COVID-19-Related Coagulopathy

Admin visible only- Edit this block in event that visitors need additional messaging, ie Under maintenance, slow loading times, etc.

Please note! ...Put your alert here. (SOP for editing this block)

COVID-19-Related Coagulopathy

Blood Clotting—Through Thick and Thin

By Ruth Werner

Read this special preview of Ruth Werner's Pathology Perspectives column scheduled to appear in the July/August 2020 issue of Massage & Bodywork.

Picture this: A person infected with SARS-CoV-2 is making blood clots. Gazillions of them. All over their body. Some are tiny, blocking the capillary supply to the skin and organs. Others are big enough to cause heart attacks, strokes, and pulmonary embolism.

At the same time, the person has signs of bleeding in other parts of their body. Bruises form with little or no trigger. Their gums bleed with regular toothbrushing. Petechiae may develop in the skin: small, reddish or purplish spots that are the result of microvascular bleeding under the skin. Somehow, their blood is simultaneously too thick and too thin.

What in the world is going on here? And what should massage therapists know about this situation?

To set up a conversation about blood-clotting problems related to COVID-19, we will do a cursory review of our wonderful capacity for hemostasis: maintaining our blood-clotting functions within boundaries for health and safety.

Hemostasis: Balanced Blood Clots

Under normal circumstances, our blood flows through our thousands of miles of blood vessels, delivering oxygen and nutrients, removing carbon dioxide and wastes. The O2–CO2 exchanges happen at the alveoli in the lungs and at the capillary level in the tissues. It is meant to be a closed system, meaning that red blood cells are kept within the circulatory vessels. If they manage to escape, then something is wrong.

Among our blood components, we have cell fragments called platelets or thrombocytes. These tiny, smooth corpuscles move through our circulatory system, scanning for possible breaches and rough spots. If something in the system is disrupted, then the platelets activate: they become spiky, they secrete a lot of chemicals that act on other platelets and clotting factors in the blood, a fibrin net is woven, and a plug—that is, a clot—is formed. The factors that prompt this process are identified as the Virchow triad, named for a 19th-century German pathologist who made some early observations about blood clotting.

Blood clotting is not a bad thing; this mechanism serves an important life-preserving function, and we would be in a lot of trouble if it didn’t work. But it must be balanced by clot-melting mechanisms, or we get into a different kind of trouble. Most of our clot-melting chemicals are produced by the liver; when they do their work, the fibrin nets are dismantled, clots are degraded, and blood flow is restored.

When all goes well, we form and melt clots all the time, in appropriate responses to tissue damage or other factors. But when we form more clots than we can melt, we are at risk for complications like thrombi (clots that form on site and can become big enough to block blood flow) or emboli (fragments of thrombi or debris that travel through vessels to other locations). Many things can upset our hemostatic processes. Heart disease, trauma, pregnancy, autoimmune disease, inflammation, and some types of cancer can all cause pro-clotting imbalances in these mechanisms. But the focus of this article is the hemostatic derangement that occurs in the presence of systemic infection with SARS-CoV-2, the virus that causes COVID-19.

I am deeply grateful to Dawn, a generous massage therapist and COVID-19 survivor, who experienced a version of this process, and shared her story.

Dawn’s Timeline

Dawn, a massage therapist from Texas, was kind enough to chat with me about her experience. Here is her timeline of interactions with COVID-19 and its complications:

  • December 2019: Dawn takes care of her brother who is in the hospital with an undiagnosed infection. He needs a ventilator, dialysis, and other interventions. Weeks later his health-care team agrees that he had all the signs and symptoms of COVID-19 before it was officially recognized in that part of the country.
  • March 19, 2020: Dawn wakes with a feeling of heaviness in her chest. She has had bronchitis in the past, and she assumes this is another bout. She is bedridden for three days, and then symptoms subside. 
  • March 25, 2020: Dawn has no fever, cough, congestion, or trouble breathing, but she has debilitating fatigue and needs two naps a day just to function. She has a sudden onset of extreme muscle soreness in her upper body, and spends much of the next few weeks with pain-relieving lotion on her trunk and arms. During a bath, she notices bright pink spots all over her legs. These get progressively larger over the next several days. 
  • April 16, 2020: Many of the pink spots have converged into large wheals. They are intensely itchy, like “ants biting.” Her legs are bilaterally swollen at the end of every day. In a consultation with a “tele-doc,” she is counseled to cut down on her activity (she had been walking four miles every day), to raise her legs whenever she rests, and to take a baby aspirin daily. (Although her doctor doesn’t ask about this, she is also experiencing severe and prolonged bleeding in her mouth when she brushes her teeth.)
  • April 24, 2020: After mild exercise, large bruises form over the wheals on Dawn’s legs. She has tingling sensations in her upper lip that persist for a few days.• April 25, 2020: Dawn is tested for COVID-19. Her nasopharyngeal swab is negative, but her serum antibodies are positive. This indicates that she has had the infection in the past, but the viral population in her upper respiratory tract is low.
  • April 30, 2020: Dawn’s rash is 95 percent gone, and she is almost at normal activity levels. 
  • May 12, 2020: Dawn's rash on her legs has flared up again and she now has dark purple spots on her toes: COVID-toe.

When It All Goes Wrong: Hemostatic Derangement

We know that SARS-CoV-2 first targets the lungs in most patients, but we also know it doesn’t always stop there. It turns out this virus can attack any cells with a membrane receptor site called ACE-2. This includes alveolar cells, but also myocardial cells, kidney cells, the intestinal lining, and (here is the link between COVID-19 and clotting disorders) the endothelial layer of blood vessels—in arteries, veins, and capillaries. And these attacks lead to inflammation (endotheliitis) and damage to the inner lining of blood vessels. In some people, this damage triggers an extreme inflammatory reaction called a cytokine storm—this is a topic addressed in Til Luchau’s article “Understanding COVID-19’s Cytokine Storm” in the May/June 2020 issue of Massage & Bodywork (page 80).

A complicated (and very chemistry-heavy) sequence leads from viral invasion to cytokine overreaction, inflammation, platelet activation, and the precipitation of clotting factors in the complement cascade, but the ultimate outcome is that the infected person develops clots—and lots of them. They can line the alveolar capillaries, interfering with oxygen/carbon dioxide exchange. They can develop in the liver, the kidneys, the brain, and many other tissues. These clots can damage red blood cells trying to pass through narrow spaces—a process that stimulates even more clotting. All this clotting activity leads to a type of multiorgan failure, which is a frequent cause of death for people with the infection. As of this writing, when a person with COVID-19 dies, this is the situation found during autopsy somewhere between 30 percent and 40 percent of the time. That number may change as we learn more about this virus.

But COVID-related clotting disorders have other repercussions as well. Readers may be familiar with Tony Award-winning actor Nick Cordero, whose leg was amputated because clots in his arteries were blocking circulation, which led to the threat of gangrene and blood poisoning. Also as part of the pandemic, young people (that is, people under age 50) with the virus are dying of heart attacks (clots in the coronary artery) and strokes (clots in the cerebral arteries) at higher rates than we have seen before—sometimes before other symptoms are evident. Further, the clots may be in unusual places, especially in the brain, and resistant to typical treatments. This appears to be directly related to COVID-related disruptions in blood-clotting mechanisms.

In addition, the hemostatic disruptions seen with COVID-19 may also cause blood clots in tiny blood vessels on the trunk or extremities. Readers may have seen reports of “COVID toes”—this is a consequence of microvascular obstruction with resulting skin damage. This can also take the form of skin bumps, swelling, and redness on the toes (COVID-toe), and petechiae on the extremities or trunk, with dark, flat, discolored patches of skin where microvascular bleeding has taken place.

Disseminated Intravascular Coagulation

A condition called disseminated intravascular coagulation (DIC) is a serious complication that is identified when a specific type of disordered blood clotting accompanies some other major health challenge. It’s a complicated situation involving both excessive levels of clotting in some areas and excessive levels of bleeding in others. This is because in the hypercoagulable areas, platelets and clotting factors are used up—leaving inadequate supplies to deal with tissue injuries elsewhere. This is why DIC is sometimes called consumptive coagulopathy—clotting factors are consumed.

DIC is identified when blood tests show low levels of platelets (this is called thrombocytopenia), delayed clotting times, and high levels of D-dimer, a substance that indicates fibrin breakdown, or the degradation of blood clots.

Is DIC the situation we see with COVID-19 patients? It’s not entirely clear. Some medical professionals are moving forward with that assumption, while others find some differences between classic DIC, another clotting disorder called antiphospholipid syndrome, and what is now called COVID-associated coagulopathy. For our purposes, it doesn’t matter, but understanding the phenomenon will make a difference in treatment options and survival rates for patients.

Massage Therapy Implications

It’s hard to make confident recommendations about massage therapy in the context of a situation that is so complicated and fraught with unknowns. As I processed mountains of information and held conversations with many generous people who helped talk me off the cliff of confusion, I boiled down my remaining questions to a few primary ones, some of which I was able to answer:

1. Can you have COVID-19 and not have coagulopathy? (Yes)

2. Can you have COVID-19-related coagulopathy and not be hospitalized? (Yes)

3. Can you have coagulopathy and not have obvious symptoms? (Yes)

4. Could massage lead to embolization in a client with symptomatic or asymptomatic coagulopathy? (UNKNOWN, but we have to assume YES)

5. At what point is it safe for a person with a history of coagulopathy to receive massage? (UNKNOWN)

Up until this point, our main goal in the context of COVID-19 has been to minimize the risk of catching or spreading the virus in a massage therapy setting. Now, we have an entirely different risk factor, with the possibility of contributing to blood-clotting complications by way of hands-on bodywork.

In the final analysis, we must decide if the risks related to massage therapy for people who might have COVID-related coagulopathy are any greater than the risks we see with other hidden disorders. Is COVID-related coagulopathy different?

This topic is a moving target, and our understanding of blood-clotting problems in the context of COVID-19 evolves quickly. In the short run, I propose that the best choice is to avoid working with people who are at risk for a current COVID-19 infection and to screen for blood-clotting problems in general. That might mean adding three new questions to a COVID-specific intake form:

  • Can you exercise to get your heart rate and respiratory rate up without any problem? (This would indicate whether their cardiopulmonary function is unimpaired.)
  • Have you had a new onset of muscle aches and pain since the emergence of the virus? (This is a possible early sign of coagulopathy, and a reason to defer treatment until the person has been tested and cleared of coagulopathy risk.)
  • Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin? (This indicates the possibility of microvascular clotting, and is reason to defer treatment until the person has been tested and cleared of coagulopathy risk.) In terms of clinical decision-making, we can start here: any new signs of skin lesions or discoloration need to be fully resolved before we can be sure that massage is safe. Any signs of pulmonary or cardiovascular strain needs to be resolved. And any client using an anticoagulant to treat complications related to COVID needs to delay massage until they are no longer at risk for blood clotting.

As we learn more about this situation, guidelines will change. This is a snapshot in time, and I dearly hope that in a year we will look back on this and say, “Yes, we’ve learned a lot since then.” But until that time, we must be cautious and conservative, so that we can keep to our promise to “do no harm.”

(Don’t miss the video that accompanies this upcoming article in the July/August 2020 issue of Massage & Bodywork.)

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at www.booksofdiscovery.com), now in its seventh edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.

References

Abbasi, Jennifer. “The Promise and Peril of Antibody Testing for COVID-19.” JAMA. April 22, 2020. https://doi.org/10.1001/jama.2020.6170.

Advisory Board. “It’s Not Just Lungs: Covid-19 May Damage the Heart, Brain, and Kidneys.” The Daily Briefing. April 17, 2020. www.advisory.com/daily-briefing/2020/04/17/organ-damage.

Brooks, Megan. “’Hypercoagulation,’ Antiphospholipid Antibodies Seen in COVID-19.” Medscape. April 14, 2020. www.medscape.com/viewarticle/928653.

Caplan, Arthur L. and Shailin A. Thomas. “A Better Way to Prioritize Essential Care During COVID-19.” Medscape. April 15, 2020. www.medscape.com/viewarticle/928537.

Cascella, Marco et al. “Features, Evaluation and Treatment Coronavirus (COVID-19).” In StatPearls [Internet]. Treasure Island: StatPearls Publishing, 2020. www.ncbi.nlm.nih.gov/books/NBK554776.

Cennimo, David J. “Coronavirus Disease 2019 (COVID-19).” Medscape. Updated May 4, 2020. Accessed May 5, 2020. https://emedicine.medscape.com/article/2500114-overview.

Cha, Arianna Eunjung. “A Mysterious Blood-Clotting Complication is Killing Coronavirus Patients.” Washington Post, April 22, 2020. www.washingtonpost.com/health/2020/04/22/coronavirus-blood-clots.

Cha, Ariana Eunjung. “Young and Middle-Aged People, Barely Sick with Covid-19, are Dying of Strokes.” Washington Post, April 24, 2020. www.washingtonpost.com/health/2020/04/24/strokes-coronavirus-young-patients.

Codosh, Sara. “Autopsies Provide Crucial Information for Fighting COVID-19.” Popular Science. Updated April 30, 2020. www.popsci.com/story/health/autopsy-covid-lessons.

Cooney, Elizabeth. “Blood Clots Leave Clinicians with Clues about Covid-19—But No Proven Treatments.” STAT. April 16, 2020. www.statnews.com/2020/04/16/blood-clots-coronavirus-tpa.

Eschner, Kat. “COVID-19 is Causing Strokes in Young People and Doctors Don’t Know Why.” Popular Science. April 28, 2020. www.popsci.com/story/health/covid-19-strokes-young-adults.

Giannis, Dimitrios, Ioannis A. Ziogas, and Panagiota Gianni. “Coagulation Disorders in Coronavirus Infected Patients: COVID-19, SARS-CoV-1, MERS-CoV and Lessons from the Past.” Journal of Clinical Virology 127, no. 2020 (June 2020): 104362. Accessed May 5, 2020. https://doi.org/10.1016/j.jcv.2020.104362.

Gibbs, W. Wayt and Steve Mirsky. “COVID-19: What the Autopsies Reveal.” Podcast. Scientific American. April 23, 2020. www.scientificamerican.com/podcast/episode/covid-19-what-the-autopsies-r....

Gillum, Jack, Lisa Song, and Jeff Kao. “There’s Been a Spike in People Dying at Home in Several Cities. That Suggests Coronavirus Deaths are Higher than Reported.” ProPublica. April 14, 2020. www.propublica.org/article/theres-been-a-spike-in-people-dying-at-home-i....

Glatter, Robert. “Why is COVID-19 Coronavirus Causing Strokes in Young and Middle-Aged People?” Forbes. April 27, 2020. www.forbes.com/sites/robertglatter/2020/04/27/why-is-covid-19-coronaviru....

Goodman, Brenda. “Blood Clots Are Another Dangerous COVID-19 Mystery.” WebMD Health News. April 24, 2020. www.webmd.com/lung/news/20200424/blood-clots-are-another-dangerous-covid....

Goodman, Brenda. “Cytokine Storms May Be Fueling Some COVID Deaths.” WebMD Health News. April 17, 2020. www.webmd.com/lung/news/20200417/cytokine-storms-may-be-fueling-some-cov....

Grey, Heather. “The Unusual COVID-19 Symptoms You Can Miss.” Healthline. April 26, 2020. www.healthline.com/health-news/the-covid-19-symptoms-most-people-could-miss.

“Hemostasis—An Overview.” ScienceDirect. Accessed April 30, 2020. www.sciencedirect.com/topics/neuroscience/hemostasis.

Jose, Ricardo J. “COVID-19 Cytokine Storm: The Interplay between Inflammation and Coagulation.” The Lancet. Corrected proof April 27, 2020. Accessed May 5, 2020. https://doi.org/10.1016/S2213-2600(20)30216-2.

Kanwar, Vikramjit S. “Consumption Coagulopathy.” Medscape. Updated September 30, 2019. Accessed May 5, 2020. https://emedicine.medscape.com/article/955059-overview.

Katella, Kathy. “5 Things Everyone Should Know About the Coronavirus Outbreak.” Yale Medicine. May 4, 2020. www.yalemedicine.org/stories/2019-novel-coronavirus/?fbclid=IwAR3dFwKXag....

Lee, Agnes Y. Y. et al. “COVID-19 and Coagulopathy: Frequently Asked Questions, Version 2.0.” American Society of Hematology. Updated April 14, 2020. www.hematology.org:443/covid-19/covid-19-and-coagulopathy.

Lee, Agnes Y. Y. et al. “COVID-19 and Pulmonary Embolism: Frequently Asked Questions” American Society of Hematology. Updated April 9, 2020. www.hematology.org:443/covid-19/covid-19-and-pulmonary-embolism.

Levi, Marcel M. “Disseminated Intravascular Coagulation.” Medscape. Updated October 7, 2018. Accessed May 5, 2020. https://emedicine.medscape.com/article/199627-overview.

Levi, Marcel M. “What is the Role of D-Dimer and Fibrin Degradation Product (FDP) Tests in the Workup of Disseminated Intravascular Coagulation (DIC)?” Medscape. Updated October 7, 2018. Accessed May 5, 2020. www.medscape.com/answers/199627-154495/what-is-the-role-of-d-dimer-and-f....

Lucas, Alexandra and Marsha Bryant. “Disseminated Intravascular Coagulation: The Hemorrhagic Hurricane and the Cytokine Storm.” Journal of Clinical and Experimental Cardiology 4, no. 6 (2013): 1–2. https://doi.org/10.4172/2155-9880.1000e127.

Magro, Cynthia et al. “Complement Associated Microvascular Injury and Thrombosis in the Pathogenesis of Severe COVID-19 Infection: A Report of Five Cases.” Translational Research. Corrected proof April 15, 2020. Accessed May 5, 2020. https://doi.org/10.1016/j.trsl.2020.04.007.

Mova, Suneel, Elise Belilos, and Steven Carsons. “Antiphospholipid Syndrome: Practice Essentials, Pathophysiology, Epidemiology.” Medscape. Updated September 30, 2018. Accessed May 5, 2020. https://emedicine.medscape.com/article/333221-overview.

National Institutes of Health National Heart, Lung, and Blood Institute. “Health Topics: Disseminated Intravascular Coagulation.” Last updated October 8, 2019. Accessed May 5, 2020. www.nhlbi.nih.gov/health-topics/disseminated-intravascular-coagulation.

OpenStax. “Hemostasis.” In Anatomy and Physiology. OpenStax, 2013. www.opentextbc.ca/anatomyandphysiology/chapter/18-5-hemostasis.

Phend, Crystal (Ed.). “COVID-19: Abnormal Clotting Common in More Severe Disease: Chinese Clinicians on the Early Front Lines Argue for Anticoagulation.” MedPage Today. March 24, 2020. www.medpagetoday.com/infectiousdisease/covid19/85577.

“Researchers Identify Cells Likely Targeted by COVID-19 Virus.” Press Release. April 22, 2020. www.eurekalert.org/pub_releases/2020-04/miot-ric042220.php.

Sandoiu, Ana. “Faulty Blood Clotting Mechanism May Explain COVID-19 Severity.” Medical News Today. April 23, 2020. www.medicalnewstoday.com/articles/faulty-blood-clotting-mechanism-may-ex....

Smith, Michael W. (Ed.). “Complications Coronavirus Can Cause.” WebMD Medical Reference. Reviewed April 22, 2020. www.webmd.com/lung/coronavirus-complications.

Terry, Mark. “Unexpected Cause of Death in Younger COVID-19 Patients is Related to Blood Clotting.” BioSpace. April 28, 2020. www.biospace.com/article/covid-19-increases-risk-of-heart-attacks-and-st....

Tian, S. et al. “Pathological Study of the 2019 Novel Coronavirus Disease (COVID-19) through Postmortem Core Biopsies.” Modern Pathology. April 30, 2020. www.nature.com/articles/s41379-020-0536-x.

Vincent, Jean-Louis and Fabio S. Taccone. “Understanding Pathways to Death in Patients with COVID-19.” The Lancet 8, no. 5 (May 2020): 430–32. https://doi.org/10.1016/S2213-2600(20)30165-X.

Vlahovic, Tracey. “COVID-19 Skin Manifestations and the Foot: What We Know So Far.” Podiatry Today. April 22, 2020. www.podiatrytoday.com/blogged/covid-19-skin-manifestations-and-foot-what....

Wada, Hideo, Takeshi Matsumoto, and Yoshiki Yamashita. “Diagnosis and Treatment of Disseminated Intravascular Coagulation (DIC) According to Four DIC Guidelines.” Journal of Intensive Care 2, no. 1 (February 2014). https://doi.org/10.1186/2052-0492-2-15.

Wadman, M., Jennifer Couzin-Frankel, Jocelyn Kaiser, and Catherine Matacic. “How Does Coronavirus Kill? Clinicians Trace a Ferocious Rampage through the Body, from Brain to Toes.” Science. April 17, 2020. www.sciencemag.org/news/2020/04/how-does-coronavirus-kill-clinicians-tra....

Wang, Tianbing et al. “Comorbidities and Multi-Organ Injuries in the Treatment of COVID-19.” The Lancet 395, no. 10228 (March 2020): E52. https://doi.org/10.1016/S0140-6736(20)30558-4.

Category: 

Comments

It's difficult to unpack all of the implications we are facing with reopening. This certainly helps address the clotting process and importance of prescreening. 

Hi Ruth. I want to sure I'm correctly interpreting your question #3. Are you saying that even those who are asymptomatic may have coagulopathy? And, what are your recommendations/ideas for performing cupping/Gua sha/Tui Na at this time, in light of this possible complication? Thanks.

Are you saying that even those who are asymptomatic may have coagulopathy?

Maybe, but it's probably rare. We did see some early reports of younger people having strokes, heart attacks, pulmonary embolism, who would otherwise not be considered in the high risk group for these kinds of events-- and then they tested positive for COVID-19. However, a) this does not seem to be a common pattern and b) I learned just TODAY that this can happen with other viral infections as well, including flu-- the massive inflammatory response that some people have just makes them more vulnerable. It would be good if we could predict who is most at risk for this.

In re: cupping, gua sha, Tui Na, hot rocks, or any other application like this: if there are any, any, ANY signs of rash, petechiae, skin lesions of ANY type, then no. Wait till it's completely resolved. If this is what you want to do with clients whose skin is healthy, I still urge you to start slowly, work for short periods with low intensity, and build up slowly to your pre-COVID levels of work if your clients don't have any negative reactions.

I hope this helps!

Ruth Werner

Thank you Ruth. Your explanation was most helpful!

News

Increasing Education Hours: A Trend on the Rise

Due to a revised federal rule change, states with minimum-hour education requirements lower than 600 are considering increasing their massage therapy program length. Find out which states have already introduced bills that would raise education hours, which massage boards have proposed and made final rule changes, and why this is becoming a national trend.

Blog

ABMP CE Summit: Headaches

 Headaches.

Join us online Tuesday, April 30, 2024, for the ABMP CE Summit: Headaches, which take learners on a journey from understanding headaches to working with clients with headache pain using multiple modalities and techniques.

New CE Course: Stretching the Hip

Dr. Joe Muscolino displays a massage therapy technique.

The new ABMP CE course, “Stretching the Hip,” is available in the ABMP Education Center to view and earn 1.5 CE hours.

Benefits

Podcast: Cancer, Clots, and COVID—A Complicated Client

A client was recently treated for colon cancer—and it didn’t go well. She had surgical complications, a bout of sepsis, and more. Is massage therapy safe? We discuss on this episode of “I Have a Client Who . . .” Pathology Conversations with Ruth Werner.

Please note: We have recently updated our Privacy Policy and Terms of Use. Learn more...