Jornal Vascular Brasileiro
https://jvascbras.org/article/doi/10.1590/1677-5449.200072
Jornal Vascular Brasileiro
Case Report

Alprostadil associated with low molecular weight heparin to treat limb ischemia caused by SARS-CoV2

Alprostadil associado a heparina de baixo peso molecular para o tratamento da isquemia de membros causada por SARS-CoV2

Marcos Antonio Bonacorso Manhanelli Filho; Eliud Garcia Duarte Júnior; Jamil Victor de Oliveira Mariuba; Fábio Linardi; José Augusto Costa; Julio Cesar Gali; Winston Bonetti Yoshida; Julio Cesar Gali Filho

Downloads: 12
Views: 1117

Abstract

Abstract: The current coronavirus pandemic has already taken a great toll globally, causing massive morbidity and mortality. One of its severe forms is a thrombophilic state that can damage several systems. This article reports the case of 60-year-old female patient who presented with mild flu symptoms, which turned out to be a SARS-CoV2 infection, and ended up developing arterial thrombosis with limb ischemia in a private care hospital in Sorocaba, São Paulo, Brazil. Considering this progression, we decided to intervene with low molecular weight heparin and Alprostadil, achieving a good clinical outcome. Our description aims to identify key points and clinical signs that offer evidence of the therapeutic window and a treatment option for coagulatory presentations of COVID-19.

Keywords

COVID-19, thromboembolism, limb ischemia, arterial thrombosis, heparin

Resumo

Resumo: A atual pandemia de coronavírus já gerou danos profundos ao redor do mundo, causando grande quantidade de morbidades e mortes. Uma das manifestações das formas graves da doença é o estado trombofílico, que pode provocar danos em vários sistemas. Este artigo relata o caso de uma paciente do sexo feminino, 60 anos de idade, que foi internada em um serviço hospitalar privado com sintomas gripais inespecíficos leves, mas que progrediu com trombose arterial e isquemia de membros causada pelo SARS-CoV2. Devido à essa evolução, foi optada pela administração concomitante de heparina de baixo peso molecular e Alprostadil, com bom desfecho clínico. Nossa descrição objetiva identificar pontos-chave e sinais clínicos que evidenciem essa janela terapêutica, bem como uma opção de tratamento para as apresentações coagulatórias da COVID-19.
 

Palavras-chave

COVID-19, tromboembolismo, isquemia de membros, trombose arterial, heparina

References

1 Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. http://dx.doi.org/10.1016/S0140-6736(20)30566-3. PMid:32171076.

2 Han H, Yang L, Liu R, et al. Prominent changes in blood coagulation of patients with SARS-CoV-2 infection. Clin Chem Lab Med. 2020;58(7):1116-20. http://dx.doi.org/10.1515/cclm-2020-0188. PMid:32172226.

3 Fernandez-Nieto D, Jimenez-Cauhe J, Suarez-Valle A, et al. Characterization of acute acro-ischemic lesions in non-hospitalized patients: a case series of 132 patients during the COVID-19 outbreak. J Am Acad Dermatol. 2020;83(3):e241. http://dx.doi.org/10.1016/j.jaad.2020.05.120. PMid:32497704.

4 Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-7. http://dx.doi.org/10.1111/jth.14768. PMid:32073213.

5 Walls AC, Park Y, Tortorici M, Wall A, McGuire A, Veesler D. Structure, function, and antigenicity of the SARS-CoV-2 spike glycoprotein. Cell. 2020;181(2):281-292.e6. http://dx.doi.org/10.1016/j.cell.2020.02.058. PMid:32155444.

6 Li MY, Li L, Zhang Y, Wang X. Expression of the SARS-CoV-2 cell receptor gene ACE2 in a wide variety of human tissues. Infect Dis Poverty. 2020;9(1):45. http://dx.doi.org/10.1186/s40249-020-00662-x. PMid:32345362.

7 Qin C, Zhou L, Hu Z, et al. Dysregulation of immune response in patients with Coronavirus 2019 (COVID-19) in Wuhan, China. Clin Infect Dis. 2020;71(15):762-8. http://dx.doi.org/10.1093/cid/ciaa248. PMid:32161940.

8 Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. http://dx.doi.org/10.1016/S0140-6736(20)30183-5. PMid:31986264.

9 Arantes F. Efeito dos anticoagulantes sobre a agregabilidade plaquetária: ação da heparina de baixo peso molecular Enoxaparina, e do inibidor direto da trombina Dabigatrana [tese]. São Paulo: Universidade de São Paulo; 2018.

10 Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID‐19. J Thromb Haemost. 2020;18(5):1023-6. http://dx.doi.org/10.1111/jth.14810. PMid:32338827.

11 Shi C, Wang C, Wang H et al. The potential of low molecular weight heparin to mitigate cytokine storm in severe COVID-19 patients: a retrospective clinical study. medRxiv. 2020;1-11. http://dx.doi.org/10.1101/2020.03.28.20046144.

12 Gajic O, Dara SI, Mendez JL, et al. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med. 2004;32(9):1817-24. http://dx.doi.org/10.1097/01.CCM.0000133019.52531.30. PMid:15343007.

13 Li L-F, Liu Y, Lin S, et al. Low-molecular-weight heparin reduces ventilation-induced lung injury through hypoxia inducible factor-1α in a murine endotoxemia model. Int J Mol Sci. 2020;21(9):3097. http://dx.doi.org/10.3390/ijms21093097. PMid:32353952.

14 National Center for Biotechnology Information. [site na Internet]. Alprostadil. Bethesda: National Center for Biotechnology Information; 2020. [cited 2020 may 31]. https://pubchem.ncbi.nlm.nih.gov/compound/Alprostadil

15 Yan X, Li Y, Choi Y, et al. Protective effect and mechanism of alprostadil in acute respiratory distress syndrome induced by oleic acid in rats. Med Sci Monit. 2018;24:7186-98. http://dx.doi.org/10.12659/MSM.909678. PMid:30296789.

16 Mayer K, Schmidt R, Muhly-Reinholz M, et al. In vitro mimicry of essential fatty acid deficiency in human endothelial cells by TNFα impact of ω-3 versus ω-6 fatty acids. J Lipid Res. 2002;43(6):944-51. PMid:12032170.

17 Olivecrona T, Egelrud T, Iverius P, Lindahl U. Evidence for an ionic binding of lipoprotein lipase to heparin. Biochem Biophys Res Commun. 1971;43(3):524-9. http://dx.doi.org/10.1016/0006-291X(71)90645-0. PMid:5563304.

18 Sweeney RM, Griffiths M, McAuley D. Treatment of acute lung injury: current and emerging pharmacological therapies. Semin Respir Crit Care Med. 2013;34(4):487-98. http://dx.doi.org/10.1055/s-0033-1351119. PMid:23934717.

19 Iba T, Levy J. Derangement of the endothelial glycocalyx in sepsis. J Thromb Haemost. 2019;17(2):283-94. http://dx.doi.org/10.1111/jth.14371. PMid:30582882.

20 Burzynski LC, Humphry M, Pyrillou K, et al. The coagulation and immune systems are directly linked through the activation of interleukin-1α by thrombin. Immunity. 2019;50(4):1033-1042.e6. http://dx.doi.org/10.1016/j.immuni.2019.03.003. PMid:30926232.

21 Figueiredo LT. Viral hemorrhagic fevers in Brazil. Rev Soc Bras Med Trop. 2006;39(2):203-10. http://dx.doi.org/10.1590/S0037-86822006000200014. PMid:16699651.

22 Jia Y, Chen K, Lin P, et al. Treatment of acute lung injury by targeting MG53-mediated cell membrane repair. Nat Commun. 2014;5(1):4387. http://dx.doi.org/10.1038/ncomms5387. PMid:25034454.

23 Pan A, Liu L, Wang C et al. Association of Public Health Interventions with the Epidemiology of the COVID-19 Outbreak in Wuhan, China. JAMA. 2020;323(19):1915-1923. http://dx.doi.org/10.1001/jama.2020.6130.

24 Azkur AK, Akdis M, Azkur D, et al. Immune response to SARS‐CoV‐2 and mechanisms of immunopathological changes in COVID‐19. Allergy. 2020;75(7):1564-81. http://dx.doi.org/10.1111/all.14364. PMid:32396996.

25 Arnaldez FI, O’Day S, Drake C, et al. The Society for Immunotherapy of Cancer perspective on regulation of interleukin-6 signaling in COVID-19-related systemic inflammatory response. J Immunother Cancer. 2020;8(1):e000930. http://dx.doi.org/10.1136/jitc-2020-000930. PMid:32385146.

26 Mann S, Jones R, Millar-Craig M, Wood C, Gould B, Raftery E. The safety of ambulatory intra-arterial pressure monitoring: a clinical audit of 1000 studies. Int J Cardiol. 1984;5(5):585-97. http://dx.doi.org/10.1016/0167-5273(84)90170-0. PMid:6715074.

27 Iba T, Levy J. Derangement of the endothelial glycocalyx in sepsis. J Thromb Haemost. 2019;17(2):283-94. http://dx.doi.org/10.1111/jth.14371. PMid:30582882.
 

Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)"> Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)">
5fbfc00d0e8825406bf5cc94 jvb Articles
Links & Downloads

J Vasc Bras

Share this page
Page Sections