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Background/Aims Vaccine-associated autoimmunity is not infrequent, pertaining to either the cross-reaction between antigens or the action of adjuvant. This issue is more inexplicable to the COVID-19 vaccine, because of nucleic acid formulation and the hastened development process inflicted by the urgent pandemic condition. Here we are presenting a young patient who developed a significant abnormal autoimmune profile immediately post covid vaccination. Methods A 31-year-old IT engineer was referred to Rheumatology with postvaccine arthralgia. He had a history of recent aortic root aneurysm repair after having chest pain on exertion. Echocardiography showed dilated aortic root with significant aortic regurgitation, CT aortogram confirmed spiral type A dissection. He underwent an emergency cardiothoracic surgery in October 2020, followed by an uneventful recovery. He received the first dose of Pfizer COVID-19 vaccine on 2nd February, the very next day he developed painful ankles, knees, left hip, and right shoulder. Blood tests showed elevated CRP of 45, ESR 34, rheumatoid factor positive at 92, anti-CCP >340, ANA 13, ds-DNA 202, U1RNP positive, anti-SM antibody positive, Ro and La antibodies positive, antiJo1 antibody positive, with normal complements. He denied any swelling of the joints. No history of hair loss, photosensitive skin rashes, Raynaud's, sicca symptoms, oro-genital ulceration, or cracking of the skin. There were no constitutional symptoms, chest pain, or bowel issues. He was previously labeled as asthmatic, which is stable after surgery. He doesn't smoke or drinks alcohol. There was no family history of autoimmune conditions. On examination, he has tenderness across both hands and wrists with palmar erythema but no synovitis. He has painful right shoulder abduction with left hip pain on flexion and extension. Cardiovascular and GI examination was unremarkable apart from sternotomy scar and metallic valvular heart sounds. His dipstick urinalysis was negative for blood and protein. In recent x-rays hands and feet were normal. We agreed on a trial a tapering course of prednisolone started with 20mg daily. Three weeks later in follow-up, he reported partial response to steroids. His inflammatory markers were coming down. We have started azathioprine as a steroid-sparing agent. Results This gentleman with negative autoimmune screening prior to cardiothoracic surgery expressed florid newly detected autoantibodies straightaway after the COVID-19 vaccine. This is suggestive of undifferentiated connective tissue disease with the likelihood of overlap syndrome between rheumatoid arthritis and SLE. Conclusion COVID-19 vaccination showed a beacon of light to end the pandemic by achieving herd immunity. There is an excusable socioeconomic rush towards mass vaccination without long-term safety analysis, however, it is also crucial that any vaccine licensing process should entail meticulous scrutiny of the human proteome against vaccine peptide sequences. This will minimize the risks of acute autoimmune reactions to inoculation and future chronic autoimmune pathology.
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Background: SARS -COV-2 has presented with varied symptoms and a number of factors determine clinical outcome. While hypoxemic respiratory failure remains main cause of morbidity and mortality, a hyperinflammatory state induced endothelial injury and hypercoagulability leading to thromboembolism also is a leading cause of mortality. Case Sudy: A 60-year-old diabetic, hypertensive, nonsmoker, male presented with complaints of cough, fever and breathlessness since 3 days. Patient presented with tachypnea and maintaining saturation of 85% on room air, CT severity score was 13/25. Patient was treated in ICU with Noninvasive ventilation, prophylactic Enoxaparin, Remdesivir and steroids. Patient's respiratory status was deteriorating and was intubated, kept on mechanical ventilator and later tracheostomy was done. During the course of illness patient developed pain over right foot which progressed to gangrene and ischemia over left foot .CT- Aortogram done showed complete occlusion of infra-renal abdominal aorta. Discussion: Patient developed progressive elevation of D-dimer even after thromboprophylaxis with enoxaparin. However gangrene progression was irreversible once set in, even though patient was switched over to high dose anticoagulants, with antiplatelet along with Phosphodiesterase inhibitor, implying that high degree of coagulation cascade disruption is potentially irreversible. Conclusion: To start increased dose of initial thromboprophylaxis in patient with high CT severity.
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Clinical Information Patient Initials or Identifier Number: SP Relevant Clinical History and Physical Exam: A 30-year-old female was referred to our centre with chief complaint of orthopnea. The patient had received medical attention elsewhere and was treated empirically for asthma, COVID pneumonia and antitubercular treatment. On examination the patient had a bounding pulse on right upper limb and an impalpable pulse on left upper limb, weak pulses in bilateral carotid and lower limbs. Further examination revealed a right upper limb blood pressure of 230/120 mm of Hg. [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: The chest roentgenogram of the patient revealed bat-wing pulmonary edema with cardiomegaly. ECG revealed left ventricular hypertrophy with strain pattern and echocardiography revealed left ventricular dysfunction with ejection fraction of 35%. CT aortogram revealed wall thickening with fusiform dilatation of distal thoracic, proximal abdominal aorta, and stenosis of left subclavian, celiac artery at ostium and bilateral renal arteries at ostium. The patient also had a raised ESR (40 mm/hr). Interventional Management Procedural Step: The procedure was done under local anesthetic from a right femoral artery access with 7 French sheath. A coronary angiogram was done first which revealed normal epicardial coronaries. Pull back gradient was then taken across thoracic and abdominal aorta which revealed a gradient of 20 mmHg. Next, renal angiogram was taken in individual renal arteries which revealed significant ostial stenosis of bilateral renal arteries. The lesions were serially dilated with 1.5 mm, 2.5 mm and 4 mm diameter coronary balloons. After dilatation Invatec Hippocampus 5x15 mm stent was placed in right renal artery and a 6x14 mm Boston scientific vascular SD stent placed in left renal artery. Post stenting angiography showed a good flow with relief of stenosis. [Formula presented] [Formula presented] [Formula presented] Conclusions: Although, there is controversy regarding role of angioplasty in treatment of hypertension in atheromatous renal artery stenosis, no consensus exists in Takayasu arteritis with renal artery stenosis due to a lack of randomised controlled trials. Our case represents an interesting case where the patient had a dramatic relief of hypertension and heart failure after bilateral renal angioplasty in Takayasu arteritis.
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Background/Introduction: Untreated, symptomatic, severe aortic stenosis carries significant mortality and morbidity. Timely intervention is pivotal to ensure patient safety. The COVID-19 pandemic created unprecedented challenges to the UK's National Health Service (NHS), resulting in the deferral of all elective work, including TAVI services from March 2020. Purpose: To evaluate clinical outcomes and time delays in patients undergoing TAVI during the pandemic period compared to an age and risk factor-matched cohort of patients prior to COVID-19. We hypothesized that there were significant time delays, more emergency procedures and related adverse outcomes in patients who underwent TAVI during the pandemic period. Methods: We analysed prospectively collected data (patient characteristics, procedural details, complications and in-hospital outcomes) of 210 consecutive patients who underwent TAVI between March 2019 and February 2021 in a tertiary centre in the UK (The centre serves for a population of 2.5 million and provided in-patient treatment for 5590 COVID-positive patients over a 12 month period). We compared time-lags from an initial referral to outpatient review, CT aortograms, valve implantation and 30-day mortality between patients who underwent TAVI between March 2019 and Feburary 2020 (N=134) and those who underwent TAVI between March 2020 and February 2021 (COVID Group=76). Results: The mean age of the cohort was 81.4±6.6 years and majority were females (51%) and were in moderate risk category (EuroSCORE II=4.55±5.5). Of the total cohort, 4 (5.3%) patients acquired COVID-19 pneumonia during the hospital stay. The age, cardiovascular comorbidities and risk scores were comparable between the control group and the COVID cohort. (Table 1). There were no significant differences in procedural complications in the control group compared to the COVID-19 group (Table 1). The median waiting time from referral to TAVI clinic was significantly shorter in the COVID-19 group (33 (8-66) vs. 51 (17-89) days (P=0.04)) and there was no significant difference in time delays for CT aortogram, MDT or TAVI procedure between the two groups. The median length of stay (2 (2-4) vs 2.5 (2-9) days) and 30 day mortality (1.4% vs 5.3%) was comparable between the two groups (Table 1). Conclusion: Contrary to our hypothesis, our analysis demonstrated that there were no significant time delays, excess complications or mortality in TAVI procedures during the COVID-19 pandemic period despite the excess burden imposed on our local health services. More importantly, very few TAVI patients acquired COVID-19 infection during in-hospital stay. This is likely due to prompt identification of innovative ways of re-configuring an existing local patient pathway, by the TAVI team, to deliver safe and uninterrupted TAVI services during this unprecedented pandemic setting. (Figure Presented).