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Background: Persistence of orthostatic tachycardia, palpitations, and fatigue beyond 4 weeks of an acute COVID-19 infection has been termed Post-Acute Sequelae of COVID-19 (PASC) POTS. We have previously reported 6-month outcomes of PASC POTS. Long-term management and outcomes of these patients is unknown. Objective(s): To examine the long-term management and outcomes of PASC POTS patients. Method(s): We conducted a retrospective study of all patients who were diagnosed with POTS at Cardiology, Neurology, and Rehabilitation Post-COVID clinic after a COVID-19 infection between March 1, 2020, and November 1, 2022, at the University of Texas Health San Antonio. We examined COVID history, POTS diagnosis, management, and one-year outcomes of post-COVID POTS patients. Result(s): In 42 patients that were diagnosed with PASC POTS, 33 had a one-year follow-up. 100% were female, 60.6% were Caucasian. Average age was 40.6 + 11 years while the average BMI was 31.9 + 10.4 kg/m2. The most common symptoms were fatigue (87.9%), palpitations (75.7%), brain fog (72.7%), orthostatic tachycardia, exercise intolerance, and dyspnea (70%). The mean heart rate change with 10-minute standing test was 42.68 + 26.73 beats per minute. At 12-months follow-up, the most common symptom was still fatigue (66.7%), palpitations (45.5%), orthostatic tachycardia, and orthostatic intolerance (42.4%). All patients were managed with increased salt and fluid intake, lower compression stockings and rehabilitation. Fifty five percent of patients were treated with Enhanced External Counter Pulsation (EECP), 42% were treated with beta blockers, 18% with fludrocortisone, 15% with midodrine, and 15% with Pyridostigmine. At 1 year follow-up, 33% of patients reported improvement in their symptoms, 33% reported worsening of symptoms, 24% reported stable symptoms, and 9% had resolution. Conclusion(s): PASC POTS patients continue to experience adverse symptoms even at one year. Physical therapy and rehabilitation and pharmacological therapy appear improve symptoms in a minority of patients.Copyright © 2023
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TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Transfusion-related acute lung injury (TRALI) is a well-known risk of intravenous infusions, but the true incidence is poorly defined. With the arrival of COVID-19, a new intravenous medication, Banlamivimab, may be associated with TRALI. We present a unique case of Banlamivimab TRALI from COVID-19 treatment. CASE PRESENTATION: A 69-year-old female presented to the Emergency Department with complaints of fevers, generalized weakness, nausea, vomiting, and dyspnea on exertion. She was febrile to 101.2 Fahrenheit and maintaining a normal oxygen saturation level on ambient air. Laboratory tests were positive for SARS-COV-2, elevated CRP, and troponin up to 1.37 ng/mL. Complete blood count and chemistry were both normal. Chest x-ray was unremarkable. Initially, she was set to be discharged home. Infectious Disease was consulted regarding her COVID infection and recommended Banlamivimab infusion prior to discharge. Approximately 45 minutes after starting the infusion, the patient experienced sudden onset shortness of breath and rigors. She was hypoxic to 85% on ambient air, tachypneic, febrile to 102.9 Fahrenheit, hypertensive and in acute respiratory distress. She had no evidence of an allergic reaction nor anaphylaxis. The infusion was stopped immediately and she was given Solumedrol and Benadryl. Her troponin increased to 3.23 ng/mL, white blood cell count rose to 19,300/mL and her lactic acid was 6.8. Chest x-ray showed new pulmonary edema. Echocardiogram showed normal systolic and diastolic function. She was diagnosed with transfusion related lung injury and fully recovered with supportive treatment. DISCUSSION: Banlamivimab is an investigational medicine used in patients who are considered high risk for being hospitalized or progressing to severe COVID-19 infection. Although TRALI is a well-defined risk factor of blood transfusions, there is insufficient data related to transfusion related lung injuries caused by Banlamivimab infusion or other human monoclonal antibodies. When treating COVID-19 patients with Banlamivimab, TRALI must be a side effect taken into consideration due to the possibility of causing a second hit to COVID-19 damaged lungs. As highlighted by the acuity of our patient's illness, it is feasible that such an event could increase patient mortality. CONCLUSIONS: This case uniquely demonstrates the possibility of TRALI with Banlamivimab infusions and highlights the importance of early recognition and management. Furthermore, clinicians should maintain a high index of suspicion for TRALI in patients receiving not only blood transfusions, but also any human monoclonal antibody infusions. REFERENCE #1: (2021, March 18). FACT SHEET FOR HEALTH CARE PROVIDERS EMERGENCY USE AUTHORIZATION (EUA) OF BAMLANIVIMAB AND ETESEVIMAB. Eli Lilly and Company. Retrieved April 30, 2021, from https://www.covid19.lilly.com/bam-ete/getting-started REFERENCE #2: Petraszko, T. (2019, February 26). Transfusion-related acute lung Injury (trali). Retrieved April 30, 2021, from https://professionaleducation.blood.ca/en/transfusion/publications/transfusion-related-acute-lung-injury-trali REFERENCE #3: Kleinman, S., MD. (n.d.). Transfusion-related acute lung injury (TRALI). Retrieved April 30, 2021, from https://www.uptodate.com/contents/transfusion-related-acute-lung-injury-trali#H1588910 DISCLOSURES: No relevant relationships by Pankaj Aggarwal, source=Web Response No relevant relationships by Jenna Dumovich, source=Web Response No relevant relationships by Justin Haloot, source=Web Response No relevant relationships by Jane O'Rorke, source=Web Response