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If I told you that someone had “COVID toes”, you might think I was making a joke at their expense. You wouldn’t be alone: It took the medical community a while itself to begin understanding how such an odd little finding could contribute toour knowledge of what this novel coronavirus is doing to us.

In this case, COVID toes are red, swollen, sometimes itchy digits that appear in some patients who have coronavirus — most often, those with a mild course of the disease. The toes have almost a frostbitten appearance, even though the patients have had no exposure to cold.

Fortunately, most people appear to recover from this aspect of the virus with little medical intervention, which might explain why you haven’t heard the term more often. But the suspected cause of COVID toes is something we need to watch intently — because it’s part of the reason why physicians in the ICU say COVID-19 is unlike any viral illness they’ve treated.

Increasingly, both inflammation and blood clotting– most likely, the driving factors in the condition I’ve described above — are gaining notoriety among medical experts studying the virus. From young people suffering strokes and experiencing Kawasaki-like heart inflammation to a Broadway star requiring emergency amputation of a leg, it is becoming clear to researchers and medical experts that clotting is a significant and growing concern.

In severe COVID cases, the clotting issues appear all too common. The New England Journal of Medicine recently examined the lungs of seven COVID-19 patients who had died, comparing them with the lungs of deceased influenza victims. They found that the COVID patients’ lungs were nine times more likely to be filled with microclots, and that the blood vessels within the lungs appeared inflamed and damaged.

That damage can be widespread. Professor David Werring and his colleagues, from UCL Queen Square Institute of Neurology in London, published a small case series of six COVID patients who experienced strokes. “We now know that COVID-19 is not just a disease of the lungs,” Werring commented. “Our findings suggest that blockages of large brain arteries in COVID-19 patients are associated with highly abnormal blood clotting,”

Taking it a step further, neurosurgeon Adair Prall, M.D. with Centura Health in Denver, Colorado, said his institution is seeing strokes occur in a younger cohort than usual — and not only that, but “several young patients have been really decimated by their strokes, while their pulmonary and other COVID symptoms seem to be mild in retrospect.”

Clots in the coronary arteries can cause deadly heart attacks. Those in large arteries of the extremities can impede oxygen delivery to tissues, sometimes leading to amputations. Clots in the pulmonary vessels of the lungs (pulmonary embolisms) can lead to respiratory arrest or even sudden death, and doctors have begun reporting extensive clotting in COVID-19 patients with kidney failure, finding that the clots are clogging even dialysis machine tubing.

So how big a problem are these clots? Dr. Jeffrey Laurence, a hematologist at Weill Cornell Medicine in New York City, told CNN the number of clotting problems he was seeing in the ICU was “unprecedented.” Dutch researchers reported in an observational study that approximately one-third of their 184 ICU patients had some type of clotting complication. This is extraordinary — and it’s nothing like we would see with any other virus.

Typically in an ICU population, pulmonary embolism occurs in just two to six percent of patients, so with coronavirus patients we’re talking about at least a three times higher incidence of clots forming in their lungs. And these are just the larger clots. We are not diagnosing the numerous microclots, found usually at autopsy, that may be contributing also to lower oxygenation levels, patients’ progressive clinical deterioration, and even multiorganfailure.

But there’s good news. We have a significant arsenal of anti-inflammatory and anticoagulant (blood thinner) medications at our disposal, available right now, to potentially prevent and treat some of these issues. In fact, many physicians are already treating COVID-19 patients who present with severe symptoms, using blood thinners prophylactically to prevent clots.

A study in the Journal of the American College of Cardiology recently looked at more than 2,700 hospitalized patients who were treated with blood thinners. For the 395 patients who were on ventilators, being on a blood thinner reduced their mortality by half, and adverse events were few. When you consider that the most of our cancer medicines being used today hardly reduce mortality at all, that is a significant development.

We still have plenty to learn about which medications to use, when to initiate them in the course of the disease, the most effective dosages, and the types of patients these drugs may benefit most. But every day, we are gaining more of an understanding about the pathophysiology and molecular mechanisms at work with this new virus.

It’s going to make a real difference in patient outcomes — and in lives saved. The learning curve has been steep. Keep wearing a mask and practicing social distancing, while medical science works on getting COVID toes back on their feet.

Carolyn Barber, MD is an ER physician who has a B.A. from Princeton University, and did her medical training at Johns Hopkins School of Medicine and residency at Stanford University Medical Center. She’s practiced emergency medicine for 25 years, and co-founded a homeless work program, Wheels of Change.

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