ABSTRACT
Aims: Venous thromboembolism represents frequent complication of patients with severe COVID-19 disease. Several reports about atypical thrombosis are described, rarely it has been described a right venticular thrombus during the course of infection. We report a case of right endoventricular thrombosis in a patient with SARSCov- 2 pneumonia. Methods and results: A 58-year-old man was admitted to our ward for severe respiratory failure in interstitial pneumonia. The nasopharyngeal swab for COVID-19 resulted positive. Steroids and prophylaxis with LMWHwere started, associated to CPAP to maintain good gas exchange. During hospitalization a venous ECD was performed with evidence of left popliteal thrombosis despite the therapy. D-Dimer was 44±3 ng/ml. A new onset AF was documented at the telemetry, without troponin elevation. A cardiac ultrasound was performed showing a right endoventricular lesion of 1.8 cm adhering to the free wall of the right ventricle. A CT-pulmonary angiogram (CTPA) resulted negative for pulmonary embolism and confirmed suspected right ventricular thrombus. Treatment with fondaparinux 7.5mg was started. After 10 days, cardiac ultrasound shown complete resolution of thrombosis, and CT confirmed the disappearing of the mass. Dabigatran 150 mg twice/day was started. Patient clinically improved and he was discharged after 20 days of hospitalization. Conclusions: SARS-CoV-2 infection may cause inflammation with cytokine storm and hypercoagulability leading to venous thromboembolism. Atypical thrombus formation was reported, including right-ventricle free wall. Early caridac ultrasound was critical to make diagnosis and starting prompt treatment, therefore routine cardiac ultrasound is mandatory in severe COVID-19 patients.
ABSTRACT
Background: The association between CoViD-19 and thrombotic complication such as pulmonary embolism or deep vein thrombosis, is well known. However, SARS-CoV-2 infection may cause also thrombotic microangiopathy with significant clinical pictures. We report a case of a patient with CoViD-19 infection, thrombocytopenia, hemolitic anemia and neurological manifestation. Description of the case: A 70-year-old patient was admitted to the hospital for CoViD-19 pneumonia needing non-invasive ventilation. After 15 days he developed severe diffuse weakness and altered mental status with episodes of hyperkinetic delirium. A head CT scan and brain MRI performed were negative for lesions. On blood examination elevated creatinine (2.9 mg/dL), anemia (Hb 8,3g/dL) and thrombocytopenia (76∗103mmc) were present. The study for the hemolysis revealed total bilirubin 2.46 mg/dL, haptoglobin non detectable, direct and indirect Coombs test negatives and elevated presence of schistocytes >100/1000 blood cells. The ADAMTS-13 was negative. During the hospitalization platelet count drop to 16∗103mmc and patient developed a right ileopsoas hematoma. The patient died before the treatment started. Conclusions: Acquired thrombotic thrombocytopenic purpura represent a fearsome CoViD-19 complication with unfavorable outcome. The early recognition may be associated with a better prognosis. The presence of thrombotic microangiopathy on blood tests and Moskowitz's pentad in the clinic should rise the suspicion: the first step in diagnosing aPTT is to suspect it.
ABSTRACT
Background and Aim: CoViD-19 patients with mild to severe ARDS, need to be treated with invasive or non-invasive ventilation (NIV);among those pneumomediastinum (PNM) is a frequent complication. The objective of our retrospective study is to identify predisposing factors and risk factors for PNM in a population admitted to Internal Medicine ward. Materials and Methods: We analyzed 304 CoViD patients from 17th October 2020 till 25th January 2021: 176 males (57.9%) and 128 females (42.1%), with a mean age of 69.6 years. During hospitalization, 129 patients (42.4%) needed NIV. Of these, 5 (3.8%) presented PNM. Results: PNM was associated with higher in-hospital stay (27±7 days vs 8±4 days) and in-hospital mortality (40% vs 16.7% p=0.04). Among NIV patients, higher inspiratory positive airway pressure (IPAP) and positive expiratory end pressure (PEEP), were associated with higher incidence of PNM at point-biserial correlation (p=0.042). There were no statistically significant differences between bilevel and CPAP (p=0.160) or according to pressure support (PS) ≥8 cmH2O (p=0.509) or days of ventilation (p=0,869). Conclusions: An increased lung frailty in CoViD-19 pneumonia could partially explain the incidence of barotrauma: however, the incidence is also related to a more aggressive ventilation, when higher pressure support are used. A gentle ventilatory approach aimed to avoid excessive high pressure should be pursued, supporting a gentle ventilation and permissive hypoxemia.
ABSTRACT
Background: Venous thromboembolism represents frequent complication of patients with severe CoViD-19 disease. The occurrence of venous thromboembolism is mainly in typical district, however several reports about atypical thrombosis are described. We report a case of isolated right endoventricular thrombosis in a patient with SARS-CoV-2 infection. Case Report: A 60-year-old man was admitted to our ward for severe respiratory failure in interstitial pneumonia. The nasopharyngeal swab for CoViD-19 resulted positive. Prophylaxis with LMWH were started associated to CPAP to maintain good gas exchange. During hospitalization a new onset AF was documented at the telemetry and an echocardiogram was performed showing a right endoventricular lesion of 1.8 cm adhering to the free wall. A CTpulmonary angiogram (CTPA) resulted negative for pulmonary embolism. Doppler ultrasound showed left popliteal thrombosis. A treatment with fondaparinux was started. After 10 days, an echocardiogram was repeated showing complete resolution of thrombosis. Another CTPA confirmed the absence of pulmonary embolism. The patient clinically improved and he was discharged with dabigatran. Conclusions: SARS-CoV-2 infection may cause hypercoagulability and inflammation leading to venous thromboembolism and this seems to be related with worse outcome of these patients. For this reason, to monitor the venous thrombosis complication is an important step in the assessment of patients with CoViD-19.
ABSTRACT
Background: Pyomysitis is a bacterial infection of skeletal muscle characterized by intramuscular abscess formation that arises in endemic areas (tropical) or in patients with immunocompromised condition such as HIV or Diabetes Mellitus. Staphylococcus aureus is the most common culprit, with rising proportion of MRSA. Description of the case: A 35-year-old man with history of diabetes mellitus in poor control was admitted to our ward with ketoacidotic state, fever, repiratory insufficiency and diffuse myalgia. After the prompt correction of DKA, Chest X-ray reveald bilateral interstitial pneumonia and nasopharyngeal swab for CoViD-19 resulted positive. He started dexamethasone, remdesivir and noninvasive ventilation with improvement of gas exchanges. A MRI revealed an intramuscular abscess on left paravertebral muscle and bedside ultrosound showed multiple muscolar abscesses (right rectus femoris, right gastrocnemius, left teres minor and left semitendinosus). Ultrasound assisted drainage was performed and liquid culture yielded MSSA, thus antibiogram guided treatment with linezolid plus sulphametoxazole/trimetroprim was started. Follow-up PET at two weeks demonstrated a dramatic reduction in the inflammations. Conclusions: Pyomyositis is a potentially severe but uncommon complication of poorly controlled diabetes that could be difficult to detect in the setting of a concomitant viral illness. Bedside ultrasound has a unique role in the diagnosis, in the surgical drainage and in the follow-up. The cornerstone of optimal antimicrobic therapy is antibiogram-guided due to the rising proportion of MRSA.