The successful management of an elderly Covid-19 infected patient by plasmapheresis

Abstract

Letter to the Editor The successful management of an elderly Covid-19 infected patient by plasmapheresis Dear Editor, Coronavirus disease 2019 (COVID-19) is a pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China since December 2019. The epidemic spread rapidly worldwide, became a global threat and was characterized as a pandemic on March 11, 2020 by World Health Organization (WHO) [1]. It is not just a viral pneumonia, it can also cause a multisystemic disorder called COVID-19 immune syndrome [2]. In severe COVID-19 patients it was reported that the pro-inflammatory cytokins, mainly IL-6, IL-10, TNF-α were significantly increased around 7-14 days after onset, named as cytokine storm, which is also associated with the aggravation of disease and higher mortality [3,4]. Furthermore, most of these patients have already been in an induced-hypercoagulable state and predisposed to thrombosis. Currently, there isn't any specific effective and approved antiviral treatment for COVID-19 [5]. There aren't sufficient randomized controlled trials and so strong recommendations for the management of COVID-19 even from the international societies [2]. For better results and lower mortality rates, clinicians must both control the viral replication and also optimize the immun response. Plasmapheresis can take place successfully in the management of these patients with the use of anticoagulants and removal of both the inflammatory molecules and high molecular weight viscous components [6]. We want to emphasize the role of plasmapheresis by a critically ill Covid-19 patient whose clinical status worsen despite antiviral and tocilizumab treatments and who was successfully managed via performing plasmapheresis. A 65 year old female patient complaining of cough, myalgia and fatigue was admitted to our clinic who had a history of contact with a confirmed Covid-19 case. She had 3 comorbities: asthma, hypertension and type 2 Diabetes Mellitus. Her SARS-CoV-2 PCR test resulted negative, but her chest computed thomography(CT) revealed two small ground glass opacities in both lungs, which indicated COVID-19 pneumonia. According to our national Covid-19 treatment guidelines provided by the Ministry of Health, she was given hydroxychloroquine, azitromycine and oseltamivir. During hospital follow up, her maximum body temperature was 37.8 • C; all other vital signs were normal. Laboratory findings are summarized in Table 1. She completed the treatment schedule and was discharged from hospital after 5 days. On 10th day of the symptom onset she was readmitted to hospital with fever, cough, sputum and shortness of breath. Her fever was 38.5 • C, hearth rate was 118beats/min, respiratory rate was 26/min, blood pressure was 156/84 mmHg and oxygen saturation was 88 % at room air with intermittent prone positioning. Her thorax CT revealed bilateral multiple ground glass infiltrations (Fig. 1). Favipravir, enoxaparine prophylaxis, ceftriaxone and oxygen supplementation of 3 L/min were initiated. Laborat...

RETRACTED: Clinical and Scientific Rationale for the “MATH+” Hospital Treatment Protocol for COVID-19

“…Increasing publications of case series and case reports from centers across the world have now described the efficacy of TPE in over 60 COVID-19 patients that did not respond to initial therapies, with the majority having been treated with corticosteroids. 185 -195 Nearly all describe similar positive physiologic and clinical responses temporally associated with initiation or completion of TPE. Further, 3 retrospective, observational cohort studies including a total of 74 patients treated with plasmapheresis have reported dramatic differences in both extubation and survival.…”

On Therapeutic Plasma Exchange Against Severe COVID-19-Associated Pneumonia: An Observational Clinical Study

“…COVID-19 is an asymptomatic disease in most cases, but some patients develop life-threatening diseases characterized by acute respiratory distress syndrome (ARDS), sepsis, multisystem organ failure (MOF), extrapulmonary manifestations, thromboembolic disease, and associated cytokine release syndrome (CRS) (1)(2)(3). Although the pathophysiology of COVID-19 is far from being completely understood, the severe form of the disease is correlated with overrelease of proinflammatory cytokines (tumor necrosis factor, IL-6, and IL-1β), which cause strong inflammation, endothelial injury, thrombotic microangiopathy, MOF, and eventually death (4)(5)(6). The strict biological criteria to diagnose the CRS associated with COVID-19 remain however poorly defined (7).…”

On whether therapeutic plasma exchange is an effective cure against severe/critical COVID-19 pneumonia

“…COVID-19 is an asymptomatic disease in most cases, but some patients develop life-threatening disease characterized by acute respiratory distress syndrome (ARDS), sepsis, multisystem organ failure (MOF), extrapulmonary manifestations, thromboembolic disease and associated cytokine release syndrome (CRS) [1]. Although the pathophysiology of COVID-19 is far from being completely understood, the severe form of the disease is generally believed to be correlated with over-release of proinflammatory cytokines (tumor necrosis factor, IL-6, and IL-1β), which cause strong inflammation, endothelial injury, thrombotic microangiopathy, multiorgan failure and eventually death [2-4]. The strict biological criteria to diagnose the Cytokine Release Syndrome (CRS) associated with COVID-19 remain however poorly defined [5].…”

“…Therapeutic plasma exchange (TPE) is an extracorporeal treatment performed by filtrating a volume of plasma equivalent to the estimated plasma volume that selectively removes circulating pathogenetic substances, such as auto-reactive antibodies, immune complexes, paraproteins, lipoproteins, and inflammatory mediators like cytokines. TPE has been applied to manage different critical diseases - including the acute respiratory distress syndrome (ARDS) [8], pneumonia and respiratory failure from H1N1 influenza A virus [9], Kawasaki disease [10] and sepsis - effectively reducing the elevated levels of cytokines and inflammatory mediators, avoiding lethal complications as septic shock, pulmonary embolism, renal injury or disseminated intravascular coagulation [2,8,10- 12]. TPE as a remedy for the cytokine storm has also already been used as a supportive treatment for critically ill COVID-19 patients [2, 8], especially among those admitted to intensive care unit (ICU) [4].…”

“…TPE has been applied to manage different critical diseases - including the acute respiratory distress syndrome (ARDS) [8], pneumonia and respiratory failure from H1N1 influenza A virus [9], Kawasaki disease [10] and sepsis - effectively reducing the elevated levels of cytokines and inflammatory mediators, avoiding lethal complications as septic shock, pulmonary embolism, renal injury or disseminated intravascular coagulation [2,8,10- 12]. TPE as a remedy for the cytokine storm has also already been used as a supportive treatment for critically ill COVID-19 patients [2, 8], especially among those admitted to intensive care unit (ICU) [4].…”