[Ischaemic stroke due to basilar artery occlusion in a puerperal patient with SARS-CoV-2 infection]. / Ictus isquémico por oclusión de la arteria basilar en una paciente puérpera con infección por SARS-CoV-2.

INTRODUCTION: Infection by coronavirus type 2, which is the cause of severe acute respiratory syndrome (SARS-CoV-2), gives rise to thromboembolic complications, including acute cerebrovascular disease. Due to the hypercoagulable state that accompanies pregnancy, the thrombotic risk in these patients may be particularly significant. CASE REPORT: We report the case of a 41-year-old woman, 34+1 weeks pregnant, diagnosed with bilateral interstitial pneumonia, caused by coronavirus disease 2019 (COVID-19). The patient presented with severe respiratory failure, and so the decision was made to perform an emergency caesarean section and she was transferred to the intensive care unit. During her stay in hospital, the patient suffered a sudden episode of decreased level of consciousness, and magnetic resonance angiography revealed thrombosis in the left vertebral artery and in the basilar artery, with the presence of acute ischaemic infarction in both cerebellar hemispheres and bilateral involvement of the brainstem. CONCLUSION: Severe SARS-CoV-2 disease results in a prothrombotic state that correlates with the prognosis of the disease. The last trimester of pregnancy and the puerperium are known prothrombotic risk factors. Recommendations for anticoagulation management in pregnant patients with COVID-19 are based on limited evidence. This is the first case to be published in Spain involving cerebral arterial thrombosis in a pregnant patient with SARS-CoV-2 infection.

TITLE: Ictus isquémico por oclusión de la arteria basilar en una paciente puérpera con infección por SARS-CoV-2.Introducción. La infección por coronavirus de tipo 2 (SARS-CoV-2), causante del síndrome respiratorio agudo grave (COVID-19), produce complicaciones tromboembólicas, incluyendo casos de enfermedad cerebrovascular aguda. Debido al estado de hipercoagulabilidad que acompaña al embarazo, el riesgo trombótico en estas pacientes puede ser especialmente relevante. Caso clínico. Presentamos el caso de una mujer de 41 años, gestante de 34 + 1 semanas, diagnosticada de neumonía intersticial bilateral, SARS-CoV-2. La paciente presentó insuficiencia respiratoria grave, por lo que se decidió la realización de una cesárea urgente y se trasladó a la unidad de cuidados intensivos. Durante su estancia en ésta, la paciente presentó un episodio brusco de disminución del nivel de consciencia, y se evidenció por angiorresonancia magnética una trombosis en la arteria vertebral izquierda y en la arteria basilar, con presencia de infarto isquémico agudo en ambos hemisferios cerebelosos y afectación bilateral del tronco del encéfalo. Conclusión. La enfermedad grave por el SARS-CoV-2 produce un estado protrombótico que se correlaciona con el pronóstico de la enfermedad. El último trimestre del embarazo y el puerperio son factores de riesgo protrombóticos conocidos. Las recomendaciones del manejo de anticoagulación en pacientes embarazadas con COVID-19 se basan en una evidencia limitada. Éste es el primer caso publicado en España de trombosis arterial cerebral en una paciente embarazada con infección por el SARS-CoV-2.

Influence of hypoxemia on lymphocytes subpopulations in sars-cov-2 pneumonia

BACKGROUND The role of lymphocytes in the response to SARS-CoV-2 infection is crucial and lymphopenia is a well-known poor prognostic factor in COVID-19. However, the influence of a hypoxemic environment on lymphocytes and their populations is not known.We aim to evaluate the influence of hypoxemia on lymphocyte populations in patients with SARS-CoV-2 pneumonia who present with lymphopenia. METHODSWe analyzed the clinical and analytical data of a prospective cohort of 338 patients with diagnosis of SARS-CoV-2 pneumonia. The microbiological diagnosis was made by RT-PCR. Hypoxemia was defined a PaO2/FiO2 value <300 and lymphopenia for the total lymphocyte count less than 1000 109/L. Statistical analysis was made using X2 and Student's t tests. RESULTSFrom an initial cohort of 338 patients with analyzed those with ABG resulting in 118 patients. 48.3% (57 cases) presented PaO2/FiO2<300 at admission. Lymphopenia was present in 75 cases (63.6%) and it was significantly associated with the presence of hypoxemia [PaO2/FiO2 280.5 (104.5) vs 328.3 (82.7);p=0.011] and high levels of ferritine [1108.4 (1530.5) vs 539 (488.9);p=0.020]. Patients with lymphopenia who presented hypoxemia showed low levels of CD4+ T lymphocytes compared to non-hypoxemic patients [339.7 (260.7) vs. 468.8 (319.5);p=0.019], however the CD8+ T lymphocyte values were not affected by the presence of hypoxemia [247.4 (339.8) vs. 239.7 (172.1);p=0.875].The presence of lymphopenia was associated with ICU admission (44% vs. 16.7%;p=0.003) and the need of mechanical ventilation (40% vs. 14.3%;p=0.004). Survival was similar between groups (29.3% vs. 16.3%;p=0.113). CONCLUSIONS In our series, the different lymphocyte subpopulations exhibit a different behavior in patients with acute hypoxemic respiratory failure: CD4+ T lymphocytes seem to be especially susceptible to hypoxemia in patients with SARSCoV- 2 pneumonia.

Fungal co-infection in COVID-19 patients: Should we be concerned?

Critically ill COVID-19 patients have higher pro-inflammatory (IL-1, IL-2, IL-6, tumor necrosis alpha) and anti-inflammatory (IL-4, IL-10) cytokine levels, less CD4 interferon-gamma expression, and fewer CD4 and CD8 cells. This severe clinical situation increases the risk of serious fungal infections, such as invasive pulmonary aspergillosis, invasive candidiasis or Pneumocystis jirovecii pneumonia. However, few studies have investigated fungal coinfections in this population. We describe an update on published reports on fungal coinfections and our personal experience in three Spanish hospitals. We can conclude that despite the serious disease caused by SARS-CoV-2 in many patients, the scarcity of invasive mycoses is probably due to the few bronchoscopies and necropsies performed in these patients because of the high risk in aerosol generation. However, the presence of fungal markers in clinically relevant specimens, with the exception of bronchopulmonary colonization by Candida, should make it advisable to early implement antifungal therapy. (C) 2020 Asociacion Espanola de Micologia. Published by Elsevier Espana, S.L.U. All rights reserved.