Background: COVID-19 possesses a high risk for coagulopathy, being Disseminated intravascular coagulation (DIC) described in few cases. Baricitinib is a selective inhibitor of Janus kinase 1 and 2 that is used in COVID-19 with reports of increased thrombotic events.

Aims: This case will serve as an awareness to screen for DIC in severe COVID-19 infection treated with baricitinib to reduce complications, mortality and improve patient outcomes.  

Methods: A 68-year-old female with a known medical history of ischemic stroke, arterial hypertension, and diabetes mellitus type 2 admitted with pneumonia, COVID-19 infection, hypoxic respiratory failure on mechanical ventilation, acute kidney injury, and distributive shock. The patient was started on IV antibiotics, remdesivir, baricitinib, vasopressors, and thrombosis prophylaxis. Sputum culture, urine culture, and blood culture from admission were reported negative. WBC and c-reactive protein trending down. On day six patient was extubated, and vasopressors discontinued. On day eight patient became hypoxic and hemodynamically unstable, needing reintubation and vasopressors. The patient was pan-cultivated.  On day 10, sputum, blood, and urine culture reported E. coli ESBL positive. On day 14, the patient started oozing from the venipuncture site. Anticoagulation was discontinued. The International Society on Thrombosis and Haemostasis score for DIC was 5.

Results: The patient had two units of fresh frozen plasma transfused. After the transfusions, the coagulation panel showed an increase in PT, PTT, and D-dimer along with a decrease of fibrinogen level. Another unit of fresh frozen plasma was administered, but despite this treatment, the fibrinogen level kept in decreasing trend, and the patient started bleeding from the mouth and nose. Unfortunately, the patient passed away on day 15.

Conclusions: We hypothesize that the baricitinib treatment in our patient predisposed to DIC by two mechanisms: by its inherent thrombotic effect and, superinfection leading to E. coli bacteremia, and multiorgan failure leading to DIC.  

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ISTH Congress Abstracts - https://abstracts.isth.org/abstract/sepsis-induced-disseminated-intravascular-coagulation-secondary-to-covid-19-and-baricitinib-treatment/