Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan.
Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan.
Medicine (Baltimore). 2023 Oct 13;102(41):e35469. doi: 10.1097/MD.0000000000035469.
Coronavirus disease 2019 (COVID-19) is an infectious disease that often causes complications in multiple organs and thrombosis due to abnormal blood coagulation. This case report aimed to describe the clinical course of COVID-19-associated thrombotic microangiopathy (TMA) and reviewed the comprehensive information on TMA, thrombotic thrombocytopenic purpura (TTP), and atypical hemolytic uremic syndrome associated with COVID-19 in the past literature.
A 46-year-old Japanese man was diagnosed with human immunodeficiency virus infection 10 years ago and treated with antiretroviral therapy. The patient presented with fever, malaise, hematuria, and bilateral upper abdominal discomfort for the past 4 days.
COVID-19-associated TMA was diagnosed based on a positive polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 and laboratory findings such as thrombocytopenia, acute kidney injury, and hemolytic anemia. Malignant hypertension and human immunodeficiency virus infection were also considered as differential diagnoses of TMA.
Considering the possibility of TTP, plasma exchange was performed, and glucocorticoids were administered. Hemodialysis was performed for acute kidney injury. Antihypertensive drugs were administered to control the high blood pressure.
Platelet count and renal function improved, and hemodialysis was no longer required. The patient was in good general condition and was discharged from the hospital.
COVID-19-associated TMA should be considered as a differential diagnosis during the COVID-19 epidemic. Excessive inflammation and severe COVID-19 are not essential for TMA development. Early intervention using conventional TMA treatments, such as plasma exchange and corticosteroids, might be important in improving prognosis while differentiating between TTP and atypical hemolytic uremic syndrome. Antihypertensive therapy may be helpful in the treatment of COVID-19-associated TMA.
新型冠状病毒病 2019（COVID-19）是一种传染病，常因血液凝固异常而导致多器官并发症和血栓形成。本病例报告旨在描述 COVID-19 相关血栓性微血管病（TMA）的临床过程，并回顾过去文献中 COVID-19 相关 TMA、血栓性血小板减少性紫癜（TTP）和非典型溶血尿毒综合征的综合信息。
一名 46 岁的日本男性，10 年前被诊断为人免疫缺陷病毒感染，接受抗病毒治疗。患者因发热、乏力、血尿和双侧上腹部不适 4 天就诊。
根据严重急性呼吸综合征冠状病毒 2 的聚合酶链反应阳性和血小板减少、急性肾损伤和溶血性贫血等实验室发现，诊断为 COVID-19 相关 TMA。恶性高血压和人类免疫缺陷病毒感染也被认为是 TMA 的鉴别诊断。
考虑到 TTP 的可能性，进行了血浆置换，并给予糖皮质激素。急性肾损伤行血液透析。给予降压药控制高血压。
血小板计数和肾功能改善，不再需要血液透析。患者一般情况良好，出院。
在 COVID-19 流行期间，应将 COVID-19 相关 TMA 作为鉴别诊断。过度炎症和严重的 COVID-19 并非 TMA 发展的必要条件。早期使用常规 TMA 治疗，如血浆置换和皮质类固醇，可能对改善预后、区分 TTP 和非典型溶血尿毒综合征非常重要。降压治疗可能有助于 COVID-19 相关 TMA 的治疗。
