COVID-19 vasculitis and novel vasculitis mimics.
COVID-19 vasculitis and novel vasculitis mimics.
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DOI：
10.1016/s2665-9913(20)30420-3
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发表时间：
2021-03
期刊：
影响因子：
--
通讯作者：
Watad A
中科院分区：
文献类型：
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作者：
McGonagle D;Bridgewood C;Ramanan AV;Meaney JFM;Watad A
COVID-19偶尔与组织学证实的皮肤血管炎和川崎样血管炎有关，这些实体通常具有最小或无肺部受累，预后良好。与这些血管炎类型不同，严重COVID-19肺炎患者可能出现皮肤血管炎样病变和全身动脉和静脉血栓栓塞，包括隐源性中风和其他血管病变特征。这些严重表现的潜在机制包括免疫失调，包括抗磷脂综合征样状态、补体激活、病毒传播伴直接全身性内皮感染、病毒性RNA血症伴免疫血栓形成、低氧血症介导的凝血途径激活和不动。在本观点中，我们强调了COVID-19患者的成像和尸检结果如何表明肺泡毛细血管床远端肺静脉区域中的新型血栓形成，该区域通常作为凝块过滤系统，这可能代表了未被认识到的全身微栓塞病灶。此外，我们认为这种机制代表了一种与COVID-19相关的新型血管炎模拟，可能导致多支血管区域的隐源性卒中、急性肾损伤伴血尿、皮肤血管炎模拟、肠道缺血和其他器官缺血表现。这一发现得到了广泛肺小静脉血栓形成和外周器官血栓形成伴免疫细胞浸润的病理报告的支持。因此，严重的COVID-19肺炎伴广泛的肺血管内凝血病可能有助于解释COVID-19的众多全身性并发症，其中直接器官感染的证明并不能充分解释病理学。
COVID-19 has been occasionally linked to histologically confirmed cutaneous vasculitis and a Kawasaki-like vasculitis, with these entities generally having minimal or no lung involvement and a good prognosis. Unlike these vasculitis types, patients with severe COVID-19 pneumonia can develop cutaneous vasculitis-like lesions and systemic arterial and venous thromboemboli, including cryptogenic strokes and other vasculopathy features. Proposed underlying mechanisms for these severe manifestations have encompassed immune dysregulation, including an anti-phospholipid syndrome-like state, complement activation, viral dissemination with direct systemic endothelial infection, viral RNAaemia with immunothrombosis, clotting pathway activation mediated by hypoxaemia, and immobility. In this Viewpoint, we highlight how imaging and post-mortem findings from patients with COVID-19 indicate a novel thrombosis in the pulmonary venous territory distal to the alveolar capillary bed, a territory that normally acts as a clot filtration system, which might represent an unappreciated nidus for systemic microembolism. Additionally, we suggest that this mechanism represents a novel vasculitis mimic related to COVID-19 that might lead to cryptogenic strokes across multivessel territories, acute kidney injury with haematuria, a skin vasculitis mimic, intestinal ischaemia, and other organ ischaemic manifestations. This finding is supported by pathological reports of extensive pulmonary venular thrombosis and peripheral organ thrombosis with pauci-immune cellular infiltrates. Therefore, severe COVID-19 pneumonia with extensive pulmonary intravascular coagulopathy might help to explain the numerous systemic complications of COVID-19, in which the demonstration of direct organ infection has not adequately explained the pathology.