key: cord-0818095-0473ooh5
authors: Airoldi, A.; Perricone, G.; De Nicola, S.; Molisano, C.; Tarsia, P.; Belli, L.S.
title: COVID-19-related thrombotic microangiopathy in a cirrhotic patient
date: 2020-06-15
journal: Dig Liver Dis
DOI: 10.1016/j.dld.2020.06.019
sha: 868883626d89620e4d3c85061a069e83761e882b
doc_id: 818095
cord_uid: 0473ooh5

nan

He had an history of hepatitis C virus infection with sustained virological response to direct acting antivirals in 2015. In 2016, he developed a non-neoplastic spleno-porto-mesenteric thrombosis with cavernomatous transformation and was started on fondaparinux 5 mg/day. At the last outpatient visit on February 2020, his Child-Pugh score was B8 and the MELD score was 14, haemoglobin level was 13 g/dL and the platelet count was 36,000 x 10^9/L. The most recent upper endoscopy showed small oesophageal varices without red signs and mild hypertensive gastropathy.

At admission, a rhino-pharyngeal swab was performed which tested positive for SARS-CoV-2 infection and a chest CT showed bilateral interstitial pneumonia. The patient presented mild dyspnea with a respiratory rate of 22 and a SpO2 of 95% on room air. Platelet count was 1,000 x 10^9/L and haemoglobin level was 8.5 g/dL; over the first 48 hours haemoglobin dropped to a minimum level of 5.5 g/dL. Laboratory tests were consistent with thrombotic microangiopathy:

LDH 400 IU/L, D-dimer 10,5 mcg/mL. Fondaparinux was stopped. The patient required a total amount of 14 units of erythrocytes and 19 units of buffy-coat platelets. Antiplatelet indirect antibodies were found to be negative while anti-HLA class I antibodies were positive.

Dexamethasone and intravenous immunoglobulins were used but proved ineffective.

At day seven, the patient experienced acute liver decompensation with large ascites, and acute kidney injury-hepatorenal syndrome type I, requiring treatment with albumin and terlipressin infusion. At day 20, RF swab was repeated and tested negative for SARS-CoV-2 infection and the result was confirmed on two other swabs, 48 hours apart. After viral clearance, laboratory tests and clinical conditions progressively improved. Platelet count increased and stabilized around 10-15,000/10^9/L, haemoglobin level exceeded 8 g/dL without further transfusion requirement.

Haemorrhagic manifestations also resolved. The Child-Pugh score gradually improved from C11 to B8, and the MELD score from 22 to 16. Bacterial infections are a recognized precipitant factor of acute decompensation and/or acute-onchronic liver failure in patients with cirrhosis. This case suggests that SARS-CoV-2 infection could be a causal factor precipitating liver decompensation.

None

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Mechanism of thrombocytopenia in COVID-19 patients

Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: a meta-analysis

Online ahead of print