ABSTRACT
Background/Purpose: MIS-C is uncommon and yet potentially life threatening disorder associated with COVID-19 infection. MIS-C Malaysia Study Group had reported 174 cases, mostly affecting children < 12 years old (93.7%). The fatality rate was 4%. Hereby, we report a case of MIS-C at our adult rheumatology centre. Method(s): Patient's admission note and electrical medical information were reviewed. Result(s): This is a 17 year-old adolescent with underlying obesity (BMI 42 kg/m2). He completed COVID-19 vaccination (Pfizer-BioNTech x 2 doses) in October 2021. In end-February 2022, he presented acutely with recurrent seizures associated with fever (40.3degreeC) and headache. The COVID-19 RTK antigen and PCR tests were positive, and COVID-19 IgM & IgG were negative. At emergency room, he developed haemodynamic instability, needing ventilatory support for respiratory failure and inotropic therapy on Day 1 of illness. The initial diagnosis was severe COVID-19 infection with encephalitis and secondary bacterial infection. Subsequent investigations showed evidence of systemic inflammation with organ dysfunction involving neurological (seizures, CNS vasculitis), cardiac (myocarditis), renal (acute kidney injury) and gastrointestinal (acute livery injury) systems. MIS-C was then diagnosed with early initiation of immunomodulatory treatment (IVIg 2 g/kg and IV methylprednisolone 1-2 mg/kg/day) according to ACR recommendation. Low dose aspirin and high intensity prophylactic SC enoxaparin were prescribed but were discontinued soon due to bleeding tendency. Antimicrobial therapy was continued until microbiological study was proven sterile. With the immunomodulatory treatment, he had rapid clinical and laboratory improvement within first week and was transferred out from ICU on Day 10 of illness. The organ dysfunction was mostly resolved with no sequelae except for high blood pressure requiring antihypertensive. Inflammatory markers were markedly reduced;Serum ferritin reduced from 22,339 to 565.8 mug/L, procalcitonin decreased from 26.7 ng/ml to 1.5 ng/ml and CRP normalised (<5 mg/L). Home discharge was made on Day 16 of illness with oral prednisolone 60 mg daily without antiplatelet. During clinic visit after D30 of illness, he remained asymptomatic with good effort tolerance and normal blood pressure readings. He subsequently completed the high school examination in April 2022 and even enrolled at college later. Oral prednisolone was eventually tapered off at 3rd month of illness with appointments for MRI cardiac and brain scheduled for further assessment. Conclusion(s): MIS-C is a hyperinflammatory syndrome which requires high clinical suspicion as many patients response well to early immunodulatory treatment without sequelae. Long term follow up maybe needed for those with cardiac involvement. (Table Presented).
ABSTRACT
Background: The coagulation system showed significant variations in COVID-19 patients. These variations may parallel the disease stage of COVID-19 toward either a hyper-activation or coagulopathy syndrome. Classical clotting tests assist in exploring coagulation disorders, but they are unsuitable to examine prothrombotic conditions. In this regard, thrombin generation assay helps for a global assessment of the coagulation process, being appropriate for investigating hypercoagulable states and bleeding tendency. Aim(s): It was investigated whether thrombin generation assay reveals coagulation variations in COVID-19 patients by a care setting design. Method(s): From October to December 2020, it have been enrolled 27 and 40 patients with a confirmed COVID-19 diagnosis who were hospitalised in an Intensive Care Unit (ICU) and a Medical Ward (MW), respectively. Also, 34 healthy subjects were included in this study. Thrombin generation parameters were evaluated using a Calibrated Automated Thrombogram system. Informed consent and approval by the local medical Ethics Committee were obtained. Result(s): Lag-Time and time-to- peak found in ICU and MW patients were significantly higher than those found in healthy subjects (Kruskal-Wallis test: P < 0.0001). Endogenous-Thrombin- Potential and thrombin-peak observed in ICU and MW patients were significantly lower than those observed in healthy subjects (Kruskal-Wallis test: P < 0.0001). No statistically significant differences in all the parameters measured were observed between ICU and MW patients. Conclusion(s): Thrombin generation assay performed in this study evidenced an acquired coagulopathy in COVID-19 patients that, however, seems to be unrelated to the care setting and, in turn, to the clinical disease severity.
ABSTRACT
The relevance of coagulation malfunction in COVID-19 (severe coronavirus disease) is ambiguous. Current study aimed to assess the coagulation among SARS-CoV-2 hospitalized patients. A cross sectional study with qualitative approach was conducted among 300 patients who are already diagnosed as COVID 19 compared to 300 apparently healthy control group attended to Red Sea State during study period from April 2020 to April 2021. The Humaclot Due Plus1 coagulation analyser was used to estimate the prothrombin time (PT), activated partial prothrombin time (APTT), and international normalized ratio (INR) (Wiesbaden 1, Germany), adding 25 μL of plasma in cuvette. The study result showed that in COVID-19 patients D.dimer level is high (2000-10000 ng/mL) compared with control group (up to 500 ng/mL). COVID-19 infection cause high D. dimer level which can lead to thrombosis event or bleeding tendency. Abnormal coagulation results were revealed among SARS-CoV-2, with markedly elevated D. dimer.
ABSTRACT
Background: Recent scientific evidence states that a subset of COVID-19 patients have a risk of increased bleeding tendency. This case report presents a 38-year-old woman with periodontitis, generalized stage III, grade C with an abnormal post-operative blood clot formation, who tested positive for COVID-19 5 days after a standard periodontal surgery. nature.com/articles/s41598-020-80010-z. Description of the procedure: After initial periodontal treatment and re-evaluation, we proceeded to the surgical phase including: 1. regenerative procedure with EMD 15 2. regenerative procedure with EMD 44 3. open flap debridement 13-23 4. shortened flap 34-37. Outcomes: Periodontal surgical procedures (1) and (2) proceeded without any complications and were considered standard. On day 1 after the third periodontal surgery (3), the patient was called for post-operative control. The patient had no complaints.On day 2 post-operative, the patient reported by email excess of bleeding in the oral cavity from the operated area, simultaneously with fever and loss of taste. A photo taken by the patient confirmed the abnormal blood clot. On day 3, in compliance with COVID-19 protocols, the patient was seen urgently in our clinic while her COVID-19 symptoms had started to decline. During the appointment, the bleeding tendency was less acute than the day before. Further suturing for precaution was decided. The same day the patient received a COVID-19 PCR test. On day 4 post-operative, the report of the PCR test was confirmatory for COVID-19 and the patient reported no further complaints of intraoral bleeding. Conclusions: After considering the normal response of the initial treatment and the well documented good post-operative healing pattern of the periodontal tissues for this patient, we concluded that the abnormal bleeding tendency was associated with an active phase of COVID-19. Clinicians should be aware that during the first days after a periodontal surgery patients could have bleeding complications due to an active phase of COVID-19. labblog.uofmhealth.org/lab-report/ subset-of-covid-19-patients-have-increased-bleeding-risk.
ABSTRACT
[Formula presented] Background: The COVID-19 pandemic has brought a spotlight on the high incidence of thrombosis and abnormal coagulation parameters in patients with the 2019 novel coronavirus. We evaluated 30 day mortality and thrombotic events relative to anticoagulation therapy and coagulation parameters in Hispanic and non-Hispanic patients in California's central valley. Methods: We identified 886 non-pregnant adults hospitalized at Community Medical Centers in the Central Valley of California with SARS-CoV2 infections from 3/1/20 to 9/1/20. We conducted manual chart review and excluded patients on long term anticoagulation prior to admission. We collected data on ethnicity, coagulation labs, thrombotic events and 30 day all-cause mortality outcomes. The distributions of variables were reviewed to detect illogical and out of range values. Differences in means of continuous variables were evaluated via the t-test. Differences in categorical variables were evaluated with chi square tests. All tests are two-sided and a p-value < 0.05 was considered statistically significant. Results: Among the 866 COVID positive patients, 568 (64%) were Hispanic and 318 (36%) were non-Hispanic. The gender distribution was equivalent with 57% males and 43% females. Hispanic patients were younger with a mean age of 56.1 years vs 63.2 years in non-Hispanics. Mean BMI was 32.7 for Hispanics and 30.5 for non-Hispanics (p<0.05). The risk factor assessment for severe COVID-19 infection revealed a history of thrombosis or thrombophilia, bleeding tendency, obesity, active cancer, diabetes, cardiovascular disease, end stage renal disease, liver cirrhosis and immunosuppression, all of which were not statistically significant between Hispanics and non-Hispanics. However, chronic lung disease (p<0.05) and residing in a skilled nursing or long-term care facility (p<0.001) were statistically significant (Table 1). 16% of non-Hispanics had chronic lung disease vs 10.9% of Hispanics. Likewise, 10.4% of non-Hispanics inhabited care facilities compared to 3.9% of Hispanics. Review of initial CRP values exhibited statistical significance (p=0.017) amidst Hispanics at 145.3 and non-Hispanics at 124.8. Other labs including PT, INR, PTT, d-dimer, fibrinogen, platelets, ferritin and ESR were not statistically significant between ethnic groups. Mean hospital stay for Hispanics and non-Hispanics were analogous at 12.8 days and 12.9 days respectively. Intensive care unit admission rates were higher for Hispanics at 32.7% (186/568) in contrast to non-Hispanics at 28.3% (90/318) (p=0.171). Evaluation of 30 day mortality revealed that 14.2% (81/568) of Hispanic patients died compared to 17.9% (57/317) of non-Hispanic patients. (p=0.147). The bleeding rate was 4.8% in Hispanics and 3.8% in non-Hispanics. 59 (6.6%) patients experienced some form of thrombosis, which was dichotomized to show that 39 (6.8%) Hispanics and 20 (6.2%) non-Hispanics incurred thrombosis during hospitalization. 19.4% (18/93) of patients on therapeutic anticoagulation and 5.1% (34/657) of patients on prophylactic low dose anticoagulation developed thrombosis (P=0.00001). 30 day mortality was higher in patients receiving therapeutic vs low dose standard anticoagulation prophylaxis (20.4% Vs 14.5%. p=0.006). Thrombotic events transpired at 4.7% (22/464) in patients with initial d-dimer <2500 in comparison to 15.8% (19/120) of patients with values ≥2500 (p<0.001). Additionally, 30 day mortality was lower for patients with d-dimer < 2500 at 13.4% (62/464) than for patients with d-dimer ≥ 2500 at 30.8% (37/120) (p<0.001). Prothrombin time (PT) > 16 correlated with a higher incidence of thrombosis (17% vs 6.7%. p<0.001) and 30-day mortality (36% vs 15.9%. p <0.001). Similarly, 30 day mortality was increased in patients with ferritin > 1000 (22.7% vs 12.1%. p= 0.002). However, the same was not observed for ferritin levels and thrombosis. Conclusions: This study illuminates ethnic variances with respect to COVID-19 hospital outcomes. Hispanic patients were younger and had less risk factors or severe COVID-19 infections. Regardless of ethnic differences, incidence of thrombosis and 30 day mortality were similar. Despite sicker patients receiving therapeutic anticoagulation, the 30 day mortality and rate of thrombotic events remain higher among these patients. D-dimer ≥ 2500 and elevated PT were associated with higher rate of thrombosis and death. [Formula presented] Disclosures: Abdulhaq: BMS, Alexion, Oncopeptides, Morphosys, Pfizer, Norvartis: Honoraria;Oncopeptides, Alexion, Amgen: Speakers Bureau;Morphosys, BMS, Amgen: Membership on an entity's Board of Directors or advisory committees.