СУЧАСНІ АСПЕКТИ РОЗВИТКУ КОАГУЛОПАТІЇ У ПАЦІЄНТІВ ПРИ COVID‑19 ІНФЕКЦІЇ: ОГЛЯД ЛІТЕРАТУРИ

This review summarizes current knowledge about coagulation disorders associated with COVID-19 infection. Despite a significant amount of research, it is currently unclear whether COVID-19 is the direct cause of coagulopathic disorders or they occur as the infectious process progresses. Different authors have proposed several pathogenetic mechanisms for the development of coagulopathy in this disease. However, the most important is the release of a large number of cytokines that provoke interstitial inflammation, endothelial damage and activation of coagulation, in the pathogenesis of which the tissue factor plays a key role. Hyperinflammatory reactions lead to tissue damage, disruption of the endothelial barrier and uncontrolled activation of coagulation. In the lungs and, possibly, in other organs, under the influence of the virus, local damage to the vascular endothelium occurs, which leads to angiopathy, activation and aggregation of platelets with the formation of blood clots and concomitant consumption of platelets. Systemic hypercoagulation and hyperfibrinogenemia significantly increase the likelihood of large vessel thrombosis and thromboembolic complications, which are detected in 20–30% of patients in the intensive care units. Along with an increase in the level of cytokines in the blood, their content also increases in the lungs and in the bronchoalveolar lavage fluid. Cytokine storm leads to systemic intravascular coagulation, multiple organ failure and death. The review also provides the rationale for the principles of managing patients with coagulopathy based on the known mechanisms of unique disorders inherent in COVID-19. It has been shown that the problem of the pathogenesis of the development of blood clotting disorders in COVID-19 infection remains relevant.

An Insight to ncovid-19 associated coagulopathy

: Several current studies have highlighted the high occurrence of coagulopathy in nCOVID-19 infection. The corona virus often prompts hypercoagulability along with both microangiopathy and local thrombus development, and systemic coagulation limitation which causes large vessel thrombosis and key thromboembolic issues such as pulmonary embolism in seriously ill hospitalized patients. Based on recent reports, the most severely ill patients present with coagulopathy, and disseminated intravascular coagulation (DIC)-like massive intravascular clot formation is frequently seen in this cohort. Therefore, coagulation tests may be considered useful to discriminate severe cases of nCOVID-19. The clinical presentation of nCOVID-19-associated coagulopathy is organ dysfunction primarily, while hemorrhagic events are less frequent. Changes in hemostatic biomarkers represented by increase in D-dimer and fibrin/fibrinogen degradation products indicate the essence of coagulopathy is massive fibrin formation. Overall, the patients have an increase in venous and arterial thrombotic events especially in ICU patients. Routine thromboprophylaxis with low molecular weight heparin is recommended in all hospitalized patients to reduce the incidence of thrombosis. Though, the importance of thromboembolic impediments has not been extensively spotlighted, thus the rationale of this article is to provide recent information about this severe difficulty. In this article the mechanism of coagulopathy, associated problems and possible therapeutics has been reviewed.

Fatal large-vessel cerebrovascular infarct presenting with severe coronavirus disease 2019 in a 39-year-old patient: a case report

Background Emerging reports are describing stroke in young, otherwise healthy patients with coronavirus disease 2019, consistent with the theory that some of the most serious complications of coronavirus disease 2019 are due to a systemic coagulopathy. However, the relevance of both the severity of coronavirus disease 2019 illness and established vascular risk factors in these younger patients is unknown, as reports are inconsistent. Case presentation Here we describe a 39-year-old white male, who died after presenting simultaneously with a malignant large-vessel cerebrovascular infarct and a critical coronavirus disease 2019 respiratory illness. Doppler ultrasound revealed evidence of carotid plaque thrombosis. Blood tests revealed evidence of undiagnosed diabetes mellitus; however, the patient was otherwise healthy, fit, and active. Conclusions This unique case highlights a possible interaction between established risk factors and large-vessel thrombosis in young patients with coronavirus disease 2019, and informs future research into the benefits of anticoagulation in these patients.

Mesenteric Vessel Thrombosis Treatment Experience

BACKGROUND: One of the most serious diseases among all emergency abdominal pathology is an acute violation of the mesenteric blood circulation. The rapid development of intestinal ischemia results in its infarction and necrosis. AIM: The study aims to assess the survival rate of patients with mesenteric vascular thrombosis, taking into account, the predictor characteristics influence of disease development factors. METHODS: The study presents a retrospective analysis of mesenteric vascular thrombosis clinical cases for 2016–2019. During this period, there were 147 patients with an established diagnosis at the Irkutsk Clinical Hospital No. 1, 21 of them met the study criteria. RESULTS: According to the type of thrombosis, there were two groups – occlusive (Group I, n = 11) and non occlusive (Group II, n = 10). Four patients (36.3%) of Group I and 7 patients (70%) of Group II (p = 0.388) recovered from the disease. Three patients (27.2%) of Group I and 4 patients (40%) of Group II (p = 0.662) received conservative therapy, 2 of them (66.6%) in Group I and 4 (100%) in Group II (p = 0.724) recovered from the disease. In addition, the authors performed a mortality assessment, according to the timing of the visit to a medical institution. Four (50%) out of eight patients who applied in the first 12 h, 2 (66%) out of three – in the first 12–24 h, and 5 (50%) out of 10 for more than 24 h of illness had a positive treatment result in the combined group. CONCLUSION: The patients over 70 years old with peritoneal symptoms and established intestinal necrosis have an extremely unfavorable prognosis. The primary mesenteric vessel thrombosis with additional contrast angiography still gives a moderate treatment prognosis.

A Rare Case of Xanthogranulomatous Pyelonephritis with Spontaneous Renocolic Fistula and IVC Thrombosis

Xanthogranulomatous pyelonephritis (XGPN) is a rare disorder affecting the kidney which can fistulise to the colon in exceptional cases. We herein report a case of XGPN with renocolic fistula and large vessel thrombosis presenting with sepsis and pulmonary embolism. Preoperative diagnosis and strategic planning resulted in successful management. A 64-year-old woman presented to the emergency department with abdominal pain and a septic condition, corroborated by venous thromboembolism. Workup diagnosed a left renal abscess with calicocolic fistula. Scintigraphy confirmed a nonfunctioning left kidney. The patient underwent inferior vena cava filter placement and staged surgery. The first, damage control procedure was a loop ileostomy. Ten days later, when the patient’s conditions improved, she underwent left nephrectomy and left colectomy with primary anastomosis. Finally, a year later, the ileostomy was closed. At follow-up, the patient was well, with unremarkable renal function. Scrupulous diagnostics, multidisciplinary decision making, and staged intervention have been key to optimal outcome.

A Systematic Review of Abdominal Imaging Findings in COVID-19 Patients

<b><i>Objective:</i></b> The objective of this systematic review was to evaluate key imaging manifestations of COVID-19 on abdominal imaging by utilizing a comprehensive review of the published literature. <b><i>Method:</i></b> A systematic literature search from PubMed, Google Scholar, and Scopus was performed for studies mentioning abdominal imaging findings in COVID-19 patients. Studies published from inception to 15 March 2021 were included. <b><i>Results:</i></b> A total of 116 studies comprising 1,198 patients were included. Abdominal pain was the most common indication for abdominal imaging in 50.2% of the patients. No abnormality was seen in 48.1% of abdominopelvic computed tomography scans. Segmental bowel wall thickening (14.7%) was the most common imaging abnormality, followed by bowel ischemia (7.1%), solid organ infarction (6.7%), vessel thrombosis (6.7%), and fluid-filled colon (6.2%). Other relevant findings were dilated air-filled bowel, pancreatitis, pneumatosis/portal venous gas, bowel perforation, and appendicitis. Other than abdominal findings, COVID-19-related basal lung changes were incidentally detected in many studies. Moreover, the presence of bowel imaging findings was positively correlated with the clinical severity of COVID-19 infection. <b><i>Conclusion:</i></b> This review describes the abdominal imaging findings in COVID-19 patients. This is pertinent for the early diagnosis of COVID-19 in patients presenting solely with abdominal symptoms as well as in identifying abdominal complications in a known case of COVID-19.

COVID-19-associated ischaemic stroke due to underlying carotid artery thrombosis in a healthy young woman

SARS-CoV-2 has proven its versatility in host presentations; one such presentation is a hypercoagulable state causing large-vessel thrombosis. We report a case on a previously asymptomatic COVID-19-positive patient presenting with an acute ischaemic stroke and an incidental left internal carotid artery thrombus. The patient’s medical, social and family history and hypercoagulability screening excluded any other explanation for the left carotid thrombus or stroke, except for testing positive for the COVID-19. This case explores the known hypercoagulable state associated with COVID-19 and the effect of the virus on the host’s immune response. It also questions whether administration of recombinant tissue plasminogen activator (t-PA), according to the American Heart Association guidelines, following a negative head CT for haemorrhagic stroke is safe without prior extended imaging in this patient population. We recommend, in addition to obtaining a non-contrast CT scan of the brain, a CT angiogram or carotid duplex of the neck be obtained routinely in patients with COVID-19 exhibiting stroke symptoms before t-PA administration as the effects may be detrimental. This recommendation will likely prevent fragmentation and embolisation of an undetected carotid thrombus.

Ophthalmologic manifestations in patients with antiphospholipid antibodies: Beware of iatrogenic complications

Background Antiphospholipid syndrome (APS) is characterized by several clinical manifestations such as venous and arterial thrombosis associated with persistent antiphospholipid antibodies (aPL). Several studies confirmed that retinal vein occlusion was the most common APS ocular manifestation. The purpose of this study was to identify ophthalmologic manifestations in a homogeneous cohort of well-defined persistently aPL-positive patients and to determine variables associated with these manifestations. Methods APL-positive patients were selected from two research programs. All ophthalmologic manifestations including those related to APS were recorded. Results A total of 117 patients were included and 10 of them had APS-related ophthalmologic manifestations (glaucoma, hydroxychloroquine-related maculopathy, anterior acute uveitis, anterior ischemic optic neuropathy). Systemic Lupus Erythematosus (SLE) (OR = 3.4[95%CI; 0.9-12.7), corticosteroids (OR = 9.0 [95%CI; 2.2-37.7]) and aPL-related nephropathy (OR = 7.1 [95%CI; 1.7-30.0]) were significatively associated with the risk of APS-related ophthalmologic manifestations. Conclusion Most of ocular manifestations in this study were iatrogenic related to corticosteroids or hydroxychloroquine. Patients with SLE, small vessel thrombosis in general, or with aPL-related nephropathy in particular, seemed at higher risk to develop APS-related ophthalmologic manifestations thus deserving adequate monitoring.

The Common Carotid Artery Thrombus and Embolic Stroke in the Setting of COVID-19 Infection

Since the outbreak of the COVID-19 in Wuhan, China in 2019, there have been increasing reports of large vessel thrombosis and associated embolic stroke in patients with COVID-19 infection. The pathogenesis is thought to be multifactorial, including angiotensin-converting enzyme 2 receptor-mediated endothelial damage, rupture of atherosclerotic plaques, cytokine-storm induced-inflammation, and hypercoagulability. Here, we present a case of an otherwise-healthy COVID-19 patient who developed a right common carotid artery thrombus and embolic stroke with left sided numbness and weakness. Blood tests were significant for elevated levels of inflammatory biomarkers and di-dimer. Vessel imaging showed no evidence of underlying atherosclerosis or arterial dissection. Cardiac workup was unremarkable. The etiology of the carotid artery thrombus was likely COVID-19 related inflammation and hypercoagulability. He was started on apixaban 5mg twice daily for secondary stroke prevention. After 3 months, he was transitioned from apixaban to aspirin 81mg daily. At 4-month follow-up, he improved with only residual left arm numbness. Our case study suggests that in patients with large vessel thrombosis in the setting of Covid-19 infection, oral anticoagulation for 3 months followed by daily aspirin may be a reasonable treatment option for secondary stroke prevention.