ABSTRACT
Case Report Female patient age 56 aa. with autonomous walking inability, for postpartum neurological deficits, received at the P.S. of our P.O. for strong chest compression and previous Covid-19 infection treated at home. At the entrance, examinations performed with an emergency profile showed alterations in cardiac and pancreatic markers, severe renal failure, as well as significant alterations in blood count and coagulation. Therefore, hematological, nephrological, cardiological and surgical advice and II level examinations for diagnostic classification are requested: blood count with smear for schistocytes, direct and indirect coombs test ADAMTS 13 Routine hematochemical profile + C3 and C4 Complete Coagulation tests . Results Blood count: severe thrombocytopenia (10x 10 3micronL) Hb (7.5 gr/dl) MCV 80 Fl Reticulocytes >2.5 Accentuated neutrophilia >90% Coagulation: PT 10.9 sec INR 1.01 PTT 65.2 sec (no corrected by mixing test) PTT ratio 1. 98% D-Dimer 2741ng/mL Myoglobin>12000 Troponin 68.5 pg/ml LDH 864 U/L Amylase 666 U/L Lipase398 Ui/L Phosphorus 9 mg/dl Creatinine >2 mg/dl Direct bilirubin >2 mg/dL C3 70 mg/dl C4 14 mg/dl. Discussion and Conclusion The patient arrived at the P.S. with an extremely critical and complex clinical picture, such as to require multispecialistic consultations and very difficult to frame from a diagnostic point of view, given the multiple organ involvement. Widespread ischemic damage due to microthrombosis in arterioles, thrombocytopenia due to platelet trapping, microangiopathic hemolytic anemia due to red blood cell fragmentation.SARSCOV2 patients have an increased risk of arterial and venous thrombosis. Elevated levels of D-dimer are associated with increased thrombosis and mortality. Multiple pathways likely contribute to thrombosis in COVID-19 patients.When COVID-19 patients experience cytokine storms, interleukin-8 and TNFalpha stimulate VWF release from vascular endothelial cells, while interleukin-6 inhibits both production of ADAMTS13 and its interaction with VWF, resulting in localized severe deficiency of ADAMTS13 activity. The presence at the smear of schizocytes, increased LDH, platelets in progressive decrease, and so Hb, D-Dimer in increase, led to the request for diagnostic completion with research of ADAMTS 13 (40%) and LAC (1.65 ). The patient was transfused with platelet concentrates before a certain diagnosis. This picture directed us towards the diagnosis of Moscovitz, but the positive direct coombs test (score + +-) and renal involvement, high phosphorus, altered C3 and C4, the presence of pancreatitis, directed towards an HUS atypical. Thanks to the dialogue and the active collaboration between pathologists and clinicians, the patient was subjected to life-saving plasma exchange, but the diagnostic doubt still remains.
ABSTRACT
Background SARS-CoV-2, which appeared in December 2019 in Wuhan, China (1) in the first pandemic wave (from February 24 to June 11, 2020) infected more than 236,000 people, in the second wave (from September 14 to December 31, 2020) the number of infected was more than 1,822,000 (2). During the first wave, in our P.O., the number of deceased, as well as hospitalizations in intensive care were higher. Purpose of the work In our study we evaluated haematological alterations in hospitalized COVID 19 patients and, often in critical condition, for a hyperinflammatory state secondary to cytokine storm related to alterations of CD4/CD8 T lymphocytes. Materials and methods In the period between March and December 2020, 160 patients (97 males, 63 females average age 63.33 years + / -10.2) were enrolled in the COVID department of the P.O. S.Giuliano, because they were positive for the molecular swab in RT-PCR for SARS CoV-2. For each patient, blood count with smear, routine blood chemistry tests and in particular c-reactive protein, ferritin, ves, LDH, procalcitonin, troponin, fibrinogen, D-Dimer were performed. Results In COVID 19 patients with more severe symptoms, there was an increase in the value of white blood cells with an average of 20.0+/-5.0X103/microlitre (increase in neutrophils and monocytes, reduction in lymphocytes with NLR>5.92). Cytofluorimetric analysis has shown that CD3 T lymphocytes are significantly reduced. Patients with more severe syntoms showed a significant increase in C-Reactive Protein (10.6+/-7.5mg/dl), Troponin (433+/-400pg/ml), Myoglobin (3700+/-3000ng/ml),Fibrinogen(800+/-500mg/ dl),D-Dimer(800-5800ng/ml),Ferritin(950+/-450ng/ ml),LDH (850+/-250U/L)) Discussions and conclusions From our study it is evident that the hematological parameters associated with specific biomarkers of inflammation are useful to identify and differentiate covid positive patients with more severe and critical pathology even in the second pandemic wave. The severity of the pathology is positively correlated with the percentage values of neutrophils and NLR and negatively with the percentage of lymphocytes.