Abstract
We present a case series of three patients with COVID-19 who were admitted to our
intensive care unit due to acute respiratory distress syndrome, brain
infarction, pulmonary embolism, and antiphospholipid antibodies. We applied
therapeutic plasma exchange on all cases. On intensive care unit admission, all
patients had low (<10) Glasgow Coma Scale, and central nervous imaging showed
multiple brain infarctions. COVID-19 was confirmed by reverse transcriptase
polymerase chain reaction assays. Patients underwent rescue therapeutic plasma
exchange using the Spectra Optia
TM
Apheresis System (Terumo BCT Inc.,
USA), which operates with acid-citrate dextrose anticoagulant as per Kidney
Disease Improving Global Outcomes 2019 guidelines. A dose of 1.5 plasma volume
was used for the first dose and then 1 plasma volume daily for a total of five
doses. Plasma was replaced with Octaplas LG
®
(Octapharma AG, USA),
which is an artificial fresh frozen plasma product that has undergone viral
inactivation by prion reduction technology. We administered ARDS-net/prone
positioning ventilation, empiric antiviral treatment, therapeutic
anticoagulation, and intensive care unit supportive care. Laboratory tests
showed lymphocytopenia; elevated levels of D-dimer, fibrinogen, total bilirubin,
C-reactive protein, lactate dehydrogenase, and ferritin; as well as low levels
of ADAMTS-13 activity and antibody. Serology tests depicted positive IgM and IgG
antiphospholipid antibodies (anti-cardiolipin and anti-β2-glycoprotein I
antibodies). No side effects of therapeutic plasma exchange were recorded. After
the completion of therapeutic plasma exchange, patients improved clinically and
gradually recovered neurologically (after 27–32 days). To conclude, in
life-threatening COVID-19, especially when immune dysregulation features such as
antiphospholipid antibodies exist, therapeutic plasma exchange could be an
effective rescue therapy.