Alharthy Abdulrahman, Faqihi Fahad, Balhamar Abdullah, Memish Ziad A, Karakitsos Dimitrios
Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia.
Research and Innovation Center, King Saud Medical City, Riyadh, Saudi Arabia.
SAGE Open Med Case Rep. 2020 Oct 8;8:2050313X20964089. doi: 10.1177/2050313X20964089. eCollection 2020.
We present a case series of three patients with COVID-19 who were admitted to our intensive care unit due to acute respiratory distress syndrome, brain infarction, pulmonary embolism, and antiphospholipid antibodies. We applied therapeutic plasma exchange on all cases. On intensive care unit admission, all patients had low (<10) Glasgow Coma Scale, and central nervous imaging showed multiple brain infarctions. COVID-19 was confirmed by reverse transcriptase polymerase chain reaction assays. Patients underwent rescue therapeutic plasma exchange using the Spectra Optia Apheresis System (Terumo BCT Inc., USA), which operates with acid-citrate dextrose anticoagulant as per Kidney Disease Improving Global Outcomes 2019 guidelines. A dose of 1.5 plasma volume was used for the first dose and then 1 plasma volume daily for a total of five doses. Plasma was replaced with Octaplas LG (Octapharma AG, USA), which is an artificial fresh frozen plasma product that has undergone viral inactivation by prion reduction technology. We administered ARDS-net/prone positioning ventilation, empiric antiviral treatment, therapeutic anticoagulation, and intensive care unit supportive care. Laboratory tests showed lymphocytopenia; elevated levels of D-dimer, fibrinogen, total bilirubin, C-reactive protein, lactate dehydrogenase, and ferritin; as well as low levels of ADAMTS-13 activity and antibody. Serology tests depicted positive IgM and IgG antiphospholipid antibodies (anti-cardiolipin and anti-β2-glycoprotein I antibodies). No side effects of therapeutic plasma exchange were recorded. After the completion of therapeutic plasma exchange, patients improved clinically and gradually recovered neurologically (after 27-32 days). To conclude, in life-threatening COVID-19, especially when immune dysregulation features such as antiphospholipid antibodies exist, therapeutic plasma exchange could be an effective rescue therapy.
我们报告了一组3例新冠肺炎患者的病例系列，这些患者因急性呼吸窘迫综合征、脑梗死、肺栓塞和抗磷脂抗体而入住我们的重症监护病房。我们对所有病例均应用了治疗性血浆置换。入住重症监护病房时，所有患者的格拉斯哥昏迷量表评分均较低（<10分），中枢神经影像学检查显示多发脑梗死。通过逆转录聚合酶链反应检测确诊为新冠肺炎。患者使用Spectra Optia血液成分分离系统（美国Terumo BCT公司）进行挽救性治疗性血浆置换，该系统按照2019年改善全球肾脏病预后组织的指南使用枸橼酸葡萄糖抗凝剂。首剂使用1.5个血浆量，之后每天使用1个血浆量，共使用5剂。血浆用Octaplas LG（美国Octapharma公司）置换，Octaplas LG是一种经过朊病毒减少技术进行病毒灭活的人工新鲜冰冻血浆产品。我们给予了ARDSnet/俯卧位通气、经验性抗病毒治疗、治疗性抗凝以及重症监护病房支持治疗。实验室检查显示淋巴细胞减少；D-二聚体、纤维蛋白原、总胆红素、C反应蛋白、乳酸脱氢酶和铁蛋白水平升高；以及ADAMTS-13活性和抗体水平降低。血清学检查显示抗磷脂抗体（抗心磷脂和抗β2糖蛋白I抗体）IgM和IgG阳性。未记录到治疗性血浆置换的副作用。完成治疗性血浆置换后，患者临床症状改善，神经功能逐渐恢复（27 - 32天后）。总之，在危及生命的新冠肺炎中，尤其是存在抗磷脂抗体等免疫失调特征时，治疗性血浆置换可能是一种有效的挽救治疗方法。
