Front-line providers need to consider anti-coagulating their rapidly deteriorating COVID-19 patients. Could it be that severe endothelial dysfunction, resulting in microvascular thrombosis, is playing a major role in the rapid deterioration that we see in days 7-10?
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There are a number of anecdotal reports of coincident pulmonary emboli and other clots, and subsequent rapid improvement with anticoagulation and even thrombolysis. commented on here: bit.ly/3c1drZN here: bit.ly/2VaSwwP, and here: bit.ly/2xZk4Nx
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Recent Italian research in this Webinar by ESICM posits two phenotypes, a type 'L' and a type 'H' Type L could be due to pulmonary microthrombosis and leads to a biphasic course with severe deterioration as clots hit multiple organs.
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Covid is a strange beast. Like with @BorisJohnson, pts appear initially stable, are often discharged home, and return in critical condition. Imaging won't see it, and pathology studies would miss microthrombi as end-stage ARDS with DAD will obliterated findings.
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Dr. @farid__jalali wrote about this theory over a week ago on Facebook, surmising that Covid mimics Dengue in important ways, causing a cytokine storm, IL-6 raises PAI-1, suppresses tPA and leads to microthrombi in the lungs and everywhere. Original post: facebook.com/permalink.php?…
I've simplified his figure here; we've submitted a letter to NEJM to try to get the word out about his theory. We've also released the text with references - which we'll continue to revise as new data comes to light.
docs.google.com/document/d/1vG…
docs.google.com/document/d/1vG…
What are the implications? Likely closer monitoring of stable covid pt's coag state with D-dimer, PTT, TEG. If you see these numbers rising and other inflammatory markers are going down, consider starting heparin, even tPA if in critical state. More research is needed stat
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As @emupdates mentions, providers are so busy that we have only anecdotes and clinical judgement to rely on, spread by social media. Traditional publication methods will not save the hundreds of thousands who may die in the next few weeks. emupdates.com/cv3w/
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Watching @farid__jalali, a community GI who never forgot his basic physiology, work hard to get us all to listen to a groundbreaking insight into Covid-19 is inspiring. It reminds me very much of Barry Marshall and Robin Warren with H.pylori. Please get the word out there!
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Here's another paper that provides an algorithm for spotting and treating coagulopathies in Covid patients, and here is their algorithm
onlinelibrary.wiley.com/doi/abs/10.111…
onlinelibrary.wiley.com/doi/abs/10.111…
This figure graciously shared by @DrBrandon55 shows more targets to test in this theory, and is being studied now jointly between centers in the US and Italy. I'm told also that many NY ICUs are starting to anticoag their patients.
And now some evidence on autopsy of possibly microvascular thrombosis:
A new name for a new disease: San Raffaele hospital in Milan is calling the syndrome microCLOTS:
