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Doctors: Blood clots, chaotic immune system are the havoc COVID-19 causes internally

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Doctors: Blood clots, chaotic immune system are the havoc COVID-19 causes internally
Dr. Paul Porter, chief medical Officer of Saint Mary’s Hospital in Waterbury

Doctors treating critically ill COVID-19 patients say they are seeing widespread blood clotting throughout the body as well as an immune system gone haywire.

These blood clots lead to multiorgan failure, which causes death.

“The severe tendency for such extensive clotting is something I haven’t seen in 30 years,” said Dr. Mark L. Metersky, professor of medicine and pulmonologist at UConn Health.

It is not unusual for patients lying immobile in the hospital to develop clots. “But the ferocity and the frequency with which we are seeing this, I’ve just never seen before.”

Pathology studies have found clots forming in the small vessels and capillaries of patients critically ill with COVID-19. When blot clots it impedes the flow of oxygenated blood from reaching the tissue on the other side of the clot. Without oxygen, the tissue dies. If enough tissue dies, organs begin to fail.

“If you can imagine that all your capillaries are being blocked off by all these thrombus (clots), which are microscopic, your organs are not doing well,” said Metersky. “Think of the multiple holes in a shower head gradually becoming blocked. Clots are happening much, much more frequently than I have seen before.”

Doctors in Italy, China and Britain have also observed the aggressive clotting in patients with the virus. Dr. Bin Cao, with the National Clinical Research Center for Respiratory Diseases in Beijing, described “clots in the small vessels of all organs, not only the lungs but also including the heart, the liver, and the kidney,” in a March 19 webinar on the disease.

Meanwhile, many doctors find that some critically ill COVID-19 patients are dying after an overly aggressive immune system meant to attack the virus ends up killing them instead.

This process, known as a “cytokine storm” was also observed in patients with the Spanish Flu in 1918-19, said Dr. Paul Porter, of Saint Mary’s Hospital.

“It’s essentially your immune system making war on itself,” Porter said.

Cytokines are small, short-lived proteins that are part of the immune system’s ammunition and are released into the blood stream to combat disease. When too many are released, the immune system calls for more and more cells to fight the infection, exacerbating the inflammation. “It’s part of a generic description of a dangerously exuberant inflammatory reaction, where the inflammation itself causes more harm than good,” Metersky said.

Mark Metersky, M.D., specializes in adult sleep disorders, bronchiectasis care, pulmonary medicine, and critical care medicine at the UConn Health Center. (Lanny Nagler for UConn Health Center)

Such a process can lead to sepsis, a drop of blood pressure, damage to organs and acute respiratory distress syndrome, in which fluid builds up in the lung’s air sacks. Such patients tend to need a ventilator.

“Anytime the body gets into a cytokine storm, the end result is multisystem organ failure,” Porter said. “These antibodies and cytokines damage the heart, the kidneys, the lungs. They overdo it. ”

Typically, that level of inflammation would spur doctors to treat patients with corticosteroids. But doctors have been leery to use steroids with Covid-19 patients out of concerns the drugs stifle the body’s own immune system response.

“Steroids shut down the immune response,” Porter said. “The sense of steroids is that they would let the body be overwhelmed.”

Porter said Saint Mary’s had expected to see such cytokine storms in COVID-19 patients and was working to treat them with immune-modulating drugs. “You shut down the immune system, you shut down the body’s ability to fight the virus but you don’t want to shut it down so that the virus overwhelms the body,” he said. He said such interventions haven’t “changed night into day” but that doctors are using it so that the damage to the body is not worse than that done by the virus alone.

“It’s balance that we are new to, so there’s some guess work involved,” he said.

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