RESUMEN
Introduction: During the Covid-19 pandemic, 540,895 people were identified as immunosuppressed and believed to be at increased risk of severe disease.1 As the pandemic evolved, biologic immunosuppression became a treatment of severe Covid-19.2 The true impact of immunosuppression on disease severity remains unclear. Objective(s): 1. Identify the incidence of immunosuppressed patients admitted to the ICU. 2. Analyse the mortality of those who are immunocompetent and immunosuppressed. 3. Examine the differences in mortality and level of care required between sub groups of patients on immunosuppression;those on biologics, non-biologics, and a combination of both. Method(s): A retrospective search of all Covid-19 positive admissions from March 2020 to November 2021 across two adult ICUs at Chelsea & Westminster NHS Trust was performed, using the EPR system. We identified those on immunosuppressive drugs, the level of care they required, and 28 day mortality. We categorised different types of immunosuppression, vaccination status, if applicable and co-morbidities. The exclusion criteria were primarily those with false positive swabs or incomplete data. Result(s): Baseline characteristics were median age (56 vs 56), and APCHE II score (20.08 in the immunosuppressed group vs 14.0 in immunocompetent). Thirteen immunosuppressed patients were identified. Reasons for drug immunosuppression in this group included solid organ transplant (6/13), and autoimmune conditions (7/13). Two patients were on biologic drugs alone, 8 were on non-biologics, and 3 were on a combination. Four of this group had received at least 2 doses of a Covid-19 vaccine. Mortality was 61.54% (8/13) in the immunosuppressed group vs 36.65% (199/543) in the immunocompetent group. Conclusion(s): Despite similar demographics, patients on immunosuppression had a significantly higher mortality than the immunocompetent group. Interestingly, those on targeted biological immunosuppression had the lowest incidence of requiring level 3 care, and no deaths. It is a possibility that biologics dampen the hyper-inflammation seen in severe Covid-19 pneumonitis, raising the question of a possible protective benefit from severe disease. This reflects the findings of the REMAP-CAP investigators,3 who showed that the IL-6 inhibiting biologics Tocilizumab and Sarilumab are efficacious against the most severe disease following admission to ICU with Covid-19 pneumonitis. The single centre and retrospective observational design, combined with small numbers on immunosuppression, despite a large inclusion criterion, mean it is not possible to make statistical conclusions. Confounding factors include the effects of vaccination, shielding and the change in SARS-CoV-2 variant prevalent during different times during the pandemic.
RESUMEN
Doctors from various specialties across the world are faced with the management of coronavirus disease 2019 (COVID-19). The typical presentation is one of viral pneumonia, with a large spectrum of disease severity. Increasingly, extra-pulmonary manifestations are being reported, often in those with significant pulmonary pathology. Here we discuss a novel presentation of COVID-19, with no pulmonary involvement and the challenges faced by clinicians in achieving the correct diagnosis. A previously fit and well 30-year-old female presented with gastroenteritis, pyrexias, myalgia, rashes, conjunctivitis, and myocarditis. There were no respiratory features, either from her history or clinical examination. Initial and subsequent reverse transcription polymerase chain reaction (RT-PCR) swabs were negative for severe acute respiratory failure coronavirus 2 (SARS-CoV-2), alongside normal appearances of her lungs on computed tomography scans. Her third and final COVID-19 RT-PCR swab was positive, just prior to transfer for her ongoing myocarditis management, at a specialist cardiac critical care. She went on to make a full recovery. Novel presentations of COVID-19 signify a new challenge to clinicians. Correct diagnosis is important for the patient, as well as staff safety. Atypical presentations often have non-specific clinical features, and so a strong index of suspicion, appropriate exclusion of differentials and a multi-disciplinary approach are needed. © Journal of Emergency and Critical Care Medicine. All rights reserved.