ABSTRACT
BACKGROUND: Peripheral vascular disease affects nearly 10 million of the Indian population. It is also associated with decrease in functional capacity and quality of life and an increased risk of amputations. The underlying clinical conditions which present with features of peripheral limb ischemia are numerous. Since the differential diagnosis of the peripheral ischemia is vast, there are a multitude of clinical and lab tests available for diagnosis of the condition. This is further complicated by the numerous invasive and non-invasive imaging modalities available at the clinician's disposal. The choice of the best modality of investigation or treatment needs to be individualized in each clinical scenario for optimal management of the patient. AIM OF THE STUDY: Here we describe a case of 55-year-old male patient who developed gangrenous changes of digits of upper and lower limbs and in spite of all the available workup diagnosis could not be made. METHOD(S): A 55-year-old male patient non-smoker with no past history of diabetes hypertension CAD CVA presented with history of left lower limb pain and swelling of 8 days duration. Soon after initiation of pain and swelling, there was also associated discoloration with blue/black color changes. On further reviewing patient gave history of consuming some antibiotic and painkillers from local hospital and came to us when symptoms persisted. The patient otherwise denied any Raynaud's phenomenon skin tightening oral ulcerations genital ulceration chest pain shortness of breath abdominal pain hematuria ear pain sinus pain fevers chills night sweats or smoking history. No past history of COVID and vaccination. No significant family history. Pt hemodynamically stable all peripheral pulses felt. Local examination revealed swelling of left lower limb up to knee. Blackish discoloration of left foot up to ankle with ulcer of 3cm * 3cm at the plantar aspect of great toe. By 4th day patient started developing ischemic changes in opposite leg as well as in B/L upper limbs. He developed tingling numbness discoloration of skin and blebs formation. Skin biopsy was taken. After counseling patient was subjected for left below knee amputation after SDP transfusion. Amputated foot was sent for histopathological examination. Post-operative period was uneventful RESULTS: Due to rapid progression of disease and no evidence of sepsis, immune-mediated disease was thought of, and patient was started on pulse methylprednisolone therapy 500 mg for 3 days. Following steroid initiation patient skin lesions did not progress further. Renal function and liver parameters normalized;Platelets normalized. Patient gradually improved with skin lesions disappearing. Patient was discharged with oral steroids plus anticoagulation. Initial lab reports showed Hb - 14.3, TLC- 8600, Platelets- 19000, ESR - 29, Creatinine - 2.07, T.Bil - 4.27, D.Bil-4.13, SGOT- 219, SGPT- 69, Serum Procalcitonin - 0.1, Urine Examination - no sediments, C3 - 83, Coagulation profile normal, Direct and Indirect Coombs test negative, Virals- neg, Blood cultures - negative 2D ECHO - Normal Homocysteine Levels - 6.53 Coombs Test Direct/ Indirect Neg ANA Profile- PM- SCL Borderline positive, Rest all negative ANCA Profile Negative APLA Antibodies Negative Protein C Activity - Normal Protein S Activity - Normal Antithrombin Activity Normal Factor V Leiden Mutation Not Detected Cryoglobulin antigens negative Histopathology of amputated limb - arteriosclerosis CONCLUSION(S): We have presented atypical unexplained case of vasculitis in 55-year-old male patient. This is an original case report of particular interest wherein diagnosis was made clinically even though all the investigations returned normal. We were unable to find in the literature any other case of unexplained vasculitis.
ABSTRACT
BACKGROUND: The COVID-19 pandemic has led to the biggest global health crisis of our lifetime. There is accumulating evidence that a substantial number of critically ill COVID-19 patients exhibit a dysregulated host response manifesting as cytokine storm or cytokine release syndrome which in turn contributes to the high observed rates of mortality. Just as in other hyperinflammatory conditions extracorporeal cytokine removal may have potential beneficial effects in this subgroup of COVID-19 patients. The CytoSorb blood purification device is the most extensively investigated cytokine removal platform with considerable evidence suggesting that early intervention can provide rapid hemodynamic stabilization and improvement in vital organ functions AIM OF THE STUDY: Here we describe 4 cases of severely ill adult patients with coronavirus disease 2019 admitted to intensive care unit who were treated with CytoSorb therapy. METHOD(S): All 4 patients were admitted in the ICU with CT severity score of >15/25. During their clinical course, all patients were prescribed tocilizumab (an interleukin-6 receptor blocker) antivirals hydroxychloroquine azithromycin and other antibiotics and general antipyretic drugs. All patients received low-molecular-weight heparin thromboprophylaxis adjusted to baseline weight and renal function Patient A and C required invasive mechanical ventilation whereas Patients B D were on NIV The mean age of the patients was 67.7 years (range = 29-79) Patients received a median of 2 attempts of hemoperfusion. The median CytoSorb perfusion time was 20hrs. RESULT(S): The level of IL-6 significantly decreased after treatments. It reduced by 95% for Patient A, 70% for Patient B, 99% for Patient D Mean Arterial Pressure improved by 15 mmHg average for Patients A, B, D PaO2/FiO2 Ratio improved by 143 average for Patients A, B, D HsCRP levels fell by average of 39 mg/l for patients A, B, D Patient A expired 2 days after the cytosorb dialysis (Refractory Shock) Patient C expired following Dialysis Albumin mildly decreased after CytoSorb. No significant changes were found in red blood cell counts, white cell counts, and platelets. ICU and in-hospital mortality was 50%. CONCLUSION(S): In this case series, critically ill patients with COVID-19 with severe acute respiratory failure refractory to prone positioning and hypercytokinemia who received adjuvant treatment with cytokine hemoadsorption showed a significant reduction in IL-6 plasma levels and other inflammatory biomarkers. Improvements in oxygenation and MAP were also observed.