COVID-19 vasculitis and novel vasculitis mimics
Open accessAbstract
COVID-19 has been occasionally linked to histologically confirmed cutaneous vasculitis and a Kawasaki-like vasculitis, with these entities generally having minimal or no lung involvement and a good prognosis. Unlike these vasculitis types, patients with severe COVID-19 pneumonia can develop cutaneous vasculitis-like lesions and systemic arterial and venous thromboemboli, including cryptogenic strokes and other vasculopathy features. Proposed underlying mechanisms for these severe manifestations have encompassed immune dysregulation, including an anti-phospholipid syndrome-like state, complement activation, viral dissemination with direct systemic endothelial infection, viral RNAaemia with immunothrombosis, clotting pathway activation mediated by hypoxaemia, and immobility. In this Viewpoint, we highlight how imaging and post-mortem findings from patients with COVID-19 indicate a novel thrombosis in the pulmonary venous territory distal to the alveolar capillary bed, a territory that normally acts as a clot filtration system, which might represent an unappreciated nidus for systemic microembolism. Additionally, we suggest that this mechanism represents a novel vasculitis mimic related to COVID-19 that might lead to cryptogenic strokes across multivessel territories, acute kidney injury with haematuria, a skin vasculitis mimic, intestinal ischaemia, and other organ ischaemic manifestations. This finding is supported by pathological reports of extensive pulmonary venular thrombosis and peripheral organ thrombosis with pauci-immune cellular infiltrates. Therefore, severe COVID-19 pneumonia with extensive pulmonary intravascular coagulopathy might help to explain the numerous systemic complications of COVID-19, in which the demonstration of direct organ infection has not adequately explained the pathology.
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Acute arterial obstruction of the small intestinal vessels and mesenteric ischemia may appear due to hypercoagulability associated with SARS-CoV-2 infection, mucosal ischemia, viral dissemination, and endothelial cell invasion via ACE-2 receptors.
“Acute arterial obstruction of the small intestinal vessels and mesenteric ischemia may appear due to hypercoagulability associated with SARS-CoV-2 infection, mucosal ischemia, viral dissemination, and endothelial cell invasion vis ACE-2 receptors [65,66].”
From Acute mesenteric ischemia in COVID-19 patients (2021) · cites this paper as [66]
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Severe Acute Respiratory Syndrome and Venous Thromboembolism in Multiple Organs
Yi, X., Wang, L., Aibin, L., Zhu, G., Ri-quan, L., Xu-you, Z., Wei-wei, R., & Ye-nan, W. (2010) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/ajrccm.182.3.436 · Cited by 86 · see citing works
Senzaki, H. (2006) · Archives of Disease in Childhood · doi:10.1136/adc.2005.087437 · Cited by 84 · see citing works
Harenberg, J., & Favaloro, E. J. (2020) · Clinical Chemistry and Laboratory Medicine (CCLM) · doi:10.1515/cclm-2020-0502 · Cited by 74 · see citing works
Leyendecker, P., Ritter, S., Riou, M., et al. (2020) · European Radiology · doi:10.1007/s00330-020-07226-5 · Cited by 71 · see citing works
Potential role of platelets in COVID‐19: Implications for thrombosis
Koupenova, M. (2020) · Research and Practice in Thrombosis and Haemostasis · doi:10.1002/rth2.12397 · Cited by 52 · see citing works
Cerebral nervous system vasculitis in a Covid-19 patient with pneumonia
Vaschetto, R., Cena, T., Sainaghi, P. P., Meneghetti, G., Bazzano, S., Vecchio, D., Pirisi, M., Brustia, D., Barini, M., Cammarota, G., et al. (2020) · Journal of Clinical Neuroscience · doi:10.1016/j.jocn.2020.07.032 · Cited by 51 · see citing works
Retiform purpura as a dermatological sign of coronavirus disease 2019 (COVID‐19) coagulopathy
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Concurrent chilblains and retinal vasculitis in a child with COVID‐19
Quintana‐Castanedo, L., Feito‐Rodríguez, M., Fernández-Alcalde, C., et al. (2020) · Journal of the European Academy of Dermatology and Venereology · doi:10.1111/jdv.16801 · Cited by 45 · see citing works
Increased cardiovascular mortality in African Americans with COVID-19
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Self-citationCOVID-19 Presented With Deep Vein Thrombosis: An Unusual Presenting
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Coronaviruses and Central Nervous System Manifestations
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Ischemic stroke in COVID-19: An urgent need for early identification and management
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Flagged first, then by citations
Research works printed but not linked: 4
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Cited by
Sorted by citations
Acute mesenteric ischemia in COVID-19 patients
Serban, D., Tribus, L. C., Vancea, G., Stoian, A. P., Dascalu, A. M., Suceveanu, A. I., Tanasescu, C., Costea, A. C., Tudosie, M. S., Tudor, C., et al. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm11010200 · Cited by 46 · see citing works
- Authors
- McGonagle, D., Bridgewood, C., Ramanan, A. V., Meaney, J. F. M., & Watad, A.
- Affiliations
- University of Leeds (GB)
- University Hospitals Bristol NHS Foundation Trust (GB)
- Trinity College Dublin (IE)
- Corresponding author
- McGonagle, Dennis
- Venue
- The Lancet Rheumatology
- Publisher
- Elsevier BV
- Published
- 2021-03
- Volume
- 3
- Issue
- 3
- Pages
- e224-e233
- ISSN
- 2665-9913 (ISSN-L)
- PMC
- PMC7832717
- OpenAlex
- W3120773459
- Cited by
- 192
- References
- 99
- Citations by year
- 2026: 6 · 2025: 12 · 2024: 18 · 2023: 28 · 2022: 79 · 2021: 48
- FWCI
- 5.06
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- The Lancet Rheumatology (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Bristol Research (University of Bristol) (publishedVersion)
- Explore Bristol Research (submittedVersion)
- Topics
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Health Sciences › Medicine › Dermatology › Dermatological and COVID-19 studies
- Health Sciences › Medicine › Surgery › Kawasaki Disease and Coronary Complications
- Keywords
- COVID-19 pandemic, vasculitis mimic, cutaneous vasculitis, intravascular coagulopathy, cryptogenic stroke, thromboembolism, microembolism, immune dysregulation, antiphospholipid syndrome, complement activation, endothelial cell infection, acute kidney injury, intestinal ischemia, severe pneumonia, autopsy findings
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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