Infection by New Coronavirus Can Induce AHA, Case Report Says

Infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the coronavirus causing COVID-19, can induce the onset of acquired hemophilia A (AHA), a case report has found.

As such, blood coagulation should be monitored closely in patients hospitalized for COVID-19, scientists said.

The study, “The first case of acquired hemophilia A associated with SARS-CoV-2 infection,” was published in the American Journal of Hematology.

AHA is an autoimmune disease in which the patients’ immune system starts producing self-reactive antibodies that wrongly recognize and destroy a blood clotting protein called factor VIII (FVIII).

This shortage in FVIII leads to blood clotting problems and spontaneous bleeds that resemble the symptoms of hemophilia A, a disorder caused by a mutation in the F8 gene that leads to lack of functional FVIII.

AHA tends to occur in elderly individuals who do not have underlying or predisposing medical conditions.

In this report, physicians described the clinical case of a 66-year-old man who developed AHA after being infected with SARS-CoV-2 associated with COVID-19.

He first went to the emergency room of a hospital in Mantua, Italy in November 2011, with severe spontaneous bleeding in the skin and muscles.

The patient had no history of blood disorders. Lab tests revealed he had anemia, with normal platelet and white blood cell counts. Additional tests suggested he had inhibitors (neutralizing antibodies) against FVIII in his blood, which prompted the diagnosis of idiopathic (no known cause) AHA.

He immediately was given recombinant (man-made) activated factor VII intravenously to stop the bleeding, along with oral prednisone and cyclophosphamide to reduce the overactivation of his immune system. Notably, factor VII is another protein in the coagulation cascade, given to bypass the need for FVIII.

Complete remission was achieved 21 days after initiating treatment and lasted for nine years.

However, in March 2020, he was re-admitted to the hospital due to high fever, cough, lack of energy (asthenia), and difficulty breathing that had been going on for the past three days. A nasal swab test led to a COVID-19 diagnosis, and a chest CT scan revealed he had interstitial pneumonia in both lungs.

Additional tests performed due to the presence of a large hematoma (a collection of blood outside a blood vessel) in his trunk revealed, once again, low levels of FVIII and prolonged blood clotting indicative of AHA — assessed via the activated partial-thromboplastin time test (aPTT).

He was given the same treatments he had received in 2011, and entered in remission 20 days later. He also was treated with anti-viral therapies (lopinavir-ritonavir) and put on non-invasive mechanical ventilation with oxygen for COVID-19, which resolved within two weeks.

“In this case, the first reported in literature, the re-appearance of AHA was triggered by acute SARS-Cov-2 infection,” the scientists wrote.

“We therefore recommend a daily coagulation monitoring (APTT) in patients admitted with acute COVID-19 infection and the inhibitor search (…) in those cases with otherwise unexplained onset or worsening [bleeding episodes],” they concluded.