, inter‐rater agreement rose to 100%.…”

“…Twelve studies were enrolled in this category and PE was introduced as a therapeutic strategy for critically ill patients with COVID‐19. This category included 1/12 clinical trial, 24 1/12 cohort, 26 1/12 case‐control, 22 5/12 case series, 23 , 25 , 28 , 38 , 40 and 4/12 case reports 30 , 31 , 33 , 37 (Table 3 ).…”

“…Of the rest, 59 papers were excluded in the next level. Eventually, after reading the full text of these articles, 21 articles were included for the final data extraction 13,21–40 . Inter‐rater agreement following the first round of screening between the two investigators was 94.26% (Cohen's k = 0.55).…”

“…This category included 1/12 clinical trial, 24 1/12 cohort, 26 1/12 case-control, 22 5/12 case series, 23,25,28,38,40 and 4/12 case reports 30,31,33,37 (Table 3). Zhang et al 25 applied one session of PE for three patients with a plasma separator multi-filtration system, and about 3000 ml of normal FFP was exchanged for one person.…”