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1.
Blood Purif ; 50(3): 290-297, 2021.
Article in English | MEDLINE | ID: covidwho-1533118

ABSTRACT

The principles and use of plasmapheresis are often little understood by intensivists. We propose to review the principles, the main indications, and the methods of using this technique.


Subject(s)
Critical Care/methods , Plasma Exchange/methods , Animals , Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis/therapy , COVID-19/therapy , Equipment Design , Guillain-Barre Syndrome/therapy , Humans , Liver Failure, Acute/therapy , Membranes, Artificial , Plasma Exchange/instrumentation , Purpura, Thrombotic Thrombocytopenic/therapy
2.
Neurologist ; 26(5): 196-224, 2021 Sep 07.
Article in English | MEDLINE | ID: covidwho-1398198

ABSTRACT

BACKGROUND: Central nervous system complications are reported in an increasing number of patients with Coronavirus Disease 2019 (COVID-19). COVID-19-related Guillain-Barré syndrome (GBS) is of particular importance given its association with higher mortality rates and prolonged respiratory failure. REVIEW SUMMARY: We conducted a systematic review of published cases for COVID-19-related GBS, and provide a summary of clinical management strategies for these cases. Sixty-three studies, including 86 patients, were included. Seventy-six cases with reported outcome data were eligible for the outcome analysis. Ninety-nine percent of patients were diagnosed with COVID-19 before diagnosis of GBS (median: 14 d prior, interquartile range: 7 to 20). Intravenous immunotherapy (intravenous immunoglobulin: 0.4 g/kg/d for 5 d) was the most frequently used treatment approach. The review indicated that the outcome was not favorable in 26% of cases (persistent neurological deficits). A mortality rate of 3.5% was observed in patients with COVID-19-related GBS. CONCLUSIONS: Although evidence to support specific treatments is lacking, clinicians should consider the benefits of immunotherapy and plasma exchange in addition to the standard antimicrobial and supportive therapies for patients who meet the diagnostic criteria for acute sensory and motor polyradiculoneuritis. Intravenous immunoglobulin treatment alone is not shown to result in improved outcomes or mortality. More extensive studies aimed at exploring the neurological manifestations and complications of COVID-19 and distinctive treatment options for COVID-19-related GBS are warranted.


Subject(s)
COVID-19/drug therapy , Guillain-Barre Syndrome/drug therapy , Immunoglobulins, Intravenous/therapeutic use , SARS-CoV-2/drug effects , Thyroid Neoplasms/drug therapy , Guillain-Barre Syndrome/diagnosis , Humans , Plasma Exchange/methods , Plasmapheresis/adverse effects , Plasmapheresis/methods
3.
Clin Neurol Neurosurg ; 207: 106775, 2021 08.
Article in English | MEDLINE | ID: covidwho-1338371

ABSTRACT

Post-infectious/immune mediated effects of COVID-19 infection include descriptions of Guillain-Barré syndrome (GBS) in patients usually with respiratory failure and after 1-2 weeks from the onset of viral illness. Asymptomatic cases for COVID-19 infection were rarely described. Herein, we studied a 62-year-old patient with progressive weakness of lower extremities, rapidly evolving to a severe, flaccid tetraplegia and dysphagia. Neurological symptoms weren't preceded by fever or pulmonary symptoms. Because of laboratory test abnormalities (thrombocytopenia, lymphocytopenia, high inflammation indexes), the patient underwent to nasopharyngeal swab, resulted positive for SARS-CoV-2 on RT-PCR assay; cerebrospinal fluid (CSF) was negative for SARS-CoV-2. The clinical (severe symmetric distal upper and lower limbs weakness, grade 0/5; decreased proprioceptive sensitivity and hypoesthesia involving the four limbs; loss of deep tendon reflexes), electrophysiological (prevailing axonal polyradiculoneuritis) and CSF features (albumino-cytological dissociation) disclosed the GBS diagnosis (level 1 of diagnostic certainty according to the Brighton criteria). The patient received plasma exchange and immunoglobulin, and, at 4 weeks after treatment and physical therapy, the patient had moderate improvement (weakness at lower and upper extremities was grade 2/5 and 3/5, respectively). Neurologists and clinicians should be aware of the possible link between neurological symptoms and COVID-19 infection, not only after viral prodrome and pulmonary symptoms, but also without COVID-19 symptoms.


Subject(s)
COVID-19/complications , COVID-19/diagnostic imaging , Guillain-Barre Syndrome/diagnostic imaging , Guillain-Barre Syndrome/etiology , COVID-19/therapy , Guillain-Barre Syndrome/therapy , Humans , Male , Middle Aged , Plasma Exchange/methods
4.
Transfus Apher Sci ; 60(4): 103174, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1251570

ABSTRACT

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is associated with high titers of immunoglobulin G class antibodies directed against the cationic platelet chemokine platelet factor 4 (PF4). These antibodies activate platelets via FcγIIa receptors. VITT closely resembles heparin-induced thrombocytopenia. Inflammation and tissue trauma substantially increase the risk for forming pathogenic PF4 antibodies. We therefore propose the use of therapeutic plasma exchange as rescue therapy in VITT to deplete antibodies plus factors promoting inflammation such as excess cytokines in the circulation as well as extracellular vesicles derived from activated platelets.


Subject(s)
COVID-19 Vaccines/adverse effects , Plasma Exchange , Platelet Factor 4/immunology , Purpura, Thrombotic Thrombocytopenic/therapy , Salvage Therapy , Albumins , Antibody Specificity , Anticoagulants , Autoantibodies/immunology , COVID-19 Vaccines/pharmacology , Citrates , Contraindications, Procedure , Cytokines/blood , Extracellular Vesicles , Humans , Immunoglobulin G/immunology , Inflammation , Plasma Exchange/adverse effects , Plasma Exchange/methods , Platelet Activation , Platelet Transfusion/adverse effects , Purpura, Thrombotic Thrombocytopenic/etiology , Purpura, Thrombotic Thrombocytopenic/immunology , Registries , Thrombocytopenia/etiology , Thrombosis/etiology
5.
Int J Antimicrob Agents ; 57(5): 106334, 2021 May.
Article in English | MEDLINE | ID: covidwho-1213262

ABSTRACT

Assessment of efficacy of therapeutic plasma exchange (TPE) following life-threatening COVID-19. This was an open-label, randomised clinical trial of ICU patients with life-threatening COVID-19 (positive RT-qPCR plus ARDS, sepsis, organ failure, hyperinflammation). Study was terminated after 87/120 patients enrolled. Standard treatment plus TPE (n = 43) versus standard treatment (n = 44), and stratified by PaO2/FiO2 ratio (>150 vs. ≤150), were compared. Primary outcomes were 35-day mortality and TPE safety. Secondary outcomes were association between TPE and mortality, improvement in SOFA score, change in inflammatory biomarkers, days on mechanical ventilation (MV), and ICU length of stay (LOS). Eighty-seven patients [median age 49 (IQR 34-63) years; 82.8% male] were randomised (44 standard care; 43 standard care plus TPE). Days on MV (P = 0.007) and ICU LOS (P = 0.02) were lower in the TPE group. 35-Day mortality was non-significantly lower in the TPE group (20.9% vs. 34.1%; Kaplan-Meier, P = 0.582). TPE was associated with increased lymphocytes and ADAMTS-13 activity and decreased serum lactate, lactate dehydrogenase, ferritin, d-dimers and interleukin-6. Multivariable regression analysis provided several predictors of 35-day mortality: PaO2/FiO2 ratio (HR, 0.98, 95% CI 0.96-1.00; P = 0.02]; ADAMTS-13 activity (HR, 0.89, 95% CI 0.82-0.98; P = 0.01); pulmonary embolism (HR, 3.57, 95% CI 1.43-8.92; P = 0.007). Post-hoc analysis revealed a significant reduction in SOFA score for TPE patients (P < 0.05). In critically-ill COVID-19 patients, addition of TPE to standard ICU therapy was associated with faster clinical recovery and no increased 35-day mortality.


Subject(s)
COVID-19/drug therapy , COVID-19/etiology , Plasma Exchange/methods , Adult , COVID-19/mortality , COVID-19/therapy , Critical Care , Critical Illness , Female , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Plasma Exchange/adverse effects , Treatment Outcome
6.
J Thromb Thrombolysis ; 52(2): 504-507, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1202813

ABSTRACT

Thrombotic thrombocytopenic purpura (TTP) which can cause significant mortality is a thrombotic microangiopathy due to deficiency of VWF cleaving protease ADAMTS13 and as per medical literature there are examples that TTP can be caused by COVID 19 infection. A 35 years old female after admission with right sided weakness and slurring of speech was found to be COVID positive and diagnosed as a case of TTP. Patient had absent ADAMTS13 level on day 1. Treatment was started with therapeutic plasma exchange (TPE) later injection Vincristine and Rituximab was given after 4th TPE as it was suspected as refractory case. Finally patient received 16 TPE procedures with cryo poor plasma as exchange fluid and gradually her platelet count started to maintain normal and she was discharged. Specific management and such association of this type of cases need to be studied more judiciously.


Subject(s)
ADAMTS13 Protein , COVID-19 , Purpura, Thrombotic Thrombocytopenic , Rituximab/administration & dosage , Vincristine/administration & dosage , ADAMTS13 Protein/blood , ADAMTS13 Protein/deficiency , Adult , Antineoplastic Agents/administration & dosage , COVID-19/blood , COVID-19/complications , COVID-19/diagnosis , Female , Humans , Immunologic Factors/administration & dosage , Plasma Exchange/methods , Platelet Count/methods , Purpura, Thrombotic Thrombocytopenic/blood , Purpura, Thrombotic Thrombocytopenic/diagnosis , Purpura, Thrombotic Thrombocytopenic/etiology , Purpura, Thrombotic Thrombocytopenic/therapy , SARS-CoV-2/isolation & purification , Treatment Outcome
7.
Ther Apher Dial ; 25(4): 390-400, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1197083

ABSTRACT

We retrospectively analyzed the characteristics and outcomes of five patients with COVID-19 who were received glucocorticoid (with or without pulse therapy) and therapeutic plasma exchange. The efficacy of the treatment was determined by whether the patient was able to be transferred from the COVID-19 exclusive ICU to the general ward. In comparing patients who received prednisolone pulse therapy (three cases) with those who did not (two cases), 2/3 (66%) and 0/2 (0%) patients could be discharged from the COVID-19 dedicated ICU, respectively. Among five patients who was performed plasma exchange, two elderly male patients who underwent plasma exchange as early as within 8 days of disease exacerbation survived and were able to be transferred to the general ward. This observational study indicates that plasma exchange in conjunction with methylprednisolone pulse therapy at the appropriate time may be an effective treatment for elderly patients with severe COVID-19.


Subject(s)
COVID-19/therapy , Glucocorticoids/therapeutic use , Plasma Exchange/methods , SARS-CoV-2 , Aged , Aged, 80 and over , Combined Modality Therapy , Fatal Outcome , Female , Humans , Male , Middle Aged , Retrospective Studies , Treatment Outcome
8.
Transfus Apher Sci ; 60(3): 103119, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1164555

ABSTRACT

This study aimed to evaluate the effectiveness and the role of therapeutic plasma exchange (TPE) in treatment of children with severe MIS-C. In addition, we assessed demographic data, clinical features, laboratory abnormalities, underlying conditions, treatments, and outcomes. Patients with severe MIS-C who were admitted to the pediatric intensive care unit (PICU) between September 01 and October 05, 2020 were included in this observational, descriptive, retrospective study. The data collected included the patients' demographic data, presenting symptoms, clinical features, laboratory parameters, diagnostic investigations, and medications. Of 27 children with MIS-C, 63 % were male. The median age of the patients was nine years. Intravenous immunoglobulin and corticosteroids were used for treatment in 100 % of the patients, anakinra in 51.8 %, vasopressors in 85.1 %, noninvasive mechanical ventilation in 25.9 %, and invasive mechanical ventilation in 18.5 %. Ten of the 27 patients (37 %) underwent TPE. In the patients who underwent TPE, the median PELOD score was 21 (IQR: 11-30.25) before TPE and 10 (IQR: 10-11) after TPE (p < 0.001). Moreover, their median left ventricular ejection fraction (LVEF) was 52 % (IQR: 49.25 %-55 %) before TPE and median LVEF was 66.5 (IQR: 58 %-68.5 %) after TPE (p = 0.012). The median number of TPE sessions was three (IQR: 2-4.75). The mortality rate of the patients with severe MIS-C admitted to the PICU was 7.4 %. We suggest that TPE should be considered as a therapeutic option in children with severe MIS-C. Early initiation of TPE followed by immunomodulatory therapy in critically ill children with MIS-C may help improve clinical and laboratory outcomes.


Subject(s)
Critical Illness/therapy , Multiple System Atrophy/therapy , Plasma Exchange/methods , Adolescent , Child , Female , Humans , Intensive Care Units, Pediatric , Male , Multiple System Atrophy/pathology
9.
Chest ; 159(3): e151-e154, 2021 03.
Article in English | MEDLINE | ID: covidwho-1108122

ABSTRACT

CASE PRESENTATION: A 64-year-old previously healthy man presented with 8 weeks of progressive dyspnea on exertion and cough. Prior to presentation, the patient was able to bicycle > 60 miles per week and work full-time in a home improvement store. He was up-to-date with age-appropriate cancer screening and immunizations, and home medications included famotidine for reflux and nonsteroidal antiinflammatories for osteoarthritis, both as-needed. He had no significant respiratory exposure, aside from previous work as an electrician. His symptoms began in mid-February 2020 amid the coronavirus disease 2019 pandemic, although he had no known exposure to the virus.


Subject(s)
COVID-19/diagnosis , Fructose-Bisphosphate Aldolase/blood , Glucocorticoids/administration & dosage , Lung/diagnostic imaging , Myositis , Plasma Exchange/methods , Rituximab/administration & dosage , Threonine-tRNA Ligase/immunology , Autoantibodies/blood , Diagnosis, Differential , Disease Progression , Humans , Immunosuppressive Agents/administration & dosage , Lung Diseases, Interstitial/diagnosis , Lung Diseases, Interstitial/physiopathology , Male , Middle Aged , Muscle Weakness/diagnosis , Muscle Weakness/etiology , Myositis/blood , Myositis/diagnosis , Myositis/physiopathology , Myositis/therapy , Oxygen Inhalation Therapy/methods , Prognosis , Treatment Outcome
10.
Transfus Apher Sci ; 60(3): 103107, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1104307

ABSTRACT

We report the case of a patient diagnosed with a clinical relapse of acquired immune-mediated thrombotic thrombocytopenic purpura (TTP) who was successfully treated with low-dose rituximab plus corticosteroids without the use of plasma exchange (PEx), which was unavailable at the time due to the COVID-19 pandemic. Rituximab 100 mg weekly for 4 weeks was administered, combined with 1 mg/kg of prednisone, obtaining a complete hematological response in 6 weeks. This case suggests that PEx may be unnecessary for a subset of patients with relapsed TTP who are clinically stable without significant end-organ damage. A brief literature review regarding TTP patients treated without plasma exchange is also included.


Subject(s)
COVID-19/epidemiology , Plasma Exchange/methods , Purpura, Thrombotic Thrombocytopenic/therapy , Adult , Female , Humans , Pandemics , SARS-CoV-2/isolation & purification , Young Adult
12.
J Neuroimmunol ; 353: 577521, 2021 04 15.
Article in English | MEDLINE | ID: covidwho-1091758

ABSTRACT

BACKGROUND: Serious neurological complications of SARS-CoV-2 are increasingly being recognized. CASE: We report a novel case of HHV6 myelitis with parainfectious MOG-IgG in the setting of COVID-19-induced lymphopenia and hypogammaglobulinemia. The patient experienced complete neurological recovery with gancyclovir, high dose corticosteroids, and plasma exchange. To our knowledge, this is the first case of HHV6 reactivation in the central nervous system in the setting of COVID19 infection and the first case of MOG-IgG myelitis in the setting of SARS-CoV-2 and HHV6 coinfection. CONCLUSION: Patients with neurological manifestations in the setting of COVID19-related immunodeficiency should be tested for opportunistic infections including HHV6. Viral infection is a known trigger for MOG-IgG and therefore this antibody should be checked in patients with SARS-CoV-2 associated demyelination.


Subject(s)
COVID-19/complications , Coinfection/complications , Lymphopenia/virology , Myelitis, Transverse/virology , Roseolovirus Infections/immunology , Anti-Inflammatory Agents/therapeutic use , Antiviral Agents/therapeutic use , Autoantibodies/immunology , Autoantigens/immunology , COVID-19/immunology , Coinfection/immunology , Ganciclovir/therapeutic use , Herpesvirus 6, Human , Humans , Male , Methylprednisolone/therapeutic use , Middle Aged , Myelitis, Transverse/immunology , Myelitis, Transverse/therapy , Plasma Exchange/methods , Roseolovirus Infections/drug therapy , SARS-CoV-2 , Virus Activation/immunology
13.
J Thromb Thrombolysis ; 52(2): 468-470, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1002138

ABSTRACT

Acquired thrombotic thrombocytopenic purpura (TTP) is an autoimmune disease that can be triggered by different events, including viral infections. It presents as thrombotic microangiopathy and can lead to severe complications that often require management in the intensive care unit (ICU). We report a patient who presented with acquired TTP following COVID-19 infection. A 44-year-old woman presented to the emergency department with severe anemia, acute kidney injury and respiratory failure due to COVID-19. Clinical and laboratory findings were suggestive for thrombotic microangiopathy. On day 8 laboratory tests confirmed the diagnosis of acquired TTP. The patient needed 14 plasma exchanges, treatment with steroids, rituximab and caplacizumab and 18 days of mechanical ventilation. She completely recovered and was discharged home on day 51. Acquired TTP can be triggered by different events leading to immune stimulation. COVID-19 has been associated with different inflammatory and auto-immune diseases. Considering the temporal sequence and the lack of other possible causes, we suggest that COVID-19 infection could have been the triggering factor in the development of TTP. Since other similar cases have already been described, possible association between COVID and TTP deserves further investigation.


Subject(s)
COVID-19 , Plasma Exchange/methods , Purpura, Thrombotic Thrombocytopenic , Respiration, Artificial/methods , Respiratory Insufficiency , Rituximab/administration & dosage , Single-Domain Antibodies/administration & dosage , Acute Kidney Injury/diagnosis , Acute Kidney Injury/etiology , Adult , COVID-19/complications , COVID-19/immunology , COVID-19/physiopathology , COVID-19/therapy , Female , Fibrinolytic Agents/administration & dosage , Humans , Immunologic Factors/administration & dosage , Male , Purpura, Thrombotic Thrombocytopenic/blood , Purpura, Thrombotic Thrombocytopenic/etiology , Purpura, Thrombotic Thrombocytopenic/physiopathology , Purpura, Thrombotic Thrombocytopenic/therapy , Respiratory Insufficiency/diagnosis , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , SARS-CoV-2/isolation & purification , SARS-CoV-2/pathogenicity , Thrombotic Microangiopathies/diagnosis , Thrombotic Microangiopathies/etiology , Treatment Outcome
15.
BMJ Case Rep ; 13(12)2020 Dec 17.
Article in English | MEDLINE | ID: covidwho-991776

ABSTRACT

We present the case of a 39-year-old man with epigastric pain, nausea and vomiting. The patient scored 4 in the Visual Triage Checklist of acute respiratory symptoms; a COVID-19 swab was taken. Prompt review of the peripheral blood smear showed evidence of microangiopathic haemolytic anaemia and thrombocytopenia. Because the patient had a picture of thrombotic thrombocytopenic purpura, plasma exchange and corticosteroids were started immediately. After 3 days, he developed severe ischaemic stroke and his swabs came back positive for COVID-19 by reverse transcription PCR. Therefore, triple therapy was started (lopinavir/ritonavir, ribavirin and interferon beta-1b). White blood cell count reached 50×109/L (normal range, 4.5-11×109/L), mainly neutrophils. All the workup for autoimmune diseases was negative. The patient showed delayed improvement in lactate dehydrogenase, haemoglobin and platelet count until we increased the volume of plasma exchange and subsided the inflammatory response of COVID-19. After that, the patient showed an excellent recovery.


Subject(s)
COVID-19/diagnosis , Ischemic Stroke/diagnosis , Purpura, Thrombotic Thrombocytopenic/diagnosis , Adult , COVID-19/complications , COVID-19/drug therapy , Drug Combinations , Humans , Interferon-beta/therapeutic use , Ischemic Stroke/etiology , Lopinavir/therapeutic use , Male , Plasma Exchange/methods , Purpura, Thrombotic Thrombocytopenic/etiology , Ritonavir/therapeutic use , SARS-CoV-2
16.
Int J Antimicrob Agents ; 57(2): 106273, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-987983

ABSTRACT

COVID-19 (coronavirus disease 2019), caused by the novel coronavirus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), emerged in Wuhan, China, and has spread worldwide, resulting in over 73 million cases and more than 1 600 000 deaths as of December 2020. Although the disease is asymptomatic in most cases, some patients develop life-threatening disease characterised by acute respiratory distress syndrome, sepsis, multisystem organ failure (MSOF), extrapulmonary manifestations, thromboembolic disease and associated cytokine release syndrome. The rationale for applying therapeutic plasma exchange (TPE) early in the course of fulminant COVID-19 is the suppression of thromboinflammation and amelioration of microangiopathy, thus preventing the ensuing MSOF. In the course of complicated critical illness due to COVID-19, immune dysregulation may be as important as viral replication itself. Moreover, the natural course of SARS-CoV-2 infection remains obscure, as re-infections and/or recurrently positive real-time PCR results have been reported. Although concerns still exist regarding its potential immunosuppressive effects and safety, TPE shows promise in the management of life-threatening COVID-19 as documented by various pilot studies, which remain to be confirmed by future randomised controlled trials. However, current data suggest that TPE could be an adjunctive rescue therapy in complex COVID-19 critical illness.


Subject(s)
COVID-19/drug therapy , Cytokine Release Syndrome/therapy , Plasma Exchange/methods , COVID-19/etiology , COVID-19/mortality , COVID-19/therapy , Critical Illness , Cytokine Release Syndrome/etiology , Cytokine Release Syndrome/virology , Hospital Mortality , Humans , Intensive Care Units , Respiration, Artificial
17.
Blood Purif ; 50(4-5): 513-519, 2021.
Article in English | MEDLINE | ID: covidwho-975762

ABSTRACT

BACKGROUND: In December 2019, pneumonia associated with COVID-19 has spread from Wuhan to other areas in China. In the present study, we aimed to further clarify the clinical features and outcomes of acute kidney injury (AKI) in patients infected with COVID-19 in Xiangyang, Hubei, China. METHODS: All confirmed cases of COVID-19 with AKI in Xiangyang Central Hospital from January 22 to May 31, 2020, were included in this retrospective study. Data of epidemiological, clinical, laboratory, radiological tests, treatment, complication, and outcomes were collected and analyzed. Patients were divided into intensive care unit (ICU) group and isolation ward (non-ICU) group. RESULTS: Of the total patients, 33.3% in the non-ICU group and 85.7% in the ICU group had chronic diseases. In addition, 85.7% of patients in the ICU group died. The most common symptoms were fever, cough, and fatigue. The lymphocyte count in the ICU group was significantly reduced compared with the non-ICU group. The chest computed tomography (CT) images appeared showed multiple mottles and ground-glass opacity. Strip shadow could be found in chest CT images of some recovered patients. All patients received antiviral treatment. Most patients in the ICU group were given methylprednisolone, immunoglobulin, antibiotics, and mechanical ventilation and 35.7% of patients in the ICU group received continuous renal replacement therapy. CONCLUSIONS: Elderly with chronic comorbidities were more susceptible to COVID-19, showing a higher mortality rate due to multiple organ damage, and 35.7% of patients with AKI in ICU received renal replacement therapy. Moreover, part of the cured patients might need additional time to recover for poor lung function.


Subject(s)
Acute Kidney Injury/epidemiology , COVID-19/complications , Hospital Mortality , SARS-CoV-2 , Acute Kidney Injury/etiology , Acute Kidney Injury/therapy , Adult , Aged , Antiviral Agents/therapeutic use , COVID-19/blood , COVID-19/diagnostic imaging , COVID-19/drug therapy , COVID-19/therapy , Cardiovascular Agents/therapeutic use , Cardiovascular Diseases/drug therapy , Cardiovascular Diseases/epidemiology , China/epidemiology , Chronic Disease/mortality , Comorbidity , Female , Hospitals, Urban/statistics & numerical data , Humans , Immunization, Passive , Intensive Care Units/statistics & numerical data , Lymphocyte Count , Male , Middle Aged , Multiple Organ Failure/etiology , Multiple Organ Failure/mortality , Plasma Exchange/methods , Plasma Exchange/statistics & numerical data , Renal Dialysis/methods , Renal Dialysis/statistics & numerical data , Renal Insufficiency, Chronic/complications , Respiration, Artificial/adverse effects , Respiration, Artificial/statistics & numerical data , Retrospective Studies , Symptom Assessment , Tomography, X-Ray Computed
18.
Respir Med ; 175: 106188, 2020 12.
Article in English | MEDLINE | ID: covidwho-912592

ABSTRACT

OBJECTIVES: Cytokine release syndrome (CRS) is a potentially severe complication of COVID-19 most commonly resulting in respiratory failure. This ten-patient study was designed to determine the efficacy of therapeutic plasma exchange (TPE) in improving oxygenation and in reducing the cytokine load in a critically ill subset of patients. METHODS: Five single volume plasma exchanges over eight days within a 14-day study period. In mechanically ventilated patients, oxygenation was measured via the PaO2/FiO2 (P/F) ratio and the oxygenation index (OI) daily for 14 days. Supplemental oxygen requirements were tracked daily for non-ventilated patients. RESULTS: Non-ventilated patients were liberated from supplemental oxygen after TPE. The response was rapid with an 87% average reduction in oxygenation requirements following and average time to return to room air of 5.25 days. All mechanically ventilated patients demonstrated improvement in oxygenation with a 78% average improvement in the P/F ratio and a 43% improvement in OI. C-reactive protein (CRP) and serum levels of IL-6, IL-8, IL-10, TNFα, IFNγ and GM-CSF, were measured daily with immediate post TPE levels drawn on days 1, 2, 4, 6 and 8. All patients demonstrated significant reductions in CRP, IL-6, IL-10 and TNFα. CONCLUSIONS: In the majority of patients with Penn class 3 and 4 CRS complicating COVID-19, TPE demonstrated a prompt improvement in oxygenation and reduction in cytokine load without compromising patient safety. As this pilot study was envisioned to be hypothesis generating, expanded trials using TPE alone and in conjunction with novel pharmacologic agents are warranted. REGISTRATION: ClinicalTrials.gov NCT04374149.


Subject(s)
COVID-19/complications , Cytokine Release Syndrome/therapy , Plasma Exchange/methods , SARS-CoV-2/genetics , Adult , COVID-19/epidemiology , COVID-19/metabolism , COVID-19/virology , Critical Illness/therapy , Cytokine Release Syndrome/classification , Cytokine Release Syndrome/etiology , Female , Humans , Male , Middle Aged , Oxygen Inhalation Therapy/methods , Pilot Projects , Prospective Studies , Respiration, Artificial/methods , Respiration, Artificial/statistics & numerical data , Respiratory Insufficiency/therapy , Severity of Illness Index
19.
J Investig Med High Impact Case Rep ; 8: 2324709620961198, 2020.
Article in English | MEDLINE | ID: covidwho-805892

ABSTRACT

A novel member of human RNA coronavirus, which is an enveloped betacoronavirus, has been termed severe acute respiratory syndrome coronavirus-2 (SARS COV-2). The illness caused by SARS COV-2 is referred to as the coronavirus disease 2019 (COVID-19). It is a highly contagious disease that has resulted in a global pandemic. The clinical spectrum of COVID-19 ranges from asymptomatic illness to acute respiratory distress syndrome, septic shock, multi-organ dysfunction, and death. The most common symptoms include fever, fatigue, dry cough, dyspnea, and diarrhea. Neurological manifestations have also been reported. However, the data on the association of Guillain-Barré syndrome (GBS) with COVID-19 are scarce. We report a rare case of a COVID-19-positive 36-year-old immunocompromised male who presented with clinical features of GBS. His clinical examination showed generalized weakness and hyporeflexia. The cerebrospinal fluid (CSF) analysis showed albuminocytological dissociation. Intravenous immunoglobulin (IVIG) was administered based on the high clinical suspicion of GBS. The patient's neurological condition worsened with progression to bulbar weakness and ultimately neuromuscular respiratory failure requiring mechanical ventilation. His nerve conduction studies were consistent with demyelinating polyneuropathy. He received five plasma exchange treatments and was successfully weaned from mechanical ventilation. A brain and cervical spine magnetic resonance imaging was obtained to rule out other causes, which was normal. COVID-19 is believed to cause a dysregulated immune system, which likely plays an important role in the neuropathogenesis of GBS.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Guillain-Barre Syndrome/etiology , Pneumonia, Viral/complications , Adult , Brain/diagnostic imaging , COVID-19 , Coronavirus Infections/diagnosis , Coronavirus Infections/epidemiology , Diagnosis, Differential , Guillain-Barre Syndrome/diagnosis , Guillain-Barre Syndrome/therapy , Humans , Magnetic Resonance Imaging , Male , Pandemics , Plasma Exchange/methods , Pneumonia, Viral/diagnosis , Pneumonia, Viral/epidemiology , SARS-CoV-2
20.
J Clin Apher ; 35(5): 483-487, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-801272

ABSTRACT

Clinically amyopathic dermatomyositis (CADM) is a rare, aggressive variant of dermatomyositis associated with interstitial lung disease (ILD) and refractoriness to immunosuppressants. Antibodies against melanoma differentiation-associated gene 5 (MDA-5) are often found in patients with CADM. We report a patient with advanced CADM with ILD and MDA-5 antibodies who failed to improve with immunosuppressants. We performed 2 TPE over 3 days, using 5% albumin as replacement fluid. Although five total TPE were planned, he was transferred for lung transplant evaluation after the second TPE; he died 16 days after transfer without receiving a transplant. A literature review identified four patients with CADM and MDA-5 antibodies treated with TPE; all experienced symptomatic improvement of their ILD. We attribute our patient's outcome to the advanced nature of his disease rather than a failure of TPE. Additional research may indicate a possible reclassification of CADM with MDA-5 antibodies in future ASFA guidelines.


Subject(s)
Autoantibodies/blood , Dermatomyositis/therapy , Interferon-Induced Helicase, IFIH1/immunology , Plasma Exchange/methods , Dermatomyositis/immunology , Humans , Male , Middle Aged
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