#00063325

A 67-year-old previously healthy male diagnosed with SARSCoV19 and received treatment with convalescent plasma and steroids. However, his symptoms progressed to respiratory failure, eventually developing acute intestinal hemorrhage, shock and disseminated intravascular coagulation (DIC) with prolonged prothrombin time (22.6 sec) and partial thromboplastin time (49.7 sec) with elevated D-dimer (8.21 mcg/mL). The peripheral blood smear (PBS) showed leukocytosis, red cells with significant anisopoikilocytosis including schistocytes (purple arrow), microspherocytes (pink arrows) and blister cells (green arrows), polychromasia (blue arrows) and nucleated red blood cells (red arrow) (Wright-Giemsa stain; original magnification, panel A x500, panels B, C, D x1000). Coagulopathy progressed and despite active management, patient succumbed to death.

Coagulopathy in COVID19 resembles systemic coagulopathies like sepsis induced coagulopathy and DIC. Systemic coagulopathies show schistocytes and microspherocytes, but not blister cells characteristic of G6PD deficiency. Blister cells are predominant in this case. Increased synthesis of proinflammatory cytokines leads to a cytokine storm and cause lung injury, including damage to the microvasculature and endothelial dysfunction, which trigger hemostatic derangements and pulmonary thrombi. Bleeding is a significant cause of morbidity in COVID19 and it is important to identify and describe the changes in PBS and coagulation profile, which will lead to timely intervention.