Not Feeling Swell: Superior Vena Cava (SVC) Syndrome Falsely Attributed to COVID-19 Vaccine Reaction.

BACKGROUND: The mass immunization campaign against Coronavirus disease 2019 (COVID-19) has resulted in more patients presenting to the emergency department (ED) with concern for a vaccine reaction. CASE REPORT: A 68-year-old man presented to the ED reporting an allergic reaction to the COVID-19 vaccine. He initially noted swelling of his face, neck, and right arm after receiving the first dose of the vaccine. After his second dose of the vaccine, the swelling became more pronounced and prompted him to seek care. On examination, he had fullness of the neck and engorgement of the left external jugular vein, which were exacerbated when the patient raised his arms above his head, consistent with Pemberton's sign. Apart from the swelling of the head and neck, there were no other findings consistent with an allergic reaction. The presence of Pemberton's sign prompted a computed tomography scan of the chest with contrast, which revealed a paratracheal mass measuring 4.5 × 2.0 cm with marked narrowing of the superior vena cava (SVC). The patient was admitted to the hospital for SVC syndrome, and further workup revealed a non-small cell lung cancer. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients may misattribute their symptoms to a COVID vaccine reaction when they are, in fact, experiencing a more serious underlying disease. This case highlights the importance of a thorough physical examination and maintaining a broad differential diagnosis. In this case, the presence of Pemberton's sign raised suspicion for SVC syndrome, and prompted further workup.

A case of an adolescent with antiphospholipid syndrome and persistently high PF4 levels with recurrent late thrombotic complications after mRNA SARS-CoV-2 vaccine (preprint)

Background: Anti-phospholipid syndrome (APS) is an autoimmune disease causing arteriovenous thrombosis in the presence of antiphospholipid antibodies. Pediatric APS develops at less than 18 years of age. Various factors exacerbate pediatric APS. Herein, we report a case of a patient with pediatric APS who developed deep vein thrombosis (DVT) 6 months after second vaccination due to persistent platelet activation caused by exacerbation of APS after administration of the BNT162b2 vaccine. Case presentation: A 17-year-old female developed DVT at the age of 6 years. She had no family history of thrombophilia. The thrombus was found in the right common iliac vein to the inferior vena cava, with concomitant left pulmonary infarction. After treatment with warfarin, the pulmonary infarction resolved, but the thrombus from the right common iliac vein to the inferior vena cava became organized and remained until now. The patient was treated with anticoagulants for 6 years after the onset of DVT and then without treatment for 5 years without recurrence of thrombosis. The first dose of the BNT162b2 vaccine was administered 1 week before a routine outpatient visit. However, PF4 levels were elevated after vaccination and even after 5 months, but without thrombotic symptoms. A second dose of the BNT162b2 vaccine was administered; 6 months later, the patient developed recurrent deep vein thromboembolism in the right common iliac vein and was treated with direct oral anticoagulants. Conclusions: : The persistence of high PF4 levels after vaccination in a patient with DVT may indicate an association between the vaccine and DVT due to the exacerbation of APS by the BNT162b2 vaccine. After vaccination of patients with a predisposition to thrombosis, the state of coagulation, including platelet activation markers, should be monitored to prevent the development of DVT.

Assessment of Pulmonary Artery Diameters in Pediatric COVID-19 Patients (preprint)

ABSTRACT Background: This study was conducted to investigate the relationship between clinical course and pulmonary artery (PA) diameters in children diagnosed with COVID-19. Method: The study included 62 patients who presented COVID-19 symptoms between March 2020 and April 2021. Group 1 consisted of 32 pediatric patients who were COVID-19 PCR (+), while Group 2 consisted of 30 pediatric patients who were COVID-19 PCR(-). The data were collected retrospectively from medical records. Patients who developed pneumonia due to causes other than COVID-19 and those who had a history of pulmonary hypertension or pulmonary thromboembolism were excluded. The patients were examined based on their Computerized Tomographic (CT) findings, simultaneous whole blood parameters and biochemical parameters. Results: The thoracic CT findings of 18 of the patients in Group 1 were found normal. The CT images of 14 patients showed pulmonary involvement. Among the patients with pulmonary involvement, 8 had moderate pneumonia characterized by a ground-glass pattern, and 6 had severe pneumonia indicated by consolidation and linear opacities. The right pulmonary artery, left pulmonary artery and inferior vena cava (IVC) diameters of the patients in Group 1 were significantly higher than those of the patients in Group 2. Conclusion: The results of this study suggested that increased PA diameters in children diagnosed with COVID-19 may be accompanied by increased inflammation, high vascular resistance, hypoxemia and thromboembolic events. While it is thought that increased PA and IVC diameters are a factor that may indicate clinical deterioration in COVID-19 patients, more comprehensive studies are needed.

Radiation treatment of hemato-oncological patients in times of the COVID-19 pandemic : Expert recommendations from the radiation oncology panels of the German Hodgkin Study Group and the German Lymphoma Alliance.

PURPOSE: The coronavirus pandemic is affecting global health systems, endangering daily patient care. Hemato-oncological patients are particularly vulnerable to infection, requiring decisive recommendations on treatment and triage. The aim of this survey amongst experts on radiation therapy (RT) for lymphoma and leukemia is to delineate typical clinical scenarios and to provide counsel for high-quality care. METHODS: A multi-item questionnaire containing multiple-choice and free-text questions was developed in a peer-reviewed process and sent to members of the radiation oncology panels of the German Hodgkin Study Group and the German Lymphoma Alliance. Answers were assessed online and analyzed centrally. RESULTS: Omission of RT was only considered in a minority of cases if alternative treatment options were available. Hypofractionated regimens and reduced dosages may be used for indolent lymphoma and fractures due to multiple myeloma. Overall, there was a tendency to shorten RT rather than to postpone or omit it. Even in case of critical resource shortage, panelists agreed to start emergency RT for typical indications (intracranial pressure, spinal compression, superior vena cava syndrome) within 24 h. Possible criteria to consider for patient triage are the availability of (systemic) options, the underlying disease dynamic, and the treatment rationale (curative/palliative). CONCLUSION: RT for hemato-oncological patients receives high-priority and should be maintained even in later stages of the pandemic. Hypofractionation and shortened treatment schedules are feasible options for well-defined constellations, but have to be discussed in the clinical context.

Superior vena cava syndrome during veno-venous extracorporeal membrane oxygenation for COVID-19.

Superior vena cava (SVC) syndrome is typically associated with malignant tumors obstructing the SVC, but as many as 40% of cases have other etiologies. SVC obstruction was previously described during veno-venous extracorporeal membrane oxygenation therapy (VV ECMO) in children. In this report, we describe a woman with adult respiratory distress syndrome resulting from infection with coronavirus-19 who developed SVC syndrome during VV ECMO. A dual-lumen ECMO cannula was inserted in the right internal jugular vein, but insufficient ECMO circuit flow, upper body edema, and signs of hypovolemic shock were observed. This clinical picture resolved when the right internal jugular vein was decannulated in favor of bilateral femoral venous cannulae. Our report demonstrates that timely recognition of clinical signs and symptoms led to the appropriate diagnosis of an uncommon ECMO complication.