COVID‐19 in patients with sickle cell disease: A single center experience from Ohio, United States,Journal of Medical Virology

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COVID‐19 in patients with sickle cell disease: A single center experience from Ohio, United States
Journal of Medical Virology ( IF 6.8 ) Pub Date : 2021-01-21 , DOI: 10.1002/jmv.26816
Kamal Kant Sahu ₁ , Laeth George ₂ , Nelroy Jones ₃ , Ankit Mangla _{4,

5}

Affiliation

Coronavirus disease 2019 (COVID‐19) pandemic is expanding at an enormous pace and has already affected over 15 million population.¹ Individuals with comorbidities are the worst affected with risk factors like old age, diabetes, chronic airway disease, immunosuppressed, and cancer.² Sickle cell disease (SCD) is a common genetic disease and needs special care owing to impaired immunity and compromised cardiopulmonary system. Hereby, we share our institutional experience with SCD patients during the COVID‐19 pandemic

In our chart review (approved from the institutional review board), we captured five laboratory‐confirmed COVID‐19 patients with SCD. Four patients required inpatient treatment, while the other one was managed as an outpatient. The average age of the patients was 32. 6 years (range 21–47 years) with three females and two males. Only two out of five were on chronic therapy with hydroxyurea. Importantly, two out of the five patients presented to us only with generalized body aches. Three patients had classical imaging findings suggestive of COVID‐19 disease. None of the patients required intensive care or mechanical ventilation with only one patient had a new oxygen requirement (Table 1). Only one patient (Patient no. 1) required transfusion support for symptomatic anemia. The same patient did receive remdesivir therapy for COVID‐19 pneumonia. All patients except one (Patient no. 5) received prophylactic anticoagulation as per institutional policy with 1 mg/kg enoxaparin once daily. Patient no. 5 was never hospitalized and hence did not require any anticoagulation. None of the patients develop any thrombotic complications like deep venous thrombosis or pulmonary embolism. During the hospital stay, none of the patients developed lymphopenia, thrombocytopenia, coagulopathy. There was 100% recovery with an average hospital stay of 8.75 days (Table 2).

Table 1. Demographic details, genotype, COVID‐19 symptomatology, and management

SN	Age/sex	Genotype	Comorbidities	On treatment if any	Symptoms	RT‐PCR	Imaging findings	Maximum oxygen requirement	ICU stay/mechanical ventilation	RBC exchange therapy	Simple transfusion	Treatment given for COVID	hospital stay (in days)	Outcome
1	38/M	SS	Iron overload	Hydroxyurea, dDeferasirox	Cough, malaise, abdominal pain, nausea, vomiting, anorexia X 3 days	Positive	Bilateral pulmonary congestion, multifocal opacities	3 L (via Nasal Cannula)	Not required	Not required	Yes, 4 units PRBCs	Remdesivir	6	Discharged
2	28/F	SC	Obesity (BMI 54)	None	Pain, Shortness of breath, dyspnea on exertion X 5 days	Positive	Right lower lobe opacity	Not required	Not required	Not required	Not required	Not required	15a^a Patient no. 2 got readmitted within 24 h of discharge after initial 5 days of hospitalization due to dyspnea on exertion. Second hospitalization was for 10 days (total duration of hospitalization was 15 days).	Discharged
3	47/F	S B‐thal	Asthma	None	Body pain X 2 days	Positive	Patchy bibasilar infiltrates	2 L at night (chronic, home O₂)	Not required	Not required	Not required	Not required	11	Discharged
4	29/M	SS	Hypertension	Hydroxyurea	Body pain X 3 days	Positive	Normal	1 L at night (chronic, home O₂)	Not required	Not required	Not required	Not required	3	Discharged
5	21/F	SC	Anoxic brain injury, seizures	None	None	Positive	Not done	Not required	Not required	Not required	Not required	Not required	0b^b Patient no. 5 never required admission and was managed as an outpatient.	Improved

Abbreviations: BMI, body mass index; COVID‐19, coronavirus disease 2019; ICU, intensive care unit; RT‐PCR, reverse transcription‐polymerase chain reaction.
^a Patient no. 2 got readmitted within 24 h of discharge after initial 5 days of hospitalization due to dyspnea on exertion. Second hospitalization was for 10 days (total duration of hospitalization was 15 days).
^b Patient no. 5 never required admission and was managed as an outpatient.

Table 2. Laboratory parameters of patients

SN	Nadir Hb	Nadir reticulocyte count	Nadir ALC	WBC count	Nadir Platelet count	Zenith d‐dimer	Zenith CRP	Zenith Ferritin	Zenith LDH	Zenith PT	Zenith APTT	Zenith AST	Zenith ALT	Zenith Total/Direct Bilirubin	Zenith S. creatinine
1	6.8	0.092	2.45	6.4	263	4283	4.8	3840	617	14.5	29	58	42	2.7/0.6	0.86
2	8.8	0.077	1.87	9.5	534	1197	4.63	131	471	13.2	22	38	42	1.8/0.4	0.72
3	8.2	0.262	1.92	8.5	368	21567	6.96	187	409	13.8	68	30	12	0.9/0.2	0.52
4	9.2	0.516	2.96	8.3	310	3918	0.39	425	561	11.4	27	65	38	2.7/0.5	0.87
5	Not done	Not done	Not done	Not done	Not done	Not done	Not done	Not done	Not done	Not done	Not done	Not done	Not done	Not done	Not done

Note: Reference range: Hb, 13.5–17.5 g/dl; reticulocyte count, 0.022−0.118 × 10¹²/L; ALC, 1.2−4.8 × 10⁹/L; WBC count, 4.4−11.3 × 10⁹/L; platelet count, 150 × 450 × 10⁹/L; d‐dimer, <500 ng/ml; CRP, <1.0 mg/dl; ferritin, 20–300 mcg/L; LDH, 84–246 U/L; PT, 9.7–12.7 s; APTT, 25–36 s; AST, 9–39 IU/L; ALT, 10–52 IU/L; T/C Bil. Total, 0.0–1.2 mg/dl, and direct, 0.0–0.3 mg/dl; S. creatinine, 0.5–1.3 mg/dl.
Abbreviations: ALC, absolute lymphocyte count; APTT, activated partial thromboplastin time; AST, aspartate aminotransferase; ALT, alanine aminotransferase; CRP, C‐reactive protein; Hb, hemoglobin; LDH, lactate dehydrogenase; PT, prothrombin time; WBC, white blood cells.

The severe acute respiratory syndrome coronavirus 2 virus can act as a potential trigger to acute chest syndrome (ACS) in SCD patients. Factors, such as hypersplenism, vasculopathy, iron overload, and recurrent veno‐occlusive crisis (VOCs) leads to impaired immunity that can lead to more fatal outcome than non‐SCD patients in COVID‐19 pneumonia.³ Also, to note that the clinical presentations of COVID‐19 related ACS, COVID‐19 pneumonia, and bacterial pneumonia can overlap (Figure 1). This could be challenging especially in a scenario when one or more entities co‐exist in a same patient. In general, diffuse ground glass appearance in imaging is more commonly seen in COVID‐19 pneumonia than ACS or bacterial pneumonia. Other classical findings like hemolysis, rapid falling hemoglobin, bone aches could be more suggestive of ACS than COVID‐19 per se. However, in practical scenario it might be extremely difficult to definitively rule out one possibility over the other.

**Figure 1**
Open in figure viewerPowerPoint

Three common differentials for respiratory complaints in a patient with SCD during COVID‐19 pandemic. COVID‐19, coronavirus disease 2019; SCD, sickle cell disease

SECURE‐SCD global registry, an initiative by The Medical College of Wisconsin is an excellent platform to collaborate the cases of SCD acquiring COVID‐19 and their outcome (https://covidsicklecell.org/updates-data/).⁴ The latest data (updated till July 17, 2020) shows 260 cases of SCD registered from across the world (mostly from the US) with an average age of 26.83 years, and African American females being the worst affected population. Just like our patient series, the majority of the patients from the registry were on hydroxyurea and without any chronic transfusion therapy. An interesting observation which we also noted in our case series that, 31.15% of patients (81 out of 260) presented with symptoms of pain only. The majority of the patients (54.62%) had mild symptoms with a mortality rate of 6.15%. The second‐largest study reported includes a French experience with 83 SCD patients with COVID‐19 (multicentric study, 24 hospitals).⁵ The French group showed that the prevalence of intensive care admission was more with advanced age (53% in the older group, the median age of 54 years vs. 13% in the younger group, the median age of 28 years). The majority of the patients have associated VOCs (54%, 44 out of 81 patients), followed by ACS (28%, 23 out of 82 patients). 20% of the patients required ICU care which is almost like the results reported by SECURE‐SCD global registry (25% were severe or critically ill). In addition to the above‐mentioned studies, the other two largest single‐center studies reported till now, both from the UK included 10 patients each.^{6, 7}

In conclusion, treating COVID‐19 in SCD patients' needs a multidisciplinary approach with the management of pneumonia, VOCs, ACS, and supportive care at the same time for the best outcome.

中文翻译：

镰状细胞病患者的COVID-19：美国俄亥俄州的单中心经验

2019年冠状病毒病（COVID-19）大流行正在以惊人的速度扩展，已经影响了超过1500万人口。¹合并症患者受老年，糖尿病，慢性气道疾病，免疫抑制和癌症等危险因素的影响最大。²镰状细胞病（SCD）是一种常见的遗传性疾病，由于免疫力受损和心肺系统受损，需要特别注意。因此，我们在COVID-19大流行期间与SCD患者分享了我们的机构经验

在我们的图表审查（由机构审查委员会批准）中，我们捕获了5名经实验室确认的SCD患者COVID-19。有四名患者需要住院治疗，而另一名则作为门诊病人进行治疗。患者的平均年龄为32. 6岁（21-47岁），其中三名女性，两名男性。五分之二的患者长期接受羟基脲治疗。重要的是，五分之二的患者仅表现为全身性疼痛。3例患者有经典影像学表现提示COVID-19病。没有患者需要重症监护或机械通气，只有一名患者有新的需氧量（表1）。只有一名患者（1号患者）需要输血支持以治疗有症状的贫血。该患者确实接受了雷姆昔韦治疗COVID-19肺炎的治疗。除一名患者（第5位患者）外，所有患者均根据机构政策接受每日1 mg / kg依诺肝素的预防性抗凝治疗。患者编号 5从未住院过，因此不需要任何抗凝治疗。没有患者发生任何血栓并发症，如深静脉血栓形成或肺栓塞。在住院期间，没有患者出现淋巴细胞减少，血小板减少，凝血病。有100％的恢复，平均住院时间为8.75天（表2）。在住院期间，没有患者出现淋巴细胞减少，血小板减少，凝血病。有100％的恢复，平均住院时间为8.75天（表2）。在住院期间，没有患者出现淋巴细胞减少，血小板减少，凝血病。有100％的恢复，平均住院时间为8.75天（表2）。

表1.人口统计学详细信息，基因型，COVID-19症状和管理

序号	年龄/性别	基因型	合并症	如果有治疗	症状	逆转录PCR	影像学表现	最大氧气需求	重症监护病房/机械通气	红细胞交换疗法	简单输血	COVID治疗	住院天数	结果
1个	38 /平方米	党卫军	铁过载	羟基脲	咳嗽，全身乏力，腹痛，恶心，呕吐，厌食X 3天	积极的	双侧肺充血，多灶性混浊	3 L（通过鼻插管）	不需要	不需要	是的，4单位PRBC	伦地西韦	6	出院
2个	28楼	SC	肥胖（BMI 54）	没有任何	疼痛，呼吸急促，劳累呼吸困难X 5天	积极的	右下叶混浊	不需要	不需要	不需要	不需要	不需要	15a^一个病人没有。住院最初5天，由于劳累呼吸困难，在出院后24小时内2再次入院。第二次住院为10天（总住院时间为15天）。	出院
3	47楼	SB-塔尔	哮喘	没有任何	身体疼痛X 2天	积极的	斑片状双基底浸润	晚上2升（慢性，家用O ₂）	不需要	不需要	不需要	不需要	11	出院
4	29M	党卫军	高血压	羟基脲	身体疼痛X 3天	积极的	普通的	晚上1升（慢性，家用O ₂）	不需要	不需要	不需要	不需要	3	出院
5	21楼	SC	缺氧性脑损伤，癫痫发作	没有任何	没有任何	积极的	未完成	不需要	不需要	不需要	不需要	不需要	0b^b 患者编号 5位患者从没需要入院，而是作为门诊患者进行治疗。	改良版

缩写：BMI，体重指数；COVID-19，2019年冠状病毒病; 重症监护病房，重症监护病房；RT‐PCR，逆转录聚合酶链反应。
^一个病人没有。住院最初5天，由于劳累呼吸困难，在出院后24小时内2再次入院。第二次住院为10天（总住院时间为15天）。
^b 患者编号 5位患者从没需要入院，而是作为门诊患者进行治疗。

表2.患者的实验室参数

序号	纳迪尔血红蛋白	天底网织红细胞计数	纳迪尔ALC	白细胞计数	天底血小板计数	天顶d -dimer	真力时CRP	真力时（Zenith Ferritin）	真力时LDH	真力时PT	真力时APTT	真力时AST	真力时ALT	真力时（Zenith）Total / Direct Bilirubin	Zenith S.肌酐
1个	6.8	0.092	2.45	6.4	263	4283	4.8	3840	617	14.5	29	58	42	2.7 / 0.6	0.86
2个	8.8	0.077	1.87	9.5	534	1197	4.63	131	471	13.2	22	38	42	1.8 / 0.4	0.72
3	8.2	0.262	1.92	8.5	368	21567	6.96	187	409	13.8	68	30	12	0.9 / 0.2	0.52
4	9.2	0.516	2.96	8.3	310	3918	0.39	425	561	11.4	27	65岁	38	2.7 / 0.5	0.87
5	未完成	未完成	未完成	未完成	未完成	未完成	未完成	未完成	未完成	未完成	未完成	未完成	未完成	未完成	未完成

注意：参考范围：Hb，13.5–17.5 g / dl；网织红细胞计数，0.022-0.118×10 ¹² / L; ALC，1.2-4.8×10 ⁹ /升; WBC计数4.4-11.3×10 ⁹ / L; 血小板计数150×450×10 ⁹ / L; d二聚体，<500 ng / ml; CRP，<1.0 mg / dl；铁蛋白，20–300 mcg / L；LDH，84–246 U / L；PT，9.7–12.7 s；APTT，25-36 s；AST，9–39 IU / L；ALT，10-52 IU / L；T / C帐单。总量为0.0-1.2 mg / dl，直接为0.0-0.3 mg / dl；S.肌酐，0.5–1.3 mg / dl。
缩写：ALC，绝对淋巴细胞计数；APTT，激活部分凝血活酶时间；AST，天冬氨酸转氨酶；ALT，丙氨酸转氨酶；CRP，C反应蛋白；Hb，血红蛋白；LDH，乳酸脱氢酶；PT，凝血酶原时间；白细胞，白细胞。

严重急性呼吸系统综合症冠状病毒2病毒可作为SCD患者急性胸腔综合症（ACS）的潜在诱因。脾功能亢进，血管病变，铁超负荷和反复发作的静脉闭塞性危机（VOC）等因素会导致免疫力下降，与COVID-19肺炎的非SCD患者相比，可以导致更多的致命后果。³另外，请注意，与COVID-19相关的ACS，COVID-19肺炎和细菌性肺炎的临床表现可能会重叠（图1）。这可能具有挑战性，尤其是在同一患者中一个或多个实体共存的情况下。通常，COVID-19肺炎比ACS或细菌性肺炎更常见于影像学中的弥漫性毛玻璃外观。与COVID-19本身相比，溶血，血红蛋白快速下降，骨痛等其他经典发现更可能提示ACS。但是，在实际情况下，要最终排除一种可能性可能非常困难。

图1
在图形查看器中打开微软幻灯片软件

COVID-19大流行期间SCD患者呼吸系统不适的三种常见差异。COVID-19，2019年冠状病毒病; SCD，镰状细胞病

威斯康星大学医学院发起的SECURE-SCD全球注册中心是一个很好的平台，可以协作SCD的病例获得COVID-19及其结果（https://covidsicklecell.org/updates-data/）。⁴最新数据（更新至2020年7月17日）显示，全世界（主要是美国）登记的260例SCD病例的平均年龄为26.83岁，非洲裔美国女性是受影响最严重的人群。就像我们的患者系列一样，登记处的大多数患者都接受了羟基脲治疗，并且没有进行任何慢性输血治疗。我们在病例系列中也注意到了一个有趣的发现，即31.15％的患者（260名患者中有81名）仅表现出疼痛症状。大多数患者（54.62％）有轻度症状，死亡率为6.15％。报告的第二大研究包括法国对83名SCD CD19患者的研究（多中心研究，有24家医院）。⁵法国研究组显示，重症监护病房的患病率随着年龄的增长而增加（年龄较大的组为53％，中位年龄为54岁，而年龄较小的组为13％，中位年龄为28岁）。大多数患者具有相关的VOC（54％，在81名患者中有44名），其次是ACS（28％，在82名患者中有23名）。20％的患者需要ICU护理，这几乎与SECURE-SCD全球注册机构报告的结果相似（25％为重症或重症患者）。除上述研究外，迄今为止，其他两项最大的单中心研究均来自英国，每项研究均包括10名患者。^6、7

总之，在SCD患者中治疗COVID-19需采用多学科方法，同时管理肺炎，VOC，ACS和支持治疗，以取得最佳效果。

更新日期：2021-04-01

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