ABSTRACT
SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Coronavirus disease 2019 (COVID-19) can manifest as a severe immunologic syndrome known as hemophagocytic lymphohistiocytosis (HLH). HLH is a hyper-inflammatory state with a lethal mortality rate, especially when discovered late in the disease process. The optimal timely approach to diagnosis and treatment of secondary HLH in COVID-19 is unclear, however, risk stratification with Hscore using biomarkers can be useful to increase confidence in an HLH diagnosis. CASE PRESENTATION: A 36-year-old morbidly obese male with a history of well controlled mild intermittent asthma presented to the hospital complaining of a one week history of dyspnea and cough after failing outpatient COVID-19 treatment. Upon arrival, he was hypoxic on room air and was placed on non-invasive ventilation. He unfortunately decompensated further and was transferred to the intensive care unit where he was intubated for severe hypoxia and increased work of breathing. His course was complicated by superimposed bacterial pneumonia, vasopressor dependent septic shock, and anuric acute kidney injury requiring continuous renal replacement therapy. He remained profoundly hypoxic despite rescue therapy with multiple sessions of prone ventilation. On hospital day seventeen his platelets declined acutely and a serotonin release assay confirmed heparin-induced thrombocytopenia. His clinical status remained tenuous into the third week of admission. Notably, he developed persistent fever with associated bicytopenia and elevated lactate dehydrogenase, D-dimer, fibrinogen, triglycerides, and aspartate aminotransferase. His calculated Hscore was 189. Hematology recommended initiating HLH therapy with daily dexamethasone and etoposide, however the latter was held due to the patient's rapid hemodynamic decline. The patient succumbed to illness after a twenty-day hospitalization. His HLH was confirmed with a positive postmortem soluble-IL-2-receptor test. DISCUSSION: Proposals of routine HLH screening in critically ill patients are endorsed to promote early detection of this morbid condition. Calculating Hscore using vital signs, imaging, laboratory tests, and patient history can guide suspicion of diagnosis, since HLH-specific markers are often not feasible. Hscores more than 169 correspond to 93% sensitivity and 86% specificity in HLH diagnosis. Immunosuppression is standard therapy with hematology guidance due to the complex pathophysiology and limited research. CONCLUSIONS: This case emphasizes the importance of understanding the relationship between COVID-19 and secondary HLH. A timely diagnosis is vital in order to attempt to effectively treat a syndrome that carries a 65% mortality rate. Reference #1: Dimopoulos G, Mast Q. de, Markou N, et al. Favorable Anakinra responses in severe COVID-19 patients with secondary hemophagocytic lymphohistiocytosis. Cell Host Microbe 2020;doi: 10.1016/j.chom.2020.05.007. PubMed PMID: 32411313. Reference #2: Bauchmuller K, Manson JJ, Tattersall R, et al. Haemophagocytic lymphohistiocytosis in adult critical care. J Intensive Care Soc 2020;21:256–68. Reference #3: Schnaubelt, Sebastian MDa,∗;Tihanyi, Daniel MDb;Strassl, Robert MDc;Schmidt, Ralf MDc;Anders, Sonja MDb;Laggner, Anton N. MDa;Agis, Hermine MDd;Domanovits, Hans MDa Hemophagocytic lymphohistiocytosis in COVID-19, Medicine: March 26, 2021 - Volume 100 - Issue 12 - p e25170 doi: 10.1097/MD.0000000000025170 DISCLOSURES: No relevant relationships by Kristina Catania No relevant relationships by Katie Kennedy No relevant relationships by Josef Kinderwater No relevant relationships by MaryKate Kratzer no disclosure submitted for Ogugua Obi;