ABSTRACT
Aims: Venous thromboembolism represents frequent complication of patients with severe COVID-19 disease. Several reports about atypical thrombosis are described, rarely it has been described a right venticular thrombus during the course of infection. We report a case of right endoventricular thrombosis in a patient with SARSCov- 2 pneumonia. Methods and results: A 58-year-old man was admitted to our ward for severe respiratory failure in interstitial pneumonia. The nasopharyngeal swab for COVID-19 resulted positive. Steroids and prophylaxis with LMWHwere started, associated to CPAP to maintain good gas exchange. During hospitalization a venous ECD was performed with evidence of left popliteal thrombosis despite the therapy. D-Dimer was 44±3 ng/ml. A new onset AF was documented at the telemetry, without troponin elevation. A cardiac ultrasound was performed showing a right endoventricular lesion of 1.8 cm adhering to the free wall of the right ventricle. A CT-pulmonary angiogram (CTPA) resulted negative for pulmonary embolism and confirmed suspected right ventricular thrombus. Treatment with fondaparinux 7.5mg was started. After 10 days, cardiac ultrasound shown complete resolution of thrombosis, and CT confirmed the disappearing of the mass. Dabigatran 150 mg twice/day was started. Patient clinically improved and he was discharged after 20 days of hospitalization. Conclusions: SARS-CoV-2 infection may cause inflammation with cytokine storm and hypercoagulability leading to venous thromboembolism. Atypical thrombus formation was reported, including right-ventricle free wall. Early caridac ultrasound was critical to make diagnosis and starting prompt treatment, therefore routine cardiac ultrasound is mandatory in severe COVID-19 patients.
ABSTRACT
Background: The association between CoViD-19 and thrombotic complication such as pulmonary embolism or deep vein thrombosis, is well known. However, SARS-CoV-2 infection may cause also thrombotic microangiopathy with significant clinical pictures. We report a case of a patient with CoViD-19 infection, thrombocytopenia, hemolitic anemia and neurological manifestation. Description of the case: A 70-year-old patient was admitted to the hospital for CoViD-19 pneumonia needing non-invasive ventilation. After 15 days he developed severe diffuse weakness and altered mental status with episodes of hyperkinetic delirium. A head CT scan and brain MRI performed were negative for lesions. On blood examination elevated creatinine (2.9 mg/dL), anemia (Hb 8,3g/dL) and thrombocytopenia (76∗103mmc) were present. The study for the hemolysis revealed total bilirubin 2.46 mg/dL, haptoglobin non detectable, direct and indirect Coombs test negatives and elevated presence of schistocytes >100/1000 blood cells. The ADAMTS-13 was negative. During the hospitalization platelet count drop to 16∗103mmc and patient developed a right ileopsoas hematoma. The patient died before the treatment started. Conclusions: Acquired thrombotic thrombocytopenic purpura represent a fearsome CoViD-19 complication with unfavorable outcome. The early recognition may be associated with a better prognosis. The presence of thrombotic microangiopathy on blood tests and Moskowitz's pentad in the clinic should rise the suspicion: the first step in diagnosing aPTT is to suspect it.
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Background: Severe respiratory failure associated with SARS-CoV- 2-related interstitial pneumonia is burdened by high mortality. Despite initial unfavourable evidence, recent clinical trials showed that the anti interleukin-6 receptor tocilizumab (TOCI) could improve prognosis in these patients. We report our experience about this topic. Materials and Methods: We retrospectively analyzed in-hospital mortality of patients firstly admitted to Internal Medicine wards for severe SARS-CoV-2-related interstitial pneumonia treated with off-label intravenous or subcutaneous TOCI administration on top of standard therapy. Severe pneumonia was defined as PaO2/FiO2 ratio <250 and requiring noninvasive ventilation and/or high flow nasal cannula. Results: Study population included 141 patients, 36 females, mean age 64.5±11.7 years. 72 patients received TOCI in the first pandemic wave, 69 in the second or third wave. Mean age of treated patients was 69 years in the first wave, 60.4 years in the second-third wave. Overall, 41 patients (29%) were transferred to Intensive Care Unit (ICU), and in-hospital mortality was 12%. Inhospital mortality was 16.6% in the first wave, 5.9% in the second- third wave. ICU transfer rate was 29.1% in the first wave compared with 28.9% in the second-third wave. Conclusions: TOCI was associated with a low in-hospital mortality rate, especially in the second-third pandemic wave. Lower age and the earlier administration of TOCI in hospitalized patients requiring rapidly increasing oxygen needs could explain the lowest in-hospital mortality in the second-third wave.
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Background and Aim: CoViD-19 patients with mild to severe ARDS, need to be treated with invasive or non-invasive ventilation (NIV);among those pneumomediastinum (PNM) is a frequent complication. The objective of our retrospective study is to identify predisposing factors and risk factors for PNM in a population admitted to Internal Medicine ward. Materials and Methods: We analyzed 304 CoViD patients from 17th October 2020 till 25th January 2021: 176 males (57.9%) and 128 females (42.1%), with a mean age of 69.6 years. During hospitalization, 129 patients (42.4%) needed NIV. Of these, 5 (3.8%) presented PNM. Results: PNM was associated with higher in-hospital stay (27±7 days vs 8±4 days) and in-hospital mortality (40% vs 16.7% p=0.04). Among NIV patients, higher inspiratory positive airway pressure (IPAP) and positive expiratory end pressure (PEEP), were associated with higher incidence of PNM at point-biserial correlation (p=0.042). There were no statistically significant differences between bilevel and CPAP (p=0.160) or according to pressure support (PS) ≥8 cmH2O (p=0.509) or days of ventilation (p=0,869). Conclusions: An increased lung frailty in CoViD-19 pneumonia could partially explain the incidence of barotrauma: however, the incidence is also related to a more aggressive ventilation, when higher pressure support are used. A gentle ventilatory approach aimed to avoid excessive high pressure should be pursued, supporting a gentle ventilation and permissive hypoxemia.
ABSTRACT
Background: SARS-CoV-2 infection, in the most severe cases, can cause bilateral pneumonia and respiratory failure. In these cases, therapy is based on the use of antiviral drugs, immunosuppressants (in order to reduce the cytokine-mediated inflammatory response),oxygen and sometimes non-invasive mechanical ventilation (NIV).We describe 2 cases of severe bacterial infections probably favored by the immunosuppressive therapy. Description of the cases: A 63-year-old man with no history of significant medical conditions and an 86-year-old man with history of ischemic heart disease treated with PTCA+DES, were both hospitalized for severe bilateral SARS-CoV-2 pneumonia and treated with NIV associated with high-dose steroids (Dexamethasone 8 mg IV per day). After the resolution of the pulmonary infection, the first one developed a Pneumocystis jirovecii pneumonia with the need for re-hospitalization and treatment with trimethoprim-sulfamethoxazole;the second one developed a methicillin-resistant Staphylococcus aureus (MRSA) endocarditis with infarct lesions caused by septic emboli in brain and splenic area, with subsequent clinical aggravation and death. Conclusions: The SARS-CoV-2 pneumonia treatment is based on combined use of NIV and anti-inflammatory, antiviral and immunosuppresive drugs: it is important to minimize duration of treatment because it may lead to the development of serious complications like septic states (even by opportunistic pathogens) that are lifethreatening for the patients.
ABSTRACT
Background: Venous thromboembolism represents frequent complication of patients with severe CoViD-19 disease. The occurrence of venous thromboembolism is mainly in typical district, however several reports about atypical thrombosis are described. We report a case of isolated right endoventricular thrombosis in a patient with SARS-CoV-2 infection. Case Report: A 60-year-old man was admitted to our ward for severe respiratory failure in interstitial pneumonia. The nasopharyngeal swab for CoViD-19 resulted positive. Prophylaxis with LMWH were started associated to CPAP to maintain good gas exchange. During hospitalization a new onset AF was documented at the telemetry and an echocardiogram was performed showing a right endoventricular lesion of 1.8 cm adhering to the free wall. A CTpulmonary angiogram (CTPA) resulted negative for pulmonary embolism. Doppler ultrasound showed left popliteal thrombosis. A treatment with fondaparinux was started. After 10 days, an echocardiogram was repeated showing complete resolution of thrombosis. Another CTPA confirmed the absence of pulmonary embolism. The patient clinically improved and he was discharged with dabigatran. Conclusions: SARS-CoV-2 infection may cause hypercoagulability and inflammation leading to venous thromboembolism and this seems to be related with worse outcome of these patients. For this reason, to monitor the venous thrombosis complication is an important step in the assessment of patients with CoViD-19.
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Background: Pyomysitis is a bacterial infection of skeletal muscle characterized by intramuscular abscess formation that arises in endemic areas (tropical) or in patients with immunocompromised condition such as HIV or Diabetes Mellitus. Staphylococcus aureus is the most common culprit, with rising proportion of MRSA. Description of the case: A 35-year-old man with history of diabetes mellitus in poor control was admitted to our ward with ketoacidotic state, fever, repiratory insufficiency and diffuse myalgia. After the prompt correction of DKA, Chest X-ray reveald bilateral interstitial pneumonia and nasopharyngeal swab for CoViD-19 resulted positive. He started dexamethasone, remdesivir and noninvasive ventilation with improvement of gas exchanges. A MRI revealed an intramuscular abscess on left paravertebral muscle and bedside ultrosound showed multiple muscolar abscesses (right rectus femoris, right gastrocnemius, left teres minor and left semitendinosus). Ultrasound assisted drainage was performed and liquid culture yielded MSSA, thus antibiogram guided treatment with linezolid plus sulphametoxazole/trimetroprim was started. Follow-up PET at two weeks demonstrated a dramatic reduction in the inflammations. Conclusions: Pyomyositis is a potentially severe but uncommon complication of poorly controlled diabetes that could be difficult to detect in the setting of a concomitant viral illness. Bedside ultrasound has a unique role in the diagnosis, in the surgical drainage and in the follow-up. The cornerstone of optimal antimicrobic therapy is antibiogram-guided due to the rising proportion of MRSA.
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Background and Aim: Pneumomediastinum (PNM) is not an unfrequent complication in CoViD-19 patients and IL-6 is a laboratory index which can predict a worst outcome in these patients. We analysed the role of IL-6 and his association with the incidence of PNM. Materials and Methods: In our retrospective study, we analysed a population of 304 patients with SARS-CoV-2 infection admitted to an Internal Medicine ward from 17th October 2020 till 25th January 2021, including 176 males (57.9%) and 128 females (42.1%), with a mean age of 69.6 years. During hospitalization, 129 patients (42.4%) needed NIV. Of these, 5 (3.8%) presented a PNM. Results: Higher levels of interleukin-6 (IL-6) on admission were present in PNM patients than in the overall population (168.9±296.3 pg/mL vs 37.9±69.6 pg/mL, Student t-Test p<0.001) and NIV population (168.9±296.3 pg/mL vs 30.1±76.5 pg/mL, Student t-Test p=0.015): IL-6 levels are strongly associated with incidence of PNM. In recent literature, high levels of IL-6 are strictly associated with severity of CoViD- 19 disease and severity of respiratory failure, needing for NIV and/or invasive ventilation and death. Conclusions: In conclusion, PNM represents a severe and quite frequent complication in CoViD-19 patients treated with NIV. Before CoViD-19, the occurrence of PNM during NIV in Community Acquired Pneumonia was a rare complication. The detection of high levels of IL-6 must be a warning signal in ventilated patients, addressing the choice toward a more protective ventilation.
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Background and Aim: The metabolomic profile is a valuable tool in biomedicine. In the framework of the COMETA project, metabolomic analyses are used to identify specific biochemical alterations of the CoViD-19 disease, of its severity and evolution over time. Materials and Methods: Four different groups of subjects are enrolled in the study: 1) CoViD-19 positive patients at different stages of the disease;2) CoViD-19 recovered patients;3) patients with CoViD-19-like symptoms but with negative nasopharyngeal swab;4) control subjects. Metabolomic analyses are conducted on blood plasma samples using proton nuclear magnetic resonance (1H NMR) spectroscopy. The 1H NMR spectra contain information on the number and relative concentration of the most abundant metabolites in each sample (>1 μM) and represent the metabolic fingerprint of each patient. Results: 1H NMR spectra on a first set of approximately 400 plasma samples have been acquired allowing us to measure 25 metabolites among those involved in the main biochemical pathways (glucose metabolism, glycolysis and Krebs cycle, ketone bodies, amino acids) as well as 114 parameters related to plasmatic lipoproteins. Conclusions: Based on previous studies by some of us and considering the high number of patients be enrolled in COMETA, we expect an excellent discrimination and characterization of the pathology in its various clinical manifestations. Long-term effects of the disease will be evaluated via a follow-up at 3-6 months from disease onset.