Bad Blood: New Insights Can Help Fight Blood Clot Problem in COVID-19

Researchers scour what is known to come up with a hypothesis of why blood clots can be a major problem in COVID-19

Driven by the mystery of the blood clots reported in both living and deceased COVID-19 patients, researchers from Shoolini University, India, dig deeper into the pathogenesis of COVID-19 and other similar viral diseases, looking for ways in which these clots could be formed. They propose a robust hypothesis, taking our understanding of clotting-related problems in COVID-19 one step further and opening doors to potential targeted therapies.

Soon after its emergence in December 2019, COVID-19, caused by the novel coronavirus SARS-CoV-2, rapidly spread worldwide resulting in a global pandemic within weeks and halting lives. Thus, early on, like most activities in the world shut down, attempts to understand SARS-CoV2 and COVID-19 kicked off in full swing.

SARS-CoV-2 was initially thought to be a respiratory pathogen, causing flu-like symptoms such as dry cough, sore throat, fever, and weakness. But over time several non-respiratory symptoms cropped up as well. One symptom gaining increasing attention was the blood clotting reported both in living and deceased patients. In several cases, the blood clots blocked normal blood flow, leading to stroke, organ failure, and even death. Yet, the mechanism of formation of these clots remains shrouded in a certain mystery.

As part of the continued attempt to clarify the mechanism, a team of researchers from Shoolini University, India, dove into the pathogenesis of SARS-CoV-2. Speaking of what inspired them, an assistant professor at the university and lead scientist in the team, Dr Pradeep Kumar, says: Statements in the vein of mysterious blood clots have been observed in COVID-19 patients were being made in newspapers and medical case reports. The blood clots were reported as mysterious because their cause is unknown. This fuelled our interest to dig deeper. Their conclusions are published in Medical Hypotheses and make up the latest additions to the body of work that led to Parneet Kaur, a member of this studys team, to be selected for the InSc Young Researcher Award. [A1] 

SARS-CoV-2 primarily enters through the nose and mouth moves to the lung. It binds to the angiotensin-converting enzyme 2 (ACE2) receptor on the cells of these organs and enters the cells. In the cells, it releases its RNA, which then initiates its replication process, leading to infection. Interestingly, the ACE2 receptor is also harboured by other cells in the body, such as the kidneys, heart, intestine, and endothelial cells (or cells lining blood vessels). COVID-19 has been known to affect these organs in some cases.

Based on this knowledge, the team from Shoolini formulated their hypothesis: Upon entering the body, the virus can enter our circulation system. There, it recognizes and interacts with the widely expressed ACE2 receptor on endothelial cells. As it enters the endothelial cells and begins its replication process, it causes infection, which triggers an immune response and therefore, inflammation. It also injures the blood vessel lining. To repair the blood vessel, clotting and coagulating pathways activate. However, in the presence of inflammation, these pathways can go awry, leading to the formation of clots within the blood vessels which can block the vessels at that site or travel down to other organs, such as the heart or brain, to cause fatal strokes and heart attacks.

Meanwhile, when the virus binds to the ACE2 receptor on the endothelial cells, the receptor is deactivated. Since the receptor normally protects endothelial cell function, its unavailability can help with the injuries and lead to an imbalance in the recruitment of platelets and clotting factors. This can enhance coagulation and clotting.

This hypothesis is based on a robust literature review of cases reporting similar mechanisms in relation to other influenza-like and respiratory viruses, and papers reporting post-mortem observations on COVID-19 patients. So, although it remains to be verified, it is an important step in unravelling the mystery of blood clotting in COVID-19.

Explaining the long-term implications of their study, Dr Kumar says: Our work will help us to understand in depth the diverse manifestations and pathophysiologies of COVID-19, which can eventually direct us towards developing targeted therapies to treat it and allied viral diseases.

Indeed, such analyses bring hope in these dark times.


AuthorsSourav Biswas, Vikram Thakur, Parneet Kaur, Azhar Khan, Saurabh Kulshrestha, and Pradeep Kumar
Title of the original paperBlood Clots in Covid-19 Patients: Simplifying the Curious Mystery
JournalMedical Hypotheses, Elsevier Public Health Emergency Collection
AffiliationsFaculty of Applied Sciences and Biotechnology, Shoolini University of Biotechnology and Management Sciences, Himachal Pradesh, India

Department of Virology, Post Graduate Institute of Medical Education and Research, (PGIMER), Chandigarh, India

About Dr Pradeep Kumar from Shoolini University

Dr Pradeep Kumar is a post-doctoral fellow and assistant professor at the Faculty of Applied Sciences and Biotechnology, Shoolini University. He has completed his PhD from Himachal Pradesh University, Shimla, in Biotechnology. His research currently focuses on the bench-scale production of secondary metabolites, in relation to new drug discoveries and industrially important bioactive compounds, especially from the endophytic microbial diversity of the Himalayan region.

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