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Purpose of study A 32-years old male with known multi-system sarcoidosis in remission for 5 years off treatment presented to the emergency room with complaints of generalized weakness, hematemesis, epistaxis, and bruises. Physical examination was notable for petechiae, ecchymosis along with papules and plaques suggestive of active sarcoid skin lesions on his extremities. Laboratory workup was significant for thrombocytopenia 3000/uL, acute kidney injury with sub-nephrotic proteinuria. Peripheral blood smear did not show evidence of hemolysis and direct Coombs test was negative. Infectious workup including COVID-19, HIV, and hepatitis serologies were negative. Computed Tomography (CT) of chest, abdomen, and pelvis showed mild splenomegaly and an increased number of sub-centimeter hilar and mediastinal lymph nodes. The patient was treated with dexamethasone 40 mg daily for 4 days and intravenousimmunoglobulins (IVIG-2 gm/kg) for possible Immune Thrombocytopenic Purpura (ITP) with improvement in platelet count to 42000/uL by day 3. His workup for AKI and sub-nephrotic proteinuria was negative apart from a positive ANA (1: 160) with low complements. The anti-phospholipid antibody panel was negative. The ACE level was markedly elevated (>80U/L). The patient could not get a renal biopsy due to severe thrombocytopenia. He was discharged but was re-admitted in 15 days for severe thrombocytopenia of 1000/uL, epistaxis, and bruising. We continued high dose steroids along with IVIG 1 gm/kg for refractory ITP with minimal response and started anti-CD20 agent (Rituximab) 375 mg/m2 weekly with thrombopoietin-receptor agonist (Eltrombopag). His platelets count improved in response to treatment and subsequent renal biopsy showed focal and segmental glomerulosclerosis along with mild interstitial fibrosis, tubular atrophy thought to be from long standing sarcoidosis. There was also evidence of focal arteriosclerosis with no evidence of granulomas, immune complex, complement, or IgG4 deposition. Given skin lesions, thrombocytopenia, extensive lymphadenopathy, and renal involvement with markedly elevated ACE levels the overall picture was consistent with active multi-system sarcoidosis. His platelet count increased to 177,000/uL at the time of discharge. Currently, the patient is on slow steroid taper along with Eltrombopag 25 mg every other day without any recurrence of his symptoms so far. Methods used We described one case of sarcoidosis with hematologic and renal involvement. Summary of results Our patient developed hematologic and renal complications approximately 6 years after being diagnosed with sarcoidosis. Initially, he did not demonstrate sufficient clinical response to IVIG and high dose steroids. However, after a course of anti-CD20 agent (Rituximab) and with the addition of thrombopoietin-receptor agonist (Eltrombopag) he showed improvement of platelet count and stabilization of the renal function. Currently, the patient is receiving maintenance therapy with Prednisone 7.5 mg daily along with Eltrombopag 25 mg twice weekly with no recurrence of ITP and stable renal function. A further decision on whether the patient needs another cycle of Rituximab will be determined by the patient's clinical course. Conclusions Highly variable manifestations of Sarcoidosis can pose a significant diagnostic and therapeutic challenge as can be seen from our case. ITP is a rare hematological manifestation of sarcoidosis and addition of anti-CD20 agents should be considered in refractory cases.
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Case report Background: Delayed hypersensitivity reactions to hyaluronic acid fillers are usually self-limiting and uncommon, and spontaneous resolution is frequent. These are presumably T-lymphocyte- mediated reactions that can be caused by flu-like infections and vaccinations. A delayed hypersensitivity reaction after hyaluronic acid filler following the mRNA vaccine against coronavirus has already been described in the literature. We wish to present a case that followed the ChAdOx1-s recombinant COVID-19 vaccine produced by Oxford/ AstraZeneca. Case report: Female patient, 61 years old, submitted to filling of the nasojugal sulcus and nasolabial fold with 1 ml of cross-linked hyaluronic acid -15 mg/ml and after 5 days filling in the lips with 1 ml of cross-linked hyaluronic acid -12 mg/ml, dermatological office, under aseptic technique and using cannulas. It evolved with ecchymosis on the lips and nasolabial folds, with spontaneous resolution after about a week. Sixteen weeks after the procedure, she received the first dose of the ChAdOx1-s recombinant COVID-19 vaccine, and 11 weeks later, the second dose. After 30 days of the 2nd vaccine dose, asymptomatic nodules appeared distributed in the upper and lower portions of nasolabial folds, in melomentonian grooves, in the supralabial region, in the upper and lower lip in the right and left lateral portions and in the infralabial region in the left lateral portion, coinciding with the topographies of the populated areas. Ultrasonographic evaluation with Doppler confirmed these findings. At the time, she denied fever or previous infectious signs or symptoms. Previously, the patient had already been submitted to the filling of the nasojugal and nasolabial folds with a hyaluronic acid-based filler (1 ml), 29 months before the current procedure, without intercurrences. After the appearance of the nodules, she underwent treatment with prednisone 40mg for 15 days, with total weaning after another 15 days, in addition to the use of levoceritizine 5 mg daily for 20 days, with partial reduction in the size of the nodules. Due to aesthetic complaints on the part of the patient, an intralesional injection of hyaluronidase was scheduled, but it was not performed at the request of the patient herself, who opted for expectant management and clinical treatment. In October 2021, the patient reported that the nodules had involuted and in December 2021 she remained asymptomatic, referring to resorption of the entire filler.
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Background: Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder that occurs in a sporadic, nonhereditary pattern. It is caused by circulating autoantibodies against clotting factor VIII that are triggered by several conditions. Moreover, AHA is clinically distinct from the inherited form of hemophilia A, with a different natural history and management approach, necessitating a high-index of suspicion in at-risk patients. Coronavirus disease 2019 (COVID-19) has emerged as a multisystemic disease whose manifestations are continuously being evaluated. There are few case reports of AHA associated with COVID-19 infection, while one case of AHA has been associated with COVID-19 vaccination. Similarly, deep venous thrombosis (DVT) frequently complicates COVID-19 infection, but two cases of DVT have been reported following COVID-19 vaccination. We report the occurrence of both AHA and DVT in a 63-year-old male patient within one week of receiving his first dose of the Pfizer-BioNTech SARS-CoV-2 mRNA vaccine. Case Description: Patient is a 63-year-old male who presented with a 3-day history of left lower extremity (LLE) swelling and pain. He was hemodynamically stable, but examination showed exquisite tenderness, ecchymosis, and pitting edema at the calf of the LLE. He had normal platelet counts at presentation but had mild anemia (11.9 g/dL) and elevated activated partial thromboplastin time (APTT) of 68.0 seconds. Venous Doppler ultrasound showed acute DVT in the left popliteal vein, necessitating commencement on heparin drip. He developed progressively worsening hematomas, symptomatic anemia that required red cell transfusions, and persistently elevated APTT despite stopping the heparin drip. Work up for pulmonary embolism, malignancy, and disseminated intravascular coagulopathy (DIC) were negative. Antiphospholipid antibodies and lupus anticoagulant were also negative. He had low factor VIII levels, tested positive for factor VIII inhibitor, and PTT mixing studies were consistent with acquired factor inhibitor. Treatment involved administration of Factor Eight Inhibitor Bypassing Activity (FEIBA) as well as intravenous methylprednisolone and cyclophosphamide. Following resolution of active bleeding with evidence of stable hemoglobin concentration, he was discharged home on oral prednisone and cyclophosphamide. Conclusion(s): This case report highlights the possibility of AHA and DVT as rare, potentially life-threatening adverse events that could occur following COVID-19 vaccination, which is currently the most effective tool employed in controlling the COVID-19 pandemic.Copyright © Annals of Blood. All rights reserved.
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COVID - 19 can be accompanied by a variety of cutaneous abnormalities, which mainly include vascular lesions chilblain - like lesions, livedo reticularis, purpura, ecchymosis, acral cyanosis, gangrene, etcand inflammatory lesionsdiffuse erythema, morbilliform exanthem, acute urticaria, varicella- like exanthem, etc. Some types of skin lesions may be the first symptom or the only clinical manifestation of COVID-19.Copyright © 2022 Chinese Journal of Dermatology. All rights reserved.
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Maintaining reduction of a calcaneal tuberosity avulsion fracture is challenged by the powerful force exerted upon the bone fragment by the Achilles tendon. Low-demand, elderly patients with osteoporotic bone usually undergo a low-energy mechanism when this fracture pattern occurs. Likely attributable to poor bone quality, the rate of early fixation failure has been documented to be as high as 40%. We present the cases of two 65-year-old female patients who each sustained a calcaneal tuberosity avulsion fracture. Both patients underwent a low-energy mechanism of injury and had a medical history of many comorbidities. The first patient underwent a partial calcaneal ostectomy and tenotomy after failing open reduction internal fixation (ORIF). The second patient primarily underwent a partial calcaneal ostectomy and tenotomy. Postoperatively, after the incision site was fairly healed, both patients could bear weight as tolerated. This method of excision and release may allow for decreased risk of skin compromise and return trips to the operating room for failed ORIF. In low-demand patients with low-energy calcaneal avulsion type fractures and osteoporotic bone, this technique may be the preferred surgical option.Copyright © 2022 The Author(s)
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Introduction: Acquired hemophilia A (AHA) is a rare autoimmune disease due to anti-factor VIII antibodies. It may be associated with infections and malignancies. The association with Covid vaccine is extremely rare. Immunosuppressive therapy with steroids, cytotoxic agents, is the traditionalmainstay for antibodies eradication. Rituximab standard doses have been used with success. There are few reports on low-dose Rituximab for AHA.We present a case of AHA post Covid-19 vaccination successfully treated with low dose of Rituximab. Method(s): case report Results: A non hemophilic 69-year-old male with no medical history consulted for multiple ecchymosis that spontaneously occurred with no context of trauma. Two months previously he received a second dose of CoronaVac-Sinovac vaccine. Coagulation tests revealed an isolated and prolonged aPTT (100 sec/30s;ratio=3.33) not corrected with normal plasma. The coagulation factors assay revealed an isolated decrease of factor VIII to 1% with a titer of 121 Bethesda units/ml confirming the diagnosis of AHA. Hepatitis B and C and HIV tests were negative. A full body-computed tomography scan was normal. Treatment with Prednisolone 1 mg/kg/d was started with tranexamic acid. Bypassing therapy was not considered because of the absence of life-threatening bleeding. Seventeen days after corticosteroid initiation, a worsening of the ecchymosis was noted with the non-improvement of the aPTT. A low-dose rituximab (100 mg/week) was added for 4 weeks. After 3 doses of Rituximab a complete clinical response was achieved. Factor VIII inhibitor was completely eradicated. Corticosteroid was discontinued. At 3-month follow-up the patient remains in remission without further treatment Discussion/Conclusion:More than 50 cases of AHA following COVID-19 vaccine have been reported. To our knowledge only 2 cases of AHA were successfully treated with low dose of rituximab. Low-dose Rituximab appears to be effective for Factor VIII inhibitor eradication in AHA with a lower cost.
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Introduction: Published data on the course of COVID-19 in patients with congenital bleeding disorders (CBDs) is limited. There are questions about howCOVID-19 affects the course of CBDs and, conversely, how CBDs affect the course of coronavirus infection? Some authors suggest that patients with CBDs to be less severely affected by COVID-19. The aim of the study: analysis of the prevalence and course of COVID-19 in patients with CBDs in Russia. Method(s): A web-based questionnaire was developed to collect data. The survey was conducted in the period from 25.06.2022 to 31.07.2022. A cluster of 187 patients from different regions and cities of Russia were interviewed. Result(s): The average age of patients was 37 years. The survey group consisted of 144 patients with hemophilia A, 16 with hemophilia B, 24 with vonWillebrand's disease and 1 patient with factor VII deficiency. COVID-19 affected 115 (61.5%) of 187 surveyed patients and 22 (19%) patients suffered from coronavirus infection twice. Hospitalisation was required for 14 (12.3%) patients. At the beginning of the disease, 82 (71%) patients were on prophylactic treatment with the factor concentrates;11 (10%) received therapy with emicizumab, 20 (17%) received therapy with the factor concentrates on demand and 2 (1.7%) received bypass agents. During COVID-19 different types of bleeding were observed in 9 (7.8%) patients: hemarthrosis, ecchymosis, hematomas, epistaxis, menorrhagia, haemorrhoid bleeding. Due to COVID-19 the blood coagulation parameters were monitored for 15 (13%) of 115 patients who had been ill. The haemostatic therapy regimen was changed in 19 (16.5%) patients. Anticoagulant therapy was received by 8 (7%) patients. There were no thrombotic cases. A change in the course of the underlying disease after COVID-19 was noted by 21 (18%) patients, of which 11 noted an increase in joint pain and 9 reported the appearance of pain in previously intact joints. Discussion/Conclusion: The absence of thrombotic complications in patients with CBDs and COVID-19 suggests that hypocoagulability state may be protective against COVID-19 hypercoagulability-related adverse effects. However, the aggravating condition is an increase in joint pain and the involvement of new joints possible due to both hemostatic disorders and autoimmune reaction.
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Background: Systemic lupus erythematosus (SLE), a multisystem autoimmune disease more common in females, is associated with autoantibodies against different autoantigens forming immune complexes. Inadequate removal of these complexes from the host triggers inflammatory response which causes tissue damage. Some antiviral vaccines have been associated with the onset of SLE. Few cases of SLE occurring after SARS-CoV- 2 vaccines have been reported. Herein, we describe a case of new-onset SLE associated with COVID-19 vaccine. Case Summary: A previously well 36-year- old male with unremarkable family history of autoimmune disease started to develop muscle and joint pains, hair thinning, and ecchymoses 2 months after receiving second dose of inactivated SARS-CoV- 2 vaccine. He was subsequently admitted after consultation due to thrombocytopenia (platelet count of 58). He was given high dose steroid with tapering dose during the entire 14 days admission with significant increase of platelet count after 72 hours of repeat complete blood count. He went consult at rheumatology clinic a month after due to persistent joint and muscle pains, and progression of hair fall with associated facial rash, oral ulcers, easy fatigability and weight loss. Physical exam disclosed an ambulatory well-built male with normal vital signs, alopecia, malar rash, oral ulcers, joint tenderness and no objective muscle weakness. Complete blood counts and Anti-smith were within normal. Urinalysis, Antinuclear antibody (ANA), Anti-SSA, Anti-SSB, complement factor 3 (C3), and Anti-dsDNA were positive. He was managed with tapering prednisone and hydroxychloroquine with significant improvement at time of this report. Conclusion(s): Development of autoimmune reaction following COVID-19 vaccine has been described extensively;however, evidence of autoimmunity following vaccination seems to be lacking at present. Pathomechanisms include defective elimination and/or control of self-reactive lymphocytes resulting in over-stimulation of the immune system leading to clinical manifestations strikingly similar to the infection itself. Management approach to these autoimmune reactions address the immune hyper-stimulation with immunosuppressive or immuno-modulating agents including steroids and hydroxychloroquine.
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Subcutaneous injections are recommended instead of intramuscular for patients with bleeding disorders to avoid bleeding complications. This study aimed to determine whether the intramuscular administration of COVID-19 vaccines would increase bleeding-associated complications in patients with bleeding disorders followed in our clinic. We collected the data of 47 patients with bleeding disorders older than 18 years followed at the hematology outpatient clinic and screened between March 15, 2020, and December 31, 2021. We obtained the data from the hospital's electronic information system, including age, gender, type of bleeding disorder, factor levels, and whether they received prophylaxis. We interviewed the participants about the type of vaccine they received and the duration of compression they applied to the injection site, whether they received factor replacement before and after the injection, and whether there were any complications following the injection. We included in the study thirty-nine male patients vaccinated against COVID-19. The mean age of the patients was 39.05 (18-73 years). Factor VIII deficiency constituted 79.4%, XI 10.3%, and other bleeding disorders 10.3 % of the cases. The patients with bleeding disorders had a mean factor level of 2.02 (0-9). Twenty-nine (74.4%) patients were on regular factor prophylaxis for their bleeding disorder. In terms of the compression duration to the injection site following injection, 6 (15.4%) patients had applied compression for 10 min, 4 (10.3%) for 5-10 min, and 29 (73.4%) for less than 5 min. Two (5.1%) patients developed ecchymosis after the first vaccine dose on the injection arm. The results of this study demonstrate that the rate of bleeding complications remains low in patients with bleeding disorders if they receive intramuscular vaccination after necessary precautions. Copyright © 2022 Ondokuz Mayis Universitesi. All rights reserved.
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Background: COVID-19 infection may be associated with coagulopathy, both thrombotic as well as haemorrhagic events. Bleeding manifestations are rather rare. Our case describes a possible association between acquired hemophilia A (AHA) and COVID-19 infection. This causality has been described only in several cases. Aim(s): A 78-year- old male was admitted to hospital for ecchymoses, appearing just over past several days, located on the right breast and the left upper limb, with no history of recent injury. No previous personal or family history of any bleeding symptoms. Concurrently COVID-19 infection was confirmed. During the hospital stay, the skin bruises have further spontaneously extended, covering both the pectoral areas, the abdomen and all extremities. Method(s): Basic laboratory sampling was performed. The isolated presence of striking prolongation of aPTT was discovered (aPTT ratio 4.28, normal range 0.8-1.2). Investigations on prolonged aPTT have been initiated. Result(s): Extremely low activity of factor VIII (0.4%) was found. Further studies have subsequently identified a specific factor VIII inhibitor (24 Bethesda units). During the investigations of the condition no malignancy, autoimmune disorders or drug interactions were disclosed. A 30% COVID pneumonia was discovered by CT imagining. Conclusion(s): The diagnosis of AHA was made, most likely due to an acute onset COVID-19 infection. This association can only be speculated for the time being, however, COVID-19 infection induced autoantibody production and influence on coagulation system is described by a number of studies. We therefore recommend a frequent coagulation monitoring including aPTT in patients admitted with acute COVID-19 infection and the specific/non-specific inhibitor search in cases with otherwise unexplained onset or worsening of haemorrhagic episodes and/or an aPTT prolongation.
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SESSION TITLE: Problems in the Pleura Case Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Ibrutinib is an irreversible inhibitor of Bruton's tyrosine kinase (Btk), approved for treatment of a variety of B-cell malignancies, including chronic lymphocytic leukemia (CLL). There is an association of increased risk of bleeding with ibrutinib due to platelet dysfunction caused by the medication. Bleeding is usually non-life threating such as subcutaneous or mucosal bleeding, epistaxis, and ecchymosis. But major bleeding has been reported such as intracranial hemorrhage and gastrointestinal hemorrhage. Thoracic complications from ibrutinib are rare. Below is a case report discussing a hemorrhagic pleural effusion thought to be caused by Ibrutinib. CASE PRESENTATION: Patient is a 78-year-old male initially diagnosed with CLL on flow cytometry showing a low-grade B cell lymphoproliferative process. Patient was monitored by Hematology and when kappa light chain numbers began to rise, a bone marrow biopsy was performed showing 90% infiltration of the marrow with lymphoid cells. Patient was started on Ibrutinib therapy and responded well to treatment. A year after starting therapy, patient presented to the emergency room with increased shortness of breath and fatigue. Patient was found to be COVID-19 positive and chest x-ray showed a large right sided pleural effusion. Thoracentesis was performed draining 1650cc of bloody fluid. Fluid studies revealed a lymphocytic effusion with RBC count 1,185375, WBC of 1751. Cultures and cytology were negative. On further history, patient was without recent trauma or surgery, CTA chest was negative for pulmonary embolism. QuantiFERON Gold test was negative, indicating low likelihood of tuberculosis. Patient was not on any antiplatelet or systemic anticoagulation medications. Ibrutinib therapy was held during hospitalization and pleural effusion did not reaccumulate. Patient passed away during hospital stay secondary to respiratory failure due to COVID-19. DISCUSSION: Ibrutinib is an orally bioavailable bruton tyrosine kinase inhibitor (BTKi) and forms an irreversible covalent bound to BTK at the Cysteine-481 residue. Ibrutinib predisposes to bleeding by inhibiting BTK and Tec, which play a role in the inhibitory signaling pathway of platelet collagen receptors such as glycoprotein VI (GP VI) and C-type lectin-like receptor 2 (CLEC-2). Our patient had no other risk factors for developing a hemorrhagic effusion. CLL itself can cause malignant effusions, one study found the incidence of malignant effusions among patients with CLL to be 9%, but the effusion was noted to be serous or serosanguinous and there was pleural involvement in all patients which was not the case in our patient. CONCLUSIONS: There is currently a minimal amount of data to guide clinicians regarding the use of ibrutinib in patients at high risk of bleeding or on anticoagulant or antiplatelet therapy. It is important to realize bleeding complications related to ibrutinib therapy can occur. Reference #1: Shatzel JJ, Olson SR, Tao DL, McCarty OJT, Danilov AV, DeLoughery TG. Ibrutinib-associated bleeding: pathogenesis, management and risk reduction strategies. J Thromb Haemost. 2017;15(5):835-847. doi:10.1111/jth.13651 Reference #2: Burger JA, Tedeschi A, Barr PM, et al. Ibrutinib as Initial Therapy for Patients with Chronic Lymphocytic Leukemia. N Engl J Med. 2015;373(25):2425-2437. doi:10.1056/NEJMoa1509388 Reference #3: Paydas S. Management of adverse effects/toxicity of ibrutinib. Crit Rev Oncol Hematol. 2019;136:56-63. doi:10.1016/j.critrevonc.2019.02.001 DISCLOSURES: No relevant relationships by fatima ali No relevant relationships by Joan Wiley
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SESSION TITLE: COVID-Related Critical Care Cases SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: We present a case of diffuse alveolar hemorrhage (DAH) secondary to Immune Thrombocytopenia (ITP) temporally related to SARS-CoV-2 (CoV) vaccine. CASE PRESENTATION: An 80-year-old female presented with dyspnea, hemoptysis, diffuse petechiae, and ecchymosis;no focal neurological deficits or hepatosplenomegaly. She had no history of bleeding or autoimmune disorders;no recent respiratory or gastrointestinal infections;but received Moderna CoV vaccine 4 weeks prior to presentation. Chest X-ray (CXR) and CTA of chest demonstrated multifocal bilateral patchy airspace opacities. Initial platelet was 1 x 109/L with normal morphology of platelet and WBC, and no schistocytes. Coagulation panel, LDH, haptoglobin, and bilirubin were all normal. CoV NAAT was negative. Dexamethasone and IVIG for high suspicion of ITP was initiated. Supportive care including platelet transfusion and oxygen via nasal cannula was maintained. Platelets were severely consumed in spite of treatment with platelets undetectable at nadir and rapid decrease of hemoglobin, approximately 6 g/dL, within 24 hours of admission. IgM and IgG plasma platelet autoantibodies returned positive, confirming ITP diagnosis. Additional workup was unremarkable for infections, rheumatologic disorders, and malignancy. Respiratory state rapidly declined with worsening hemoptysis and significant increase of bilateral airspace opacities on repeat CXR, indicative of DAH. Lung protective mechanical ventilation protocol was initiated on day 2 with medically induced deep sedation and paralysis to minimize hemorrhage exacerbation. Rituximab, romiplostim, and nebulized tranexamic acid were added for severe and refractory ITP, which eventually slowed platelet consumption, reduced pulmonary hemorrhage, and stabilized hemoglobin. Platelets recovered above 30 x 109/L on day 9, and subsequent bronchoscopy showed persistent blood on bronchoalveolar lavage. She was successfully extubated after prolonged 14-day intubation. Platelet normalized before discharge. DISCUSSION: Incidence of ITP related to CoV vaccine is approximately 0.8-0.9 case per million vaccinated. Most cases present with superficial bleeding and respond to first-line agents with rapid recovery. GI bleeding and intracranial hemorrhage, but not DAH, have been reported in several cases, requiring third-line agents to promote platelets recovery and achieve hemostasis. We report a case of DAH secondary to ITP following CoV vaccine. Temporal relationship and severe presentation are consistent with other reports of ITP with life-threatening internal bleeding probably secondary to CoV vaccine. CONCLUSIONS: When DAH is suspected, rapid escalation of treatment to include third-line agents is desired. If intubated, lung protective ventilation with paralysis is preferred to minimize further lung injury due to DAH. Reference #1: Lee EJ, Cines DB, Gernsheimer T, et al. Thrombocytopenia following Pfizer and Moderna SARS-CoV-2 vaccination. Am J Hematol. 2021;96(5):534-537. doi:10.1002/ajh.26132 doi:10.1016/J.VACCINE.2021.04.054 Reference #2: Welsh KJ, Baumblatt J, Chege W, Goud R, Nair N. Thrombocytopenia including immune thrombocytopenia after receipt of mRNA COVID-19 vaccines reported to the Vaccine Adverse Event Reporting System (VAERS). Vaccine. 2021;39(25):3329-3332. Reference #3: Tarawneh O, Tarawneh H. Immune thrombocytopenia in a 22-year-old post Covid-19 vaccine. Am J Hematol. 2021;96(5):E133-E134. doi:10.1002/ajh.26106 DISCLOSURES: No relevant relationships by Timothy Barreiro No relevant relationships by Tiewei Cheng No relevant relationships by Zeina El Amil No relevant relationships by Jin Huang No relevant relationships by Sanaullah Khalid
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Purpose : A high incidence of sinu-orbital Mucormycosis as a fulminant and opportunistic fungal infection happened following the COVID-19 pandemic. Traditionally, patients with apical or extensive orbital involvement are candidates for exenteration. We designed and applied CT scan guided orbital amphotericin C delivery. In this study we aimed to report this novel technique and results of this method in control of orbital mucormycosis with apical involvement. Methods : A high incidence of sinu-orbital Mucormycosis as a fulminant and opportunistic fungal infection happened following the COVID-19 pandemic. Thus named as CAM. Traditionally, patients with orbital mucormycosis with apical or extensive involvement are considered hopeless for saving the eye. We designed and applied CT scan guided orbital amphotericin C delivery. Results : A total of thirty patients with mean age of 52±11.86 were enrolled in this study. Twenty-three (76.7%) patients were male;group A: 11 (73.3%) and B: 12 (80%). The majority of the patients in both group were diabetics (A: 10 (66.7%), B: 10 (76.9%)). Most patients in both groups had received corticosteroids and antiviral therapy for their recent COVID-19, 23 (82.1%) and 25 (89.3%), respectively. No patient in group A underwent exenteration. Eleven (78.6%) patients in group B underwent orbital exenteration. Of the 6 expired patients, 5 (83.3%) were in group B (P<0.0001). Peri-orbital ecchymosis and intracranial air extension were observed in 2 (13.3%) and 1 (6.7%) in group A patients, respectively. Conclusions : Intra-orbital amphotericin injection under CT-guidance can be considered as a highly effective method in patients with orbital mucormycosis. This method may decrease exenteration without increasing mortality of patients.
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Introduction: Macroglossia is defined as an enlargement of the tongue in the resting position, protruding beyond the teeth. Many cases have been reported secondary to patient positioning while under anesthesia, post oro-pharyngeal packing, trauma or surgery, and allergic or non-allergic angioedema. However, acute macroglossia in the ICU is a rare situation. In COVID-19 related severe ARDS, endotracheal intubation and prolonged proning is an important part of management of hypoxemic respiratory failure Prone positioning also has the potential to independently cause macroglossia. Awareness of this complication of proning could help mitigate morbidity in patients. Case report: A 53-year-old diabetic, hypertensive overweight female with OSA presented with progressive shortness of breath and productive cough. She was mechanically ventilated in ICU in view of respiratory distress secondary to COVID-19 pneumonia. Intubation was minimally traumatic with minimal oral bleeding settling over few minutes. Though managed with medications as per COVID-19 management protocol, she progressed to severe ARDS hence proned on hospital day 1 for 16 hours - PaO2/FiO2 ratio improved. She was not proned further. Acute macroglossia (3 inches outside the oral cavity) with lower facial edema was noted 4 days post proning. Saline moistened gauze was loosely wrapped around the tongue every hour. Circumferential ecchymosis was noticed around her neck on the 6th day. On day 8, macroglossia did not show signs of resolution. Hence, the tongue was pushed in manually every 2 hourly and the position was maintained manually for 10 minutes. The swelling decreased gradually with the tongue staying in a retracted position on treatment day 2. On day 3, there was a complete resolution of the swelling. However, she had persistent swallowing difficulty causing difficulty in weaning from tracheostomy. MRI of neck and chest showed large pre-vertebral collection from the upper border of C2 inferiorly across the thoracic inlet to the posterior mediastinum with thin linear extension up to the lower border of T4. Mass effect with airway compression, displacement, and compression of esophagus and neck vessels was seen. Trans-oral exploration revealed mucosal rent and bulge in the posterior pharyngeal wall. The hematoma was evacuated by ENT specialists. She was discharged on tracheostomy and feeding tube. Tracheostomy decannulation was done after 1 month. Discussion: In our practice of proning patients with ARDS for >10 years, this is the first case of macroglossia as a complication of proning that we encountered. Other factors that could have contributed to this patient are obesity and mildly traumatic intubation. Development of macroglossia 4 days after proning and resolution over a short period of time is rare and suggests lymphatic and vascular compression as the cause. Later development of ecchymosis and dysphagia may be due to the posterior pharyngeal injury. Conclusion: Proning, especially in obese patients, can be a challenge. Positioning of the face and avoidance of injury to any of the structures is vital to the care of the proned patient. Medical staff involved in patient care should be aware and vigilant to pick up this condition early to avoid further injury.
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Introduction: and Importance: Severe COVID19 patients under anticoagulant therapy are at the risk of developing hematoma. Case presentation: We present case of 11 COVID19 who were presented with localized skin ecchymosis lesions in different areas of the body and retroperitoneal hematoma in the posterior wall of the abdomen and chest. Clinical discussion: Cases of hematoma with severe COVID19 patients under anticoagulant therapy are reported in several case studies, particularly in geriatric population with the previous history of blood and/or cardiac disorders. Conclusion: These patients should be carefully monitored for hematomas by skilled nurse and practitioner and timely treated and monitored.
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Introduction: and importance: COVID19 is a multifunction disease where hematological disorders are reported. Coagulopathy is seen in these patients, indicated by thromboembolic events. Case presentation: We present case of 11 COVID19 who were presented with localized skin ecchymosis lesions in different areas of the body and retroperitoneal hematoma in the posterior wall of the abdomen and chest. Clinical discussion: Increased INR and bleeding and ecchymosis in Corona patients require discontinuation of anticoagulants and, FFP, essential and tri amino injections are needed. Conclusions: Diagnosis and management of hematoma is important to avoid fatality.
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Background: The role of anticoagulation in preventing and treating thromboembolic events due to presence of micro thrombosis that may affect various end-organs especially in coronavirus disease-19 (COVID-19). Patients receiving some form of anticoagulation therapy are predisposed to more risks of bleeding complications. These bleeding may range from minor to major, or even life-threatening events. Purpose: Low molecular weight heparin (LMWH) is one of the commonly used treatment modalities in COVID-19 and its complications are thrombocytopenia, anemia, bruises, and the rare ones are ecchymosis and/ or hematoma. Case presentation: A 75-year-old male COVID-19 patient weighing 85 kg was admitted to our intensive care unit (ICU) with shortness of breath, dry cough, and myalgia. On the 10th day, he develops ecchymotic patches over the anterior abdominal wall following administration of subcutaneous enoxaparin. This case describes the importance ofindividualizing the dose ofLMWH based on several risk factors.
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Since coronavirus disease 2019 (COVID-19) vaccines were approved without long-term monitoring, tracking their adverse effects appears to be necessary. Mucocutaneous adverse events are of great importance due to their visibility and the potential effect on inducing fear in patients leading to vaccine hesitancy. We searched PubMed, Google Scholar, and Scopus in this regard, and all of the relevant papers published until June 28, 2021, were included if we could access their full texts. Moreover, we included some of our cases from Iran. We found various mucocutaneous manifestations after COVID-19 vaccination, including local injection site reactions (acute or delayed), urticarial lesions, pityriasis rosea-like rashes, angioedema, morbilliform rashes, pernio-like lesions, acrocyanosis, petechial/ purpuric/ecchymotic lesions, herpes flare-up, herpetiform rashes, oral erosive lesions, acral pustular rashes, erythema multiform, dermographism, herpes zoster, generalized pruritus, contact dermatitis, reaction to dermal fillers and non-specific rashes. We categorized them by their time of initiation (acute or delayed) and site of involvement (local injection site, remote area, or generalized). Delayed local reactions, local injection site reactions, urticarial lesions, and pityriasis rosea-like and morbilliform rashes were among the most common cutaneous adverse events. Dermatologists should be aware of these potential reactions to manage them properly, reassure patients, and encourage them to continue their vaccination.
ABSTRACT
Extrapulmonary symptoms such as cutaneous manifestations are increasingly being reported in coronavirus disease 2019 (COVID-19) infection. The rashes of COVID-19 are usually livedo and purpuric and have been classified into six main patterns. This is the first case reported in Malaysia of ecchymosis associated with COVID-19 occurring on a patient without prior history of coagulopathy. The report of this rare clinical association could have a potential pathophysiological implication and contributes to the current data of the cutaneous manifestations of COVID-19. Further knowledge regarding these cutaneous lesions could help in the diagnosis of COVID-19 related complications and earlier management.
ABSTRACT
With dermatologic side effects being fairly prevalent following vaccination against COVID-19, and the multitude of studies aiming to report and analyze these adverse events, the need for an extensive investigation on previous studies seemed urgent, in order to provide a thorough body of information about these post-COVID-19 immunization mucocutaneous reactions. To achieve this goal, a comprehensive electronic search was performed through the international databases including Medline (PubMed), Scopus, Cochrane, Web of science, and Google scholar on July 12, 2021, and all articles regarding mucocutaneous manifestations and considerations after COVID-19 vaccine administration were retrieved using the following keywords: COVID-19 vaccine, dermatology considerations and mucocutaneous manifestations. A total of 917 records were retrieved and a final number of 180 articles were included in data extraction. Mild, moderate, severe and potentially life-threatening adverse events have been reported following immunization with COVID vaccines, through case reports, case series, observational studies, randomized clinical trials, and further recommendations and consensus position papers regarding vaccination. In this systematic review, we categorized these results in detail into five elaborate tables, making what we believe to be an extensively informative, unprecedented set of data on this topic. Based on our findings, in the viewpoint of the pros and cons of vaccination, mucocutaneous adverse events were mostly non-significant, self-limiting reactions, and for the more uncommon moderate to severe reactions, guidelines and consensus position papers could be of great importance to provide those at higher risks and those with specific worries of flare-ups or inefficient immunization, with sufficient recommendations to safely schedule their vaccine doses, or avoid vaccination if they have the discussed contra-indications.