Low versus high dose anticoagulation in patients with Coronavirus 2019 pneumonia at the time of admission to critical care units: A multicenter retrospective cohort study in the Beaumont healthcare system.

PURPOSE: Coagulopathy is common in patients with COVID-19. The ideal approach to anticoagulation remains under debate. There is a significant variability in existing protocols for anticoagulation, and these are mostly based on sporadic reports, small studies, and expert opinion. MATERIALS AND METHODS: This multicenter retrospective cohort study evaluated the association between anticoagulation dose and inpatient mortality among critically ill COVID-19 patients admitted to the intensive care units (ICUs) or step-down units (SDUs) of eight Beaumont Healthcare hospitals in Michigan, USA from March 10th to April 15th, 2020. RESULTS: Included were 578 patients with a median age of 64 years; among whom, 57.8% were males. Most patients (n = 447, 77.3%) received high dose and one in four (n = 131, 22.7%) received low dose anticoagulation. Overall mortality rate was 41.9% (n = 242). After adjusting for potential confounders (age, sex, race, BMI, ferritin level at hospital admission, intubation, comorbidities, mSOFA, and Padua score), administration of high anticoagulation doses at the time of ICU/SDU admission was associated with decreased inpatient mortality (OR 0.564, 95% CI 0.333-0.953, p = 0.032) compared to low dose. CONCLUSION: Treatment with high dose anticoagulation at the time of ICU/SDU admission was associated with decreased adjusted mortality among critically ill adult patients with COVID-19.

Emicizumab Use in Treatment of Acquired Hemophilia A: A Case Report.

BACKGROUND Acquired hemophilia A (AHA) is a rare hemorrhagic disorder that is caused by producing autoantibodies against factor VIII. It is usually characterized by severe, spontaneous bleeding, which can be life-threatening. The current standard treatments for bleeding prophylaxis are highly effective but accompanied with some disadvantages such as frequent intravenous infusions, high cost, and risk of thromboembolic complications. Emicizumab is a bispecific antibody with a therapeutic FVIII-mimetic nature. Emicizumab has shown a reduction in annualized bleeding rate in congenital hemophilia patients with and without inhibitors. The pathophysiological concepts and preclinical data suggest that Emicizumab can be effectively used for treating AHA. CASE REPORT We present the case of an 87-year-old woman admitted for symptomatic anemia and large chest wall and pelvic hematomas confirmed by imaging, without history of trauma. Her coagulation studies showed isolated prolonged activated partial thromboplastin time (aPTT), low factor VIII activity level, and high levels of factor VIII inhibitor. She was successfully treated with activated prothrombin complex concentrate (aPCC), which was transitioned to Emicizumab on discharge. No recurrent bleeding episodes or adverse events related to Emicizumab were reported during the 2-month follow-up period. CONCLUSIONS A subcutaneous weekly or biweekly injection of Emicizumab, a recombinant monoclonal antibody, offers several advantages: less frequent infusions, good hemostatic efficacy, possible outpatient therapy, and even more cost-effective than bypassing agents. More clinical studies should be conducted to compare Emicizumab with the current standards of care.

A New Challenging Strategy in the Prevention and Management of Tumor Lysis Syndrome in Patients with Chemo-Sensitive Hematological Malignancies.

INTRODUCTION: Tumor lysis syndrome (TLS) is a metabolic derangement that results from rapid destruction of cells. It happens frequently in cancers receiving chemotherapy, particularly hematological malignancies. It can lead to death in severe cases. Tumor lysis syndrome that leads to acute renal failure requiring dialysis and/or ICU admission can be associated with a higher rate of complications and mortality. CASE REPORT: We present a 24-year-old male patient with Burkitt's lymphoma. After receiving one cycle therapy, he developed severe kidney injury from TLS. We initiated renal replacement therapy soon after his admission to the ICU, with marked response to therapy. This led to early discharge from the ICU. CONCLUSION: Early initiation of renal replacement therapy after TLS-AKI can improve the severity of AKI and hasten recovery and prevent complications. This can lead to earlier discharge from the hospital and better outcomes.

Inherited factor II deficiency with paradoxical hypercoagulability: a case report.

: Congenital deficiency of factor II is a very rare autosomal recessive disorder that can result in a bleeding diathesis. Genotypically, individuals are either homozygous for a defective prothrombin gene or a compound heterozygote with different mutated prothrombin genes inherited from each parent. Phenotypically, it is characterized by either a low production of normal prothrombin or a near-normal production of dysfunctional prothrombin. Treatment is aimed at restoring normally functioning factor II circulating levels to sufficient concentration for hemostasis. Paradoxical thrombosis in patients born from a nonconsanguineous marriage with factor II deficiency has not been reported. A woman with known congenital factor II deficiency confirmed by history and hemostatic laboratory analysis presented with an unprovoked spontaneous thrombosis of the common femoral vein detected on color Doppler. Venous thrombosis can occur in congenital deficiency of factor II and inferior vena cava filter can be life-saving.

Idiopathic Relapsing Thrombotic Thrombocytopenic Purpura with Persistent ADAMTS13 Inhibitor Activity Treated Sequentially with Plasmapheresis, Rituximab, Cyclophosphamide and Splenectomy.

We here describe a patient with an idiopathic thrombotic thrombocytopenic purpura (TTP) secondary to an ADAMTS13 inhibitor that continued to be dependent on plasmapheresis until the patient was treated with rituximab. TTP manifestations subsided with rituximab treatment in spite of a persistently low ADAMTS13 activity and continued a detectable inhibitor activity until the patient developed an intolerance to rituximab due to an allergic reaction when cyclophosphamide was added; this resulted in a normalization of ADAMTS13 activity and the disappearance of the inhibitor. Later, the patient developed an intolerance to rituximab due to a severe allergic reaction. Soon after stopping rituximab, the ADAMTS13 activity level dipped below 5% in addition to the appearance of the ADAMTS13 inhibitor. The patient had a splenectomy after rituximab and cyclophosphamide treatment; the medication was stopped based on several case reports of a complete remission of TTP after splenectomy. We believe that the reason TTP went into remission in our patient was because of rituximab treatment, in spite of both persistently low ADAMTS13 activity and a detectable inhibitor activity due to reducing the release of von Willebrand factor large multimers from the endothelial cells. We found that ADAMTS13 activity normalized and the inhibitor activity became undetectable when cyclophosphamide was added to rituximab. We suggest adding cyclophosphamide to rituximab for the treatment of patients with persistent ADAMTS13 inhibitors in order to prolong the remission period and lower the rate of relapse.