Personalized approach to the management of a patient with COVID-19 with a complicated comorbid background

The aim of the work is to form the principles of a personalized approach to the management of patients with COVID-19 with a complicated comorbid background. Material and methods. The article describes a clinical case of successful recovery of an 87-year-old patient from a new coronavirus infection COVID-19, complicated by pneumonia involving 36% of the lung parenchyma area. Along with age, the situation was aggravated by the comorbid status of the patient: the presence of chronic lymphocytic leukemia, hypertension, mechanical prostheses of the mitral and aortic valves, postinfarction cardiosclerosis, paroxysmal atrial fibrillation, type 2 diabetes mellitus, stage 4 CKD, anemic syndrome, and subclinical hypothyroidism. Results. The C-reactive protein level at admission was 114.46 mg/L. The patient refused hospitalization. Baricitinib 4 mg, favipiravir according to the scheme, vitamin D 2000 units were prescribed for the previously taken therapy. Already after 3 days, C-reactive protein decreased by 4.6 times, and by the 8th day by 15.5 times and amounted to 7.38 mg/ml. The temperature returned to normal on day 2 from the start of baricitinib. In dynamics, a decrease in creatinine level to 177.0 mumol/l was noted, the glomerular filtration rate increased to 30 ml/min/1.73 m2, which corresponded to stage 3b of CKD (a pronounced decrease in glomerular filtration rate). Conclusion. Despite the age of the patient, many comorbidities, each of which could be fatal, the timely use of baricitinib on an outpatient basis made it possible to stop the progressive course of the disease.Copyright © Eco-Vector, 2023. All rights reserved.

ECHO, ECHO AGAIN: PROSTHETIC MITRAL REGURGITATION PRESENTING AS B-TYPE SYMPTOMS

Background: Prosthetic valve dehiscence is a manifestation of endocarditis which may be difficult to diagnose based on imaging. Case: A 68-year-old female with mechanical mitral valve replacement (MVR) complicated by recurrent endocarditis requiring two redo MVR presented with subacute chills, nausea, fatigue and dyspnea. Evaluation revealed leukocytosis, elevated NT-proBNP, acute kidney injury, negative blood cultures, and negative SARS-CoV2. Transthoracic echocardiography (TTE) showed normal prosthetic valve function. She was managed for acute decompensated heart failure and placed on empiric antibiotics. She continued to have chills, night sweats and developed hypotension. Blood cultures remained negative, and no source of infection was identified on imaging. Decision-making: To aid in differentiation shock, patient underwent right heart catheterization. This revealed severe cardiogenic shock, with cardiac index of 1.3 L/min/m2. Repeat TTE demonstrated dehiscence of the prosthetic mitral valve, which was confirmed on transesophageal echocardiogram (Figure 1). An intra-aortic balloon pump was placed, and inotropic support provided. Patient underwent successful redo MVR using a bioprosthetic valve. Tissue microbiology was positive for coagulase negative staph. Conclusion: Unmasking the etiology of vague clinical presentations may pose a challenge. Our case highlights the importance of a high index of suspicion and serial imaging when patients present with B-type symptoms. [Formula presented]

Thrombosis of Mechanical Mitral Valve Prosthesis Treated With Fibrinolysis

Background: Mechanical prosthetic valve thrombosis is an uncommon but serious complication associated with high mortality and morbidity. Conventionally, prosthetic valve thrombosis is treated with surgical intervention, but recent literature has shown that slow-infusion of low-dose fibrinolytic therapy could be of equal efficacy. Case: A 27-year-old lady presented to the emergency department with a three-week history of worsening shortness of breath on background of mechanical mitral valve replacement for rheumatic mitral stenosis. She had recently been non-compliant with international normalised ratio (INR) checks for warfarin dosing in the setting of local lockdown for the COVID-19 pandemic. Transthoracic echocardiography revealed mechanical mitral valve thrombosis resulting in an immobile medial disc and severely restricted lateral disc, associated with severely elevated mitral inflow gradient (mean 42mmHg at 98 beats per minute) and severe pulmonary hypertension (right ventricular systolic pressure of 92mmHg). After discussion in a multidisciplinary cardiology and cardiothoracic surgical conference, the patient was treated with three daily doses of slow-infusion low-dose fibrinolytic therapy (25mg alteplase over six hours). On day three, there was complete resolution of symptoms, associated with resolution of valve thrombosis on repeat echocardiography. There were no bleeding or embolic complications, and the patient was discharged home three days later. Conclusions: This case highlights the utility of slow-infusion low-dose fibrinolytic therapy in the management of mechanical prosthetic valve thrombosis. This conservative approach may be a useful alternative in patients with high pre-operative surgical risk.