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Coagulopathy and Antiphospholipid Antibodies in Patients With Covid-19
Coagulopathy and Antiphospholipid Antibodies in Patients With Covid-19
C or r e sp ondence
Covid-19 Cases
To rapidly communicate information on the global clinical effort against Covid-19, the Journal has initiated a
series of case reports that offer important teaching points or novel findings. The case reports should be viewed as
observations rather than as recommendations for evaluation or treatment. In the interest of timeliness, these reports
are evaluated by in-house editors, with peer review reserved for key points as needed.
We describe a patient with Covid-19 and clinically CoV-2) infection was confirmed in all the patients
significant coagulopathy, antiphospholipid anti- by reverse-transcriptase–polymerase-chain-reaction
bodies, and multiple infarcts. He was one of three (RT-PCR) assay or serologic testing.
patients with these findings in an intensive care A 69-year-old man with a history of hyperten-
unit designated for patients with Covid-19. This sion, diabetes, and stroke presented with fever,
unit, which was managed by a multidisciplinary cough, dyspnea, diarrhea, and headache. Covid-19
team from Peking Union Medical College Hospi- was diagnosed in the patient on January 25, 2020,
tal in the Sino–French New City Branch of Tongji on the basis of RT-PCR testing that detected
Hospital in Wuhan, China, was set up on an SARS-CoV-2. The initial treatment was support-
emergency basis to accept the most critically ill ive; however, the illness subsequently progressed
patients during the outbreak of Covid-19. Severe to hypoxemic respiratory failure warranting the
acute respiratory syndrome coronavirus 2 (SARS- initiation of invasive mechanical ventilation.
Table 1. (Continued)
* EGFR denotes estimated glomerular filtration rate, ICU intensive care unit, and ND not determined.
On examination, the patient had evidence of serologic testing showed the presence of anti-
ischemia in the lower limbs bilaterally as well as cardiolipin IgA antibodies as well as anti–β2-
in digits two and three of the left hand. Computed glycoprotein I IgA and IgG antibodies.
tomographic imaging of the brain showed bilat- Two other patients with similar findings were
eral cerebral infarcts in multiple vascular territo- seen at the specialized intensive care unit for pa-
ries. Pertinent laboratory results on admission of tients with Covid-19 at Tongji Hospital. Serologic
the patient (Patient 1) to the intensive care unit are tests in these patients were positive for anticardio-
summarized in Table 1. They included leukocyto- lipin IgA antibodies as well as anti–β2-glycoprotein
sis, thrombocytopenia, an elevated prothrombin I IgA and IgG antibodies. Further clinical details
time and partial thromboplastin time, and elevat- are summarized in Table 1. Lupus anticoagulant
ed levels of fibrinogen and d-dimer. Subsequent was not detected in any of the patients, although
testing was performed while the patients were Dong Zhang, M.Sc.
acutely ill. Jing Xie, Ph.D.
Antiphospholipid antibodies abnormally tar- Xiaowei Yan, M.D.
get phospholipid proteins, and the presence of Xiang Zhou, M.D.
these antibodies is central to the diagnosis of the Zhengyin Liu, M.D.
antiphospholipid syndrome. However, these anti- Jinglan Wang, M.D.
bodies can also arise transiently in patients with Bin Du, M.D.
critical illness and various infections.1 The pres- Yan Qin, M.D.
ence of these antibodies may rarely lead to throm- Peng Gao, M.D.
botic events that are difficult to differentiate from Xuzhen Qin, M.D.
other causes of multifocal thrombosis in critically Yingchun Xu, M.D.
patients, such as disseminated intravascular co- Wen Zhang, M.D.
agulation, heparin-induced thrombocytopenia, Taisheng Li, M.D.
and thrombotic microangiopathy. Fengchun Zhang, M.D.
Yan Zhang, M.D. Yongqiang Zhao, M.D.
Meng Xiao, M.Sc. Yongzhe Li, M.D.
Shulan Zhang, M.D. Shuyang Zhang, M.D.
Peking Union Medical College Hospital
Peng Xia, M.D. Beijing, China
Wei Cao, M.D. yongzhelipumch@126.com
Wei Jiang, M.D. shuyangzhang103@163.com
Huan Chen, M.D. Dr. Yan Zhang, Mr. Meng Xiao, and Dr. Shulan Zhang and
Drs. Shuyang Zhang and Yongzhe Li contributed equally to this
Xin Ding, M.D.
case.
Hua Zhao, M.D. Supported by grants to Dr. Yongzhe Li from the National
Hongmin Zhang, M.D. Natural Science Foundation of China (81671618 and 81871302)
and the Chinese Academy of Medical Sciences Initiative for In-
Chunyao Wang, M.D.
novative Medicine (2017-I2M-3-001 and 2017-I2M-B&R-01).
Jing Zhao, M.D. Disclosure forms provided by the authors are available with
Xuefeng Sun, M.D. the full text of this case at NEJM.org.
Ran Tian, M.D. This case was published on April 8, 2020, at NEJM.org.
Wei Wu, M.D.
1. Uthman IW, Gharavi AE. Viral infections and antiphospho-
Dong Wu, M.D. lipid antibodies. Semin Arthritis Rheum 2002;31(4):256-63.
Jie Ma, M.D. DOI: 10.1056/NEJMc2007575
Yu Chen, B.S. Correspondence Copyright © 2020 Massachusetts Medical Society.