ABSTRACT
Il SARS-CoV2 è trasmesso tra gli umani attraverso particelle respiratorie e l'infezione può determinare un largo spettro di manifestazioni cliniche. Precedenti studi hanno dimostrato il ruolo centrale dell'immunità cellulo-mediata nel limitare la gravità delle infezioni da virus respiratori. I linfociti T-helper CD4+ sono coinvolti in funzioni di coordinazione e regolazione dell'immunità anti-virale: determinano lo sviluppo di anticorpi neutralizzanti ad alta affinità e la differenziazione dei centri germinali a cellule B in cellule della memoria secernenti anticorpi con lunga vita. Nessun dubbio sul ruolo cruciale della risposta a cellule T durante l'infezione da SARS-CoV2 o dopo la vaccinazione. Descriviamo il caso di un paziente di 39 anni, vaccinato con ChAdOx1-S. Dopo due settimane il paziente accusava dispnea e febbricola. Il test molecolare per SARS-CoV2 era negativo;agli esami ematici la PCR era aumentata. La TC del torace escludeva embolia polmonare e rivelava pattern a vetro smerigliato bilaterale, come da flogisi. All'ecocardiogramma i parametri erano nella norma. L'ECG mostrava tachicardia sinusale. Il paziente veniva dimesso dal PS con terapia cortisonica. Una settimana dopo i sintomi peggiooravano. Una nuova TC torace mostrava difetti di opacizzazione di rami secondari dell'arteria polmonare ed aspetto bilaterale a vetro smerigliato. Si iniziava terapia con EBPM ed antibiotici a largo spettro. Il test molecolare e la sierologia per SARS-CoV2 erano negativi. Negativi i test per Mycoplasma, Chlamydia, Legionella e CMV DNA. L'emocromo mostrava ridotti linfociti (6,8%) con neutrofilia relativa (90,4%), ma normale valore dei bianchi. La TC-HR mostrava aspetto “crazy paving” bilaterale suggestivo per infezione virale o micotica (pattern come da infezione da Pneumocystis Jiroveci). Il test per HIV aveva esito positivo;alla tipizzazione linfocitaria ridotti i livelli di linfociti T-Helper (CD3+/CD4+) e rapporto CD3+/CD4+ 0%. Per il rapido deterioramento del quadro clinico il paziente veniva trasferito in terapia intensiva. Dopo 30 giorni dalla diagnosi di AIDS il paziente giungeva ad exitus. Il ruolo dei linfociti T nello sviluppo di anticorpi neutralizzanti e di cellule della memoria durante l'infezione da SARS-CoV2 è la chiave nella strategia di vaccinazione per ridurre il dilagare della pandemia, tuttavia nel nostro paziente questo meccanismo non ha funzionato rivelando il deficit del suo sistema immunitario da una latente infezione da HIV. (Figure Presented).
ABSTRACT
The COVID-19 pandemic has confronted the scientific community with numerous unresolved questions. The different clinical pictures that are encountered during the infection-the asymptomatic forms and the severe forms with a negative prognosis-have the same response of the organism to the noxa patogena. Some post-mortem analysis have showed an inflammatory response involving different organs and systems, with tissue damage from lymphocyte hyperactivation, bacterial superinfections, fibroblastic proliferation and alterations of the coagulation cascade with hypercoagulability and thromboembolism present in different stages of severity, based on the basal conditions of the organism affected and the duration of the infection. A post-mortem analysis conducted in Austria showed that, regardless of the duration of the infection and the patient's basal conditions, DAD (diffuse alveolar damage) is present in different stages and also thrombotic / thromboembolic occlusion of the pulmonary vascular districts is founded. Pulmonary haemorrhages were found in 100% of cases. We describe the case of a 59-year-old smoking addict. The patient performed a positive SARS-CoV-2 molecular test, with onset of dyspnea and fever in the following days. He was hospitalized and started treatment for SARS-CoV-2 infection and LMWH for the prophylaxis of thromboembolism. Chest RX showed interstitial imbibition and bilateral pleural effusion. The patient underwent NIV due to the worsening of respiratory distress. Lymphocytopenia was present on blood tests. For the increased D-dimer level and the worsening of the patient's conditions, an echocardiogram was performed and dilation of the right chambers was found. The CT angiography showed opacification defects in the main branches of the lower lobar pulmonary artery. CT-HR showed bilateral crazy paving changes with mantle distribution. LMWH therapy was enhanced for the treatment of the detected pulmonary embolism. The clinical picture gradually improved and NIV was withdrawn, starting oxygen at low flows. To understand the mechanisms involved in the pathophysiological response and the unfavorable prognostic factors is of crucial importance nowadays for the improvement of the diagnostic and therapeutic strategies currently used in the care of these patients.
ABSTRACT
We know little about the long-term consequences of SARS-CoV-2 infection. Several studies have documented that it is an infection that causes permanent damage to many organs or systems, with symptoms reminiscent of chronic fatigue syndrome/ myalgic encephalomyelitis (CFS/ME), described for other viral infections. There is no official definition of Post-COVID Syndrome but it is beginning to clarify what are the criteria for identifying patients at high-risk, the possible causes and pathophysiological mechanisms. We describe the clinical picture of a 55-year-old smoker patient with previous removal of the colon due to cancer. For asthenia and persistent feverish state the cardiological control revealed an increase in the volumes of the left ventricle, therefore myocarditis was suspected. The patient performed a negative molecular test for SARS-CoV-2 and a serological test with positive IgG and negative IgM. Blood chemistry tests showed neutrophilic leukocytosis, increased of the inflammation indices and of the D-Dimer value (130 mg/l). Cardio MRI excluded the diagnosis of previous or current myocarditis, confirming the increase in the volumes of the left ventricle but with normal EF and documenting the dilation of the right heart chambers. Chest CT revealed reduced volume and hyperdensity of the left lower lung lobe. During hospitalization the patient complained of paresthesia in the lower limbs and then in the upper limbs. Neurological evaluation was requested and, in the suspicion of inflammatory polyradiculoneuropathy, immunological, bacteriological, virological screening was performed. Brain MRI showed no expansive lesions, ongoing bleeding and/or ischemia. The EMG findings supported the hypothesis of an inflammatory multiradiculopathy. The ophthalmologist observed conjunctival hyperemia, with suspicion of episcleritis. Therapy with Aciclovir was started, due to the presence of pleocytosis in the cerebrospinal fluid, in addition to proteinorrachia. The neurological symptoms improved but the asthenia persisted. Even though the picture for atypical variant of Guillan Barré was deposited, in consideration of the improvement of the clinical picture, treatment with IG was not started. The persistence of subtle symptoms in patients with previous SARS-CoV-2 infection is often physically and psychologically disabling. Understanding the pathophysiology and predisposing factors for the post-COVID 19 syndrome is necessary and must be the subject of targeted studies.