A mysterious blood-clotting
complication is killing coronavirus patients
Once thought a relatively straightforward respiratory virus,
covid-19 is proving to be much more frightening
Nurses describe their fears working on the front lines | Voices
from the Pandemic
5:12 / 5:13
The Post asked five nurses
across the U.S. to describe what life is like working on the front lines of the
coronavirus pandemic. (Drea Cornejo/The Washington Post)
By
Ariana Eunjung Cha
April 22, 2020 at 10:39 p.m.
GMT+2
Craig Coopersmith was up early
that morning as usual and typed his daily inquiry into his phone. “Good
morning, Team Covid,” he wrote, asking for updates from the ICU team leaders
working across 10 hospitals in the Emory University health system in Atlanta.
One doctor replied that one of
his patients had a strange blood problem. Despite being put on anticoagulants,
the patient was still developing clots. A second said she’d seen something
similar. And a third. Soon, every person on the text chat had reported the same
thing.
“That’s when we knew we had a
huge problem,” said Coopersmith, a critical-care surgeon. As he checked with
his counterparts at other medical centers, he became increasingly alarmed: “It
was in as many as 20, 30 or 40 percent of their patients.”
One month ago when the country
went into lockdown to prepare for the first wave of coronavirus cases, many
doctors felt confident they knew what they were dealing with. Based on early
reports, covid-19 appeared to be a standard variety respiratory virus, albeit a
contagious and lethal one with no vaccine and no treatment. They’ve since seen
how covid-19 attacks not only the lungs, but also the kidneys, heart,
intestines, liver and brain.
Increasingly, doctors also are
reporting bizarre, unsettling cases that don’t seem to follow any of the
textbooks they’ve trained on. They describe patients with startlingly low
oxygen levels — so low that they would normally be unconscious or near death —
talking and swiping on their phones. Asymptomatic pregnant women suddenly in
cardiac arrest. Patients who by all conventional measures seem to have mild
disease deteriorating within minutes and dying at home.
With no clear patterns in terms
of age or chronic conditions, some scientists hypothesize that at least some of
these abnormalities may be explained by severe changes in patients’ blood.
The concern is so acute some
doctor groups have raised the controversial possibility of giving preventive
blood thinners to everyone with covid-19 — even those well enough to endure
their illness at home.
Blood clots, in which the red
liquid turns gel-like, appear to be the opposite of what occurs in Ebola,
Dengue, Lassa and other hemorrhagic fevers that lead to uncontrolled bleeding.
But they actually are part of the same phenomenon — and can have similarly
devastating consequences.
Autopsies have shown some
people’s lungs fill with hundreds of microclots. Errant blood clots of a larger
size can break off and travel to the brain or heart, causing a stroke or heart
attack. On Saturday, Broadway actor Nick Cordero, 41, had his right leg
amputated after being infected with the novel coronavirus and
suffering from clots that blocked blood from getting to his toes.
Lewis Kaplan, a University of Pennsylvania
physician and head of the Society of Critical Care Medicine, said every year
doctors treat people with clotting complications, from those with cancer to
victims of severe trauma, “and they don’t clot like this.”
“The problem we are having is
that while we understand that there is a clot, we don’t yet understand why there
is a clot,” Kaplan said. “We don’t know. And therefore, we are scared.”
A mother and her child pass a
mural in Amsterdam by artist FAKE, titled “Super Nurse,” paying tribute to
health-care professionals on April 19. (Peter Dejong/AP)
‘It crept up on us’
The first sign something was
going haywire was in legs, which were turning blue and swelling. Even patients
on blood thinners in the ICU were developing clots — which is not unusual in
one or two patients in one unit but is for so many at the same time. Next came
the clogging of the dialysis machines, which filter impurities in blood when
kidneys are failing and jammed several times a day.
“There was a universal
understanding that this was different,” Coopersmith said.
Then came the autopsies. When
they opened up some deceased patients’ lungs, they expected to find evidence of
pneumonia and damage to the tiny air sacs that exchange oxygen and carbon
dioxide between the lungs and the bloodstream. Instead, they found tiny clots
all over.
Zoom meetings were convened in
some of the largest medical centers nationwide. Tufts. Yale-New Haven. The
University of Pennsylvania. Brigham and Women’s. Columbia-Presbyterian.
Theories were shared. Treatments debated.
Although there was no consensus
on the biology of why this was happening and what could be done about it, many
came to believe the clots might be responsible for a significant share of U.S.
deaths from covid-19 — possibly explaining why so many people are dying at
home.
As coronavirus cases surged in N.Y., a doctor reflected on the
tragedy | Voices from the Pandemic
5:40 / 5:40
In hindsight, there were hints
blood problems had been an issue in China and Italy as well, but it
was more of a footnote in studies and on information-sharing calls that had
focused on the disease’s destruction of the lungs.
“It crept up on us. We weren’t
hearing a tremendous amount about this internationally,” said Greg Piazza, a
cardiovascular specialist at Brigham and Women’s who has begun a study of
bleeding complications of covid-19.
Helen W. Boucher, an
infectious-disease specialist at Tufts Medical Center, said there’s no reason
to think anything is different about the virus in the United States. More
likely, she said, the problem was more obvious to American doctors because of
the unique demographics of U.S. patients, including large percentages with heart
disease and obesity that make them more vulnerable to the ravages of blood
clots. She also noted small but important differences in the monitoring and
treatment of patients in ICUs in this country that would make clots easier to
detect.
“Part of this is by virtue of
the fact that we have such incredible intensive care facilities,” she said.
Nicola Contaldi delivers a
lunchbox at Palazzo Chigi in Rome on April 20 as home deliveries keep
restaurants in business during the lockdown. (Guglielmo Mangiapane/Reuters)
A leading cause of death
The body’s cardiovascular
system often is described as a network of one-way streets that connect the
heart to other organs. Blood is the transport system, responsible for moving
nutrients to the cells and waste away from them. A common cold or a
cut on the finger can lead to changes that help repair the damage, but when the
body undergoes a more significant trauma, the blood can overreact, leading to
an imbalance that can cause excessive clots or bleeding — and sometimes both.
Scientists call this
“hemostatic derangement.” In math, a derangement is a permutation in which no
element is in its original position.
Harlan Krumholz, a cardiac
specialist at the Yale-New Haven Hospital Center, said no one knows whether
blood complications are a result of a direct assault on blood vessels, or a
hyperactive inflammatory response to the virus by the patient’s immune system.
“One of the theories is that
once the body is so engaged in a fight against an invader, the body starts
consuming the clotting factors, which can result in either blood clots or
bleeding. In Ebola, the balance was more toward bleeding. In covid-19, it’s
more blood clots,” he said.
A study published in JAMA on
Wednesday found that a large number of covid-19 patients admitted to New York
State’s largest health system came in with blood test readings that indicated
clotting problems.
And a Dutch study published
April 10 in the journal Thrombosis Research provided more evidence
the issue is widespread, finding 38 percent of 184 covid-19 patients in an
intensive care unit had blood that clotted abnormally. The researchers called
it “a conservative estimation” because many of the patients were still
hospitalized and at risk of further complications.
Early data from China on a
sample of 183 patients showed more than 70 percent of patients who died of
covid-19 had small clots develop throughout their bloodstream. Although acute
respiratory distress syndrome still appears to be the leading cause of death in
covid-19 patients, blood complications are not far behind, said Behnood
Bikdeli, a fourth-year fellow at Columbia University Irving Medical Center, who
helped anchor a paper about the blood clots in the Journal of The American
College of Cardiology.
“My guess is it’s one of the
top three causes of demise and deterioration in covid-19 patients,” he said.
That recognition is prompting
many hospitals to change the way they think about the disease and manage it.
When the novel coronavirus first hit, the Centers for Disease Control and Prevention
and others put people with asthma at the top of their lists of those who might
be the most vulnerable. But European researchers writing in the journal Lancet
noted it was “striking” how underrepresented asthma patients had been. Earlier
this month, when New York state released data about the top chronic health
problems of those who died of covid-19, asthma was not among them. Instead,
they were almost all cardiovascular conditions.
Some medical centers have begun
giving all hospitalized covid-19 patients small doses of blood thinners as
preventive measures, and many are adjusting doses upward for the most seriously
ill. The challenge is the more you give, the greater the danger of upsetting
the balance in the other direction and having the patient bleed to death.
Another big mystery the doctors
hope the blood issue will shed light on is why some maternity patients are
collapsing during or after giving birth.
A paper published in
the American Journal of Obstetrics & Gynecology MFM in late March
detailed how two women with no prior symptoms of covid-19 ended up in intensive
care. The first was a 38-year-old patient of New York-Presbyterian/Columbia
University Irving Medical Center in Manhattan who spiked a fever of 101.3 while
undergoing a C-section delivery and began bleeding profusely. The second woman,
33, also underwent a C-section but the next day developed a cough that
progressed to respiratory distress. Her heart beat irregularly and her blood
pressure jumped to as high as 200/90.
Several physician-researchers
said the relationship between covid-19, clotting and pregnant women is “an area
of interest.” Women in childbirth can experience clotting and bleeding
complications because of the involvement of the blood-rich placenta, but it’s
possible covid-19 may be triggering additional cases by making some women’s
bodies “lose balance.”
“There’s lots of speculation,”
Krumholz said. “That’s one of the frustrating things about this virus. We’re in
a lot of darkness still.”
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