Complications Of A Severe Case Of Multisystem Inflammatory Syndrome In Children

Case Presentation: A 10 year old male with prior COVID-19 exposure presented with 7 days of fever, rash, cough, vomiting, and hypotension. Laboratory evaluation was notable for SARS-CoV2 antibodies, elevated cardiac enzymes, BNP, and inflammatory markers. Initial echocardiogram showed normal cardiac function and a small LAD coronary aneurysm. He was diagnosed with Multisystemic Inflammatory Syndrome in Children (MIS-C) and given methylprednisolone and IVIG. Within 24 hours, he developed severe LV dysfunction and progressive cardiorespiratory failure requiring VA-ECMO cannulation and anticoagulation with bivalirudin. Cardiac biopsy demonstrated lymphocytic infiltration consistent with myocarditis. On VA-ECMO, he had transient periods of complete AV block. With immunomodulator treatment (anakinra, infliximab) and 5 days of plasmapheresis, inflammatory symptoms and cardiac function improved. He weaned off ECMO, and anticoagulation was transitioned to enoxaparin. He had left sided weakness 5 days later, and brain MRI revealed an MCA infarct. Ten days later, he had focal right sided weakness and repeat MRI showed multiple hemorrhagic cortical lesions, thought to be thromboembolic with hemorrhagic conversion secondary to an exaggerated inflammatory response to an MSSA bacteremia in the setting of MIS-C. Enoxaparin was discontinued. After continued recovery and a slow anakinra and steroid wean, he has normal coronary arteries, cardiac function, and baseline ECG but requires ongoing neurorehabilitation. Discussion(s): COVID-19 infection in children is often mild, but MIS-C is an evolving entity that can present with a wide range of features and severity. This case highlights two concepts. While first degree AV block is often reported in MIS-C, there is potential for progression to advanced AV block. Close telemetry monitoring is critical, especially if there is evidence of myocarditis. MIS-C shares features with Kawasaki disease, with a notable difference being a higher likelihood of shock and cardiac dysfunction in MIS-C. In MIS-C patients with cardiovascular collapse requiring ECMO, there is a risk for stroke. There should be a low threshold for neuroimaging and multidisciplinary effort to guide anticoagulation in these complex cases.

Left Ventricular Non-Compaction: An Uncommon Cause of Cardoembolic Stroke

Introduction: Left ventricular non-compaction (LVNC) is a rare, usually congenital or hereditary cardiomyopathy. The formation of deep trabecular recesses increases the likelihood of a thrombus entering the systemic vasculature which may cause cardioembolic stroke. Clinical manifestations of LVNC range from asymptomatic to severe heart failure, thromboembolic events, and sudden death. In adults, individuals with LVNC have a 21 - 38% chance of developing a cardioembolic stroke. Case Presentation: We present a case of a 29-year-old African American female, six weeks postpartum with a history of cleft palate, right sixth nerve palsy, and recent Covid-19 infection who developed stroke-like symptoms of left side numbness and weakness, left side facial droop and slurred speech upon awakening. On initial examination, the patient displayed 4/5 strength and decreased sensation to pinprick in left upper and lower extremities as well as left lower facial palsy and dysarthria. CT head without contrast revealed a large infarct in the right middle cerebral artery (MCA) territory. A brain MRI confirmed the right MCA infarct but did not reveal acute infarct in other vascular territory. CTA head/neck reported right MCA proximal M2 segment occlusion. During admission, stroke work-up included a normal EKG. A transthoracic echocardiography (TTE) with bubble study was obtained which reported no patent foramen ovale but with severely reduced systolic function with a LVEF estimated 15-20%;questionable right ventricle apical thrombus was also suspected. Cardiology was consulted for acute systolic heart failure with plans to initiate goal directed medical therapy. A cardiac MRI was recommended which revealed left ventricle increased trabeculations meeting MRI criteria for LVNC, but no cardiac thrombus was detected. Patient was started on warfarin with enoxaparin bridging for secondary stroke prevention. Discussion(s): Given our case's young age of onset of stroke and the history of postpartum and recent COVID-19 infection, cardioembolic stroke due to other more common etiologies such as hypercoagulable disorders, postpartum cardiomyopathy or COVID-19 associated cardiomyopathy were initially suspected based on the initial TTE findings. Subsequent cardiac MRI revealed LVNC as an unusual cause of her cardioembolic stroke. This case illustrates the importance of thoroughly investigating the potential managementchanging causes of stroke, including congenital structural cardiac abnormalities, in patients with young age of onset.

POST-VACCINE-INDUCED IMMUNE THROMBOTIC THROMBOCYTOPENIA (VITT) STROKE: LITERATURE REVIEW AND PROPOSAL OF A THERAPEUTIC ALGORITHM FOR THE ACUTE PHASE

Background and aims: Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare but catastrophic syndrome characterized by venous and arterial thrombosis, with thrombocytopenia and antibodies against platelet factor-4 (PF4)/polyanion, typically 5-30 days from the first dose of a DNA viral vector vaccine. Very rarely, acute ischemic stroke (AIS) can be the result of VITT. The aim of this study was to define the clinical and radiological characteristics, outcome and therapeutic options of VITT patients with AIS. Methods: We carried out a systematic review of the literature till October 27, 2021 using MEDLINE, PUBMED and Google Scholar databases in order to collect all the published articles related to the development of AIS after vaccination against SARS-CoV-2. Results: We identified 16 patients from case reports or case series published in peer-reviewed journals affected by AIS and confirmed VITT. All patients had received the first dose of ChAdOx1 ncov19 vaccine within 10 days (median). 81% (n=13/16) of the patients had occlusion of the middle cerebral artery (MCA) or its branches, 43.7% (n=7/16) also had thrombotic occlusion of the intracranial internal carotid artery. 45.4% (n=5/16) of the patients with proximal MCA occlusion developed a malignant MCA infarct. Only one patient received intravenous thrombolysis, while three patients underwent mechanical thrombectomy. Conclusions: The management of AIS due to large vessel occlusion in VITT is challenging. Based on the available literature, we propose a therapeutic protocol for acute stroke patients presenting to the Emergency Department within the time window for reperfusion strategies.

A case of brain metastases masquerading as cognitive decline

Introduction: Cognitive decline in the elderly is a diagnostic challenge - one that must consider numerous differential diagnoses, including dementia. Given the profound impact of one's cognition on functional status and quality of life, early recognition of reversible and treatable causes of cognitive decline, especially when it occurs at a rate faster than expected, is critical. Case Presentation: An 86-year-old female was admitted from long-term care for a 2-week history of cognitive decline, hypoxia, and vomiting that began after receiving the second dose of the COVID vaccine. Her past medical history was significant for dementia, right middle cerebral artery stroke, benign left parietal neoplasm under surveillance, and pulmonary emboli. Investigations for her hypoxia were unremarkable;thus, it was thought to be due to aspiration from emesis. Initially, the patient's cognitive decline was presumed to be secondary to her dementia, which has been progressive for the past 5 years, leading to her eventual admission to long-term care. However, it was highlighted that the patient's cognition rapidly declined in a period of weeks. Despite her dementia, at baseline, the patient could engage in full conversations. However, over the past few weeks, the patient could only communicate with a few words and became newly dependent with ADLs. The patient was not delirious, given the non-fluctuating cognitive decline with normal attention and level of consciousness. Laboratory studies, including TSH and vitamin B12, were normal. CT Brain was completed given patient's history of parietal neoplasm, demonstrating a new left occipital lobe lesion with vasogenic edema. The patient was started on dexamethasone given the size of the lesion and edema. With this, her cognition significantly improved over days, allowing the patient to be involved in the decision-making of her care. Unfortunately, the patient had an aspiration event during her admission. As per her wishes, she was discharged to long-term care with symptom-focused, comfort care. Discussion: In this case, we discuss our approach to cognitive decline and highlight the importance of maintaining a broad differential, even in the face of known dementia. Finding reversible causes of cognitive decline can not only improve quality of life, but as seen in our patient, it can allow individuals to participate in meaningful decisions regarding their goals of care.

The Life of a Myxoma—Transoesophageal Images of the Progressive Growth of a Myxoma Over a 19-month Period

Introduction: A paucity in data exists regarding the expected growth rate of myxomas given the prompt transition to surgical intervention on initial discovery. Most case reports describe an initial normal echocardiogram compared with a subsequent echocardiogram revealing a myxoma at the time of diagnosis [1-3]. Uniquely, our case follows the sequential monitored growth of an atrial myxoma with transoesophageal images over a 19-month period. Case: This case describes a 71-year-old woman with a history of hypertension and hypercholesterolaemia admitted with a provoked deep vein thrombosis. This was complicated by bilateral pulmonary emboli and a presumed paradoxical embolus through a patent foramen ovale (PFO) resulting in a middle cerebral artery stroke. She was thrombolysed, then managed with rivaroxaban. During PFO closure, intraoperative transoesophageal echocardiogram (TOE) revealed a new left-sided atrial mass 1.0cm x 0.6cm in size, resulting in procedure abandonment. Uncertainty around diagnosis in addition to delays related to the COVID-19 pandemic led to serial imaging. The mass was monitored via TOE at 5, 11 and 19 months, revealing an initially stable then unexpected rapid progression to a size of 3.6cm x 2.9cm in the final 8 months. The patient had prompt excision of her myxoma and patch closure of interatrial septum. Discussion: This case exhibits a rare opportunity to appreciate the visual progression of an atrial myxoma and the unpredictable rapid growth over an 8-month period, highlighting the importance of interval monitoring of undifferentiated atrial lesions. [Formula presented]

Stroke and pulmonary embolism in moderate CoViD-19

Background: Venous thromboembolism, arterial thrombosis and thrombotic microangiopathy substantially contribute to increased morbidity and mortality in CoViD-19. We report a case of 56-year old man that presented with stroke and was found to have CoViD- 19 pneumonia complicated by pulmonary embolism (PE). Description of the case: A 55-year-old man with history of hypertension presented to the emergency department after a transient loss of consciousness. He was found to have left lateral hemianopia and lower right quadrantanopsia and head CT confirmed bilateral stroke in the posterior cerebral artery territory. MR angiography excluded atherosclerosis/dissection of the vertebral and basilar artery and a positive nasopharingeal swab PCR test revealed SARS-CoV-2 infection. The patient was admitted and ASA 100 mg and enoxaparin 40 mg per day were started. He experienced dry cough and fever and 10 days after admission presented atypical chest pain. CT Angiography revealed multiple confined ground glass opacities with segmental bilateral PE. Therapeutic dose of enoxaparin was started and after 5 days switched to edoxaban 60 mg per day. The patient progressively recovered and a complete work up excluded patent foramen ovale and any other cause predisponing to combined presence of venous and arterial thrombosis Conclusions: CoViD-19 has presented many diagnostic challanges in patients with neurologic and respiratory findings: thromboembolic disease may even be the initial or unique presentation. The early recognition of these phenotipes of the disease play a dramatic role in the CoViD-19 management.