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Coronavirus disease 2019 (COVID-19) has proven to be a multifaceted disease in terms of presentation and varied complications, ranging from almost asymptomatic to death, thus setting new challenges for the medical community worldwide. Coagulopathy in associationwith thrombotic complications and perhapsevendisseminated intravascularcoagulation (DIC)have become the hallmark of severe acute respiratory syndrome coronavirus 2 infections. Klok et al evaluated a cohort of 184 intensive care unit patients, reporting a cumulative incidence of thrombotic complications as high as 31%, with pulmonary thrombosis displaying the highest occurrence despite standard thromboprophylaxis.1 Related studies have also described a high prevalence of thrombotic complications in COVID-19 patients, thus suggesting that intensification of thromboprophylaxis may be considered in patient management.2–6 The ultimate outcome of coagulopathy and the potential onset of DIC, primarily a type of prothrombotic variant, have posed many management challenges in COVID-19 patients. Several studies have predicted poor outcomes in association with markedly high levels of D-dimer, a fibrin degradation product (FDP), thus validating its prognostic role in disease management.7 The current guidancewith regard to prevention of thrombosis and management of coagulopathy and DIC recommends pharmacological thromboprophylaxis be given to all immobilized and severely ill patients with COVID-19 unless otherwise contraindicated.8 Wewish to report on four cases of DIC, encountered out of 28 COVID-19 patients admitted in our facility at the time: two cases of thrombotic complicationswith superimposedDICand two of overt DIC, despite adequate thromboprophylaxis. Case 1: 51-year-old male, physician, suffering from hypertension and diabetes mellitus, was admitted with a 10day history of cough and flu-like symptoms. Vital signs on presentation were temperature (T) 37°C, heart rate (HR) 130 beats per minute (bpm), blood pressure (BP) 167/93mm Hg, respiratory rate (RR) 45 per minute, and oxygen saturation (SpO2) of 70% on room air. Clinical characteristics and laboratory parameters on presentation are summarized in ►Table 1. The polymerase chain reaction (PCR) assay for COVID-19 was positive. Due to very high D-dimer levels (> 15,000 μg/L, fibrinogen equivalent units, low molecular weight heparin (LMWH)was initiated at prophylactic dosage of 40mg once daily subcutaneously from the first hospital day (HD). Due to hypoxemic respiratory failure, the patient was ventilated starting from the second HD, when his PaO2/ FiO2 ratiowas 65.5. On HD 10, he developed new-onset rightsided hemiplegia and ptosis. Computed tomography (CT) head plain revealed acute ischemic infarct in the left middle cerebral artery territory, involving the frontoparietal region (►Fig. 1). Aspirin and high-dose statins were started. CT pulmonary angiogram performed on that same day showed bilateral pulmonary artery thrombosis (►Fig. 2). However, due to the acute stroke, full dose of anticoagulation was withheld initially and started 48 hours later after reevaluationwith neuroimaging, to rule out extension or bleedwithin the infarct. Venous Doppler ultrasonography of lower extremities excluded deep venous thrombosis and echocardiography was normal, with no arrhythmias noted on electrocardiogram. Subsequently, he was administered an unfractionated heparin (UFH) infusion at 18 units/kg/h, with strict activated partial thromboplastin time (aPTT) monitoring; the UFH was later withheld after 12 hours as he developed melena. He was managed with blood products, including fresh frozen plasma (FFP). He continued to exhibit clinical worsening, with derangements in coagulation profile by HD 14. Prothrombin time/international normalized ratio (PT/INR) was 26.1 seconds/2.49 and based on the International Society on Thrombosis and Haemostasis (ISTH) score of 6, a diagnosis of overt DIC was made. He continued to deteriorate, eventually developing multiorgan failure (MOF) requiring single session of hemodialysis; superimposed

Fatal Disseminated Intravascular Coagulopathy in Covid-19: A Small Case Series