The Complex Interplay between SARS-CoV-2 Infection and Acquired Bone Marrow Failure


In the wake of the global COVID-19 pandemic, a growing body of evidence suggests that the repercussions of SARS-CoV-2 infection extend beyond the respiratory system, encompassing various autoimmune and hematological disorders.

Recent reports have highlighted a concerning link between COVID-19 and conditions such as pediatric inflammatory multisystemic syndrome (PIMS), systemic lupus erythematosus (SLE), immune thrombocytopenia, chronic lymphocytic leukemia, and acquired hemophilia.

Among these, acquired bone marrow failure (AA) has emerged as a particularly noteworthy manifestation, with new cases surfacing globally.

Temporal Associations and Clinical Observations:

One intriguing observation is the temporal relationship between SARS-CoV-2 infection and the onset of AA. Reports indicate a remarkably short timeframe between PCR positivity for COVID-19 and a subsequent decline in total blood cell count. This temporal correlation aligns with previous data indicating that COVID-19 might trigger immune-mediated bone marrow failure, with the infection preceding the development of pancytopenia by weeks to months.

Potential Mechanisms Linking COVID-19 and AA:

Several potential mechanisms underpinning the link between COVID-19 and AA have been proposed, shedding light on the complex interplay between the viral infection and hematopoietic processes. These mechanisms include:

  • Excessive Inflammatory Cytokines and Cytokine Storm: COVID-19 is characterized by an excessive production of inflammatory cytokines and the occurrence of cytokine storms. These inflammatory cascades may contribute to the development of AA.
  • Viral Cytotoxicity: The potential cytotoxic effects of the virus itself, either directly or through cytokine storm pathways, may play a role in the pathogenesis of AA.
  • Abnormal Hematopoiesis: SARS-CoV-2’s ability to infect bone marrow erythroid cells may lead to abnormal hematopoiesis, disrupting the delicate balance of blood cell production.
  • Aberrant Immune Response: The virus may trigger an aberrant immune response, depleting the stem cell compartment and inducing bone marrow failure.
  • Myelosuppressive Effect: Reports suggest a potential myelosuppressive effect of the virus, further contributing to the development of AA.
  • Manipulation of Stem Cell Replication: SARS-CoV-2 may manipulate hematopoietic stem cell replication processes by impairing the expression of vital proteins and disrupting intracellular biochemical cascades.
  • Abnormal Erythropoiesis: CD147 on hematopoietic cells, acting as a receptor for virus entry, may contribute to abnormal erythropoiesis.
  • Direct Infiltration into Bone Marrow: There is the possibility of direct infiltration of the virus into the bone marrow, exacerbating the hematological consequences.

Clinical Case from China:

A case from China presents a unique scenario, being the first reported instance of acquired bone marrow failure in the country. Notably, the patient exhibited a rapid progression from PCR positivity to a decline in total blood cell count within 15 days. This aligns with broader infectious disease data indicating that SARS-CoV-2 infection can lead to immune-mediated bone marrow failure, with a temporal correlation that implicates COVID-19 in the pathogenesis of AA.

Immunodeficiency and Prolonged Viral Shedding:

Immunodeficient or immunocompromised individuals face an increased risk of a prolonged viral phase, with contagious periods extending for months compared to the general population. In the reported case, the patient remained persistently positive on PCR testing of blood cells and plasma even after three months of infection. This protracted shedding supports the hypothesis that SARS-CoV-2 might be causally associated with AA.

Limitations and Future Directions:

Despite these intriguing findings, the current study acknowledges certain limitations, notably the absence of cytokine studies or viral PCR analysis of bone marrow aspirates. This gap in knowledge leaves critical questions unanswered, including whether the virus exerts a direct cytotoxic effect on hematopoietic stem cells or if the pathogenesis involves a cytokine storm or aberrant immune dysregulation following infection. Consequently, the need for extensive evaluations in large cohorts becomes apparent to unravel the intricate associations between blood system diseases and COVID-19.


The intersection of SARS-CoV-2 infection and acquired bone marrow failure introduces a complex and multifaceted dimension to the ongoing understanding of COVID-19’s systemic impact. While clinical observations suggest a compelling temporal correlation, the underlying mechanisms linking COVID-19 to AA remain enigmatic.

As researchers delve deeper into large-scale evaluations, the hope is to decipher the intricate pathways through which this viral infection influences hematological processes, paving the way for targeted interventions and a more comprehensive approach to managing COVID-19-related complications.

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