Disseminated Intravascular Coagulation in COVID-19 Setting: A Clinical Case Description

Abstract

Disseminated intravascular coagulation (DIC) is an acquired syndrome that can lead to catastrophic thrombosis and hemorrhage. In DIC, an uncontrolled release of pro-inflammatory mediators activates tissue factor-dependent coagulation. These changes cause endothelial dysfunction and increased depletion of platelets and clotting factors needed to control bleeding, which results in excessive bleeding. The clinical manifestations are microvascular thrombosis and hemorrhage, which cause severe organ dysfunction and worsening of organ failure. Its clinical management is challenging. Coronavirus disease 2019 (COVID-19) is characterized mainly by respiratory manifestations. In severe cases, however, systemic inflammatory response syndrome can develop with cytokine release that leads to coagulopathy and DIC. Among patients with COVID-19, this complication occurs rarely, leading to death in the majority of cases. We describe the case of a 67-year-old woman with asthma and class 1 obesity, hospitalized with respiratory insufficiency after diagnosis of COVID-19, in whom DIC developed with hemorrhagic manifestations on Day 4 of hospitalization. In spite of poor prognosis and multiple complications throughout the 87 days of hospitalization, including 62 days in the ICU, this patient survived.

Keywords: covid-19; d-dimers; disseminated intravascular coagulation; fibrinogen; hemorrhage.

Figure 1. Computed tomographic scan of the thorax on the day of intensive care unit admission.

Bilateral pneumonia from COVID-19, with diffuse bilateral subpleural ground glass opacities and fibrotic component.

Figure 2. Computed tomographic scan of the abdomen on the 4th day in the intensive care unit.

Hemoperitoneum (big arrow) due to splenic laceration (small arrow)

Figure 3. Radiograph of the thorax on the 10th day in the intensive care unit

Left pneumothorax (arrow) is evident.

Figure 4. Computed tomographic scan of the thorax on the 10th day in the intensive care unit

Left pneumothorax (arrow) and diffuse bilateral subpleural ground glass opacities with fibrotic components are evident.

Figure 5. Radiograph of the thorax on the 16th day in the intensive care unit

Right pneumothorax (big arrow) and subcutaneous emphysema (little arrow) are evident.

Figure 6. Computed tomographic scan of the thorax on the 20th day in the intensive care unit

Diffuse bilateral subpleural ground-glass opacities with fibrotic components and necrotizing bilateral pneumonia (arrow) are evident.