Post acute covid 19 syndrome.pptx
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This document discusses hematological manifestations of post-acute COVID-19 syndrome. It notes that lymphopenia is common due to the virus infecting lymphocyte surfaces and cytokine storm-induced apoptosis. Thrombocytopenia can occur due to platelet destruction and immune clearance. Coagulation parameters are often elevated, indicating COVID-19 associated coagulopathy rather than disseminated intravascular coagulation. Management includes anticoagulation and treatments to reduce inflammation.
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Post acute covid 19 syndrome.pptx
- 1. POST ACUTE COVID 19 SYNDROME DR.MOHAMMED SHANIL.P JR.GENERAL MEDICINE
- 2. NICE GUIDELINES-TERMINOLOGIES • ACUTE COVID 19- SIGNS AND SYMPTOMS OF COVID 19 UP TO 4 WEEKS • ONGOING SYMPTOMATIC COVID 19: SIGNS AND SYMPTOMS OF COVID 19 FOR 4-12 WEEKS • POST COVID 19 SYNDROME: SIGNS AND SYMPTOMS THAT DEVELOP DURING OR AFTER AN INFECTION CONSISTENT WITH COVID 19,CONTINUE FOR MORE THAN 12 WEEKS AND ARE NOT EXPLAINED BY ALTERNATIVE DIAGNOSIS.
- 3. • ASYMPTOMATIC-80-90% • MODERATE OR SEVERE ILLNESS-5-15%
- 6. HEMATOLOGICAL MANIFESTATIONS • AMERICAN JOURNAL OF PATHOLOGY(2020) • NEUTROPHILIA • LYMPHOCYTOPENIA(68) • EOSINOPENIA • THROMBOCYTOPENIA(20) • ELEVATED NLR • MYELOID SERIES –SHIFT TO LEFT • PS-LEUKOERYTHROBLASTIC PICTURE
- 8. LYMPHOPENIA ENSUE • EXPRESSION OF THE ACE2 RECEPTOR ON LYMPHOCYTE SURFACE • SARS-COV2 INFECT CELLS AND LYSIS • CYTOKINE STORM-IL-2,6,7,G-CSF,INTERFERON –GAMMA INDUCIBLE PROTEIN,TNF-ALPHA)LYMPHOCYTE APOPTOSIS-ATROPHY OF LYMPHOID ORGANS AND SPLEEN • LACTIC ACIDOSIS IN- CANCER-INHIBITING LYMPHOCYTE PROLIFERATION- RISK OF COMPLICATIONS
- 9. PLATELETS • THROMBOCYTOPENIA • CAUSES • CYTOKINE STORM DESTROYS THE PLATELET PROGENITORS IN BONE MARROW • INCREASE IN AUTOANTIBODIES AND IMMUNE COMPLEXES-PLATELETS CLEARED BY IMMUNE SYSTEM • LUNG INJURY-PLATELET ACTIVATION-MICROTHROMBUS AND PLATELET CONSUMPTION
- 10. ARDS RISK • INCREASED NEUTROPHILS-IL8-ENDOTHELIAL DAMAGE-HYALINE MEMBRANE • DECREASED LYMPHOCYTES • LESS THAN 20% LYMPHOCYTES AT 10-12 DAYS.LESS THAN 5% AT DAYS 17-19 • HIGH NEUTROPHIL LYMPHOCYTE RATIO---DEATH • CYTOKINE STORM DUE TO ENHANCED PLATELET ACTIVATION-HIGH PLATELET TO LYMPHOCYTE RATIO
- 11. PERIPHERAL SMEAR • LYMPHOPENIA • REACTIVE LYMPHOCYTE POPULATION-LYMPHOPLASMOCYTOID • DYSMYELOPOIESIS(ABNORMAL GRANULARITY,SPINDLE CELLS,PERINUCLEAR HALO) • LARGE HYPERCHROMATIC PLATELETS
- 13. DYSMYELOPOEISI S
- 15. COAGULATION PARAMETERS • PT>APTT(FACTOR 8 IS APR) • INCREASED FIBRINOGEN(FIBRINOGEN IS APR) • INCREASED FDP AND D DIMER(INFLAMMATION INDUCED ENDOTHELIAL CELL INJURY RESULT IN MASSIVE RELEASE OF PLASMINOGEN ACTIVATORS)
- 16. COAGULATION • LANCET HEMATOLOGY • ELEVATED D DIMER • PT>>INR • FDP
- 17. COVID 19 ASSOCIATED COAGULOPATHY(CAC) • ELEVATED D DIMER (3-4 FOLD INCREASE) • PT >>> APTT • MILD THROMBOCYTOPENIA • MICROANGIOPATHY IS NOT PRESENT • ELEVATED FIBRINOGEN
- 18. COVID DIFFERENT FROM THROMBOTIC ? • MICROVASCULAR PLATELET RICH THROMBOTIC DEPOSITIONS IN SMALL VESSELS OF LUNGS AND OTHER ORGANS • NO SIGNS OF HEMOLYSIS OR SHISTOCYTES IN BLOOD(HUS) • MILD THROMBOCYTOPENIA(TTP)
- 19. • LOW GRADE DIC AND PULMONARY THROMBOTIC MICROANGIOPATHY • ADAM TS • PLASMA EXCHANGE-REPLENISH ADAM TS AND REMOVING INFL.MEDIATORS
- 20. COAGULATION FUNCTION BETWEEN SEVERE AND NON SEVERE PATIENTS • INCREASED FIBRINOGEN,D DIMER • INCREASED FAR • ALB-NEGATIVE PHASE REACTANT • MORE INFLAMMATION,ALBUMIN DECREASED • ON ADMISSION,FAR<0.08 AND PLC>1.35 L-MILD ILLNESS
- 21. INTERNATIONAL SOCIETY OF THROMBOSIS AND HEMOSTASIS DIC SCORE • PLATELET COUNT • >1 LAKH-0 • <1 LAKH-1 • <50K-2 • FIBRINOGEN LEVEL • >100-0 • <100-1 • PT <3 SEC • 3-5 SEC • >6 SEC
- 22. • D DIMER • NO INCREASE-0 • MODERATE INCREASE-2 • STRONG INCREASE-3 • SCORE>=5 –DIC • <5-REPEAT TEST AFTER 2 DAYS
- 23. IMMUNE SYSTEM • FLOW CYTOMETRY OF CD4 CD8 RATIO • REGULATORY T-CELLS INCREASED(IL-2-SUPPRESS INFLAMMATION)-VIRUS PROLIFERATES • RAPID EXHAUSTION OF CYTOTOXIC CD8 T CELLS
- 24. • LDH • S.FERRITIN • PROCALCITONIN • IL-6 • IL-2R • IL-8,10
- 25. • KIDNEY INTERNATIONAL 2020 • FERRITIN INCREASED MORE THAN 1000-CKD • STUDIES –COVID HEMODIALYSIS->800 • MARKER CORRELATE WITH CYTOKINE STORM
- 27. MANAGEMENT • PLATELET-MILD THROMBO-OBSERVE • COAGULATION AND FIBRINOLYTIC SYSTEM-IST-RECOMMENDED LMWH • DEBATE OVER ANTITHROMBOTIC PROPHYLAXIS-4.8/1000 –VTE • HEPARIN RESISTANCE-ANTI FACTOR XA LEVELS • PATIENTS ON WARFARIN-CHANGED TO HEPARIN • RBCS-HEMOGLOBINOPATHIES-CONTINUE TRANSFUSION AND CHELATION
- 29. • WBCS-RECOVERY TRIAL-USE OF STEROIDS CAN DECREASE INFLAMMATION(6MG/DAY*10 DAYS) • MSC(MESENCHYMAL STEM CELLS)-INCREASE IN LYMPHOCYTE COUNT AND DECREASE IN CRP WITHIN 6 DAYS(CLINICAL TRIALS)