Emerging evidence of a COVID-19 thrombotic syndrome has treatment implications

Nat Rev Rheumatol. 2020 Oct;16(10):581-589. doi: 10.1038/s41584-020-0474-5. Epub 2020 Jul 30.

Abstract

Reports of widespread thromboses and disseminated intravascular coagulation (DIC) in patients with coronavirus disease 19 (COVID-19) have been rapidly increasing in number. Key features of this disorder include a lack of bleeding risk, only mildly low platelet counts, elevated plasma fibrinogen levels, and detection of both severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and complement components in regions of thrombotic microangiopathy (TMA). This disorder is not typical DIC. Rather, it might be more similar to complement-mediated TMA syndromes, which are well known to rheumatologists who care for patients with severe systemic lupus erythematosus or catastrophic antiphospholipid syndrome. This perspective has critical implications for treatment. Anticoagulation and antiviral agents are standard treatments for DIC but are gravely insufficient for any of the TMA disorders that involve disorders of complement. Mediators of TMA syndromes overlap with those released in cytokine storm, suggesting close connections between ineffective immune responses to SARS-CoV-2, severe pneumonia and life-threatening microangiopathy.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Anticoagulants / therapeutic use
  • Antiviral Agents / therapeutic use
  • Betacoronavirus / immunology*
  • Complement System Proteins / immunology
  • Coronavirus Infections / complications*
  • Coronavirus Infections / epidemiology
  • Coronavirus Infections / immunology
  • Coronavirus Infections / virology
  • Cytokines / immunology
  • Disseminated Intravascular Coagulation / drug therapy
  • Disseminated Intravascular Coagulation / immunology
  • Disseminated Intravascular Coagulation / pathology
  • Disseminated Intravascular Coagulation / virology
  • Fibrinogen / analysis
  • Humans
  • Immunoglobulins, Intravenous / therapeutic use
  • Immunosuppressive Agents / therapeutic use
  • Pandemics
  • Plasma Exchange / methods
  • Platelet Count / methods
  • Pneumonia, Viral / complications*
  • Pneumonia, Viral / epidemiology
  • Pneumonia, Viral / immunology
  • Pneumonia, Viral / virology
  • Risk Factors
  • Thrombosis / drug therapy
  • Thrombosis / immunology*
  • Thrombosis / pathology
  • Thrombosis / virology
  • Thrombotic Microangiopathies / drug therapy
  • Thrombotic Microangiopathies / immunology
  • Thrombotic Microangiopathies / pathology
  • Thrombotic Microangiopathies / virology

Substances

  • Anticoagulants
  • Antiviral Agents
  • Cytokines
  • Immunoglobulins, Intravenous
  • Immunosuppressive Agents
  • Fibrinogen
  • Complement System Proteins

Supplementary concepts

  • COVID-19
  • severe acute respiratory syndrome coronavirus 2