ABSTRACT
A 36-year-old woman presented to hospital 9 days after receiving her first dose of the ChAdOx1 nCoV-19 vaccine with fever, myalgia and a sore throat. She was previously fit and well with no prior vaccine reactions.There was no clinical response to initial treatment with intravenous (IV) antibiotics. Microbiology tests including for COVID-19 were negative. At day 5, she developed pleuritic pain and a pericardial rub. Echocardiography and subsequent cardiac magnetic resonance imaging showed evidence of constrictive pericarditis. Computed tomography revealed gross hepatomegaly and moderate splenomegaly. Blood tests showed raised inflammatory markers, deranged clotting, low platelets and a marked hyperferritinaemia.A presumptive diagnosis of a multi-system inflammatory disorder secondary to recent COVID-19 vaccination was made and high-dose IV methylprednisolone initiated. Following a high 'H score' of 70%-80% a diagnosis of secondary haemophagocytic lymphohistiocytosis (HLH) was made. She was treated with IV immunoglobulin with subsequent clinical response.HLH is a rare syndrome of acute and rapidly progressive systemic inflammation characterised by cytopenias, excessive cytokine production and hyperferritinaemia. The adult form has multiple triggers, including recent vaccination. This case prompts awareness among clinicians of HLH as a rare complication of COVID-19 vaccination but should not discourage individuals from vaccination.
Subject(s)
COVID-19 , Lymphohistiocytosis, Hemophagocytic , Adult , COVID-19 Vaccines , ChAdOx1 nCoV-19 , Female , Humans , Lymphohistiocytosis, Hemophagocytic/diagnosis , Lymphohistiocytosis, Hemophagocytic/drug therapy , SARS-CoV-2 , VaccinationABSTRACT
We present an interesting case of a healthy 47-year-old woman who presented to the acute take with symptoms of visual apraxia, splinter haemorrhages and extreme fatigue. This was a diagnostic challenge with other unusual features to this case, which includes brain infarcts on MRI, raised troponin and oeosinophilia. Naturally endocarditis was the top differential but this was ruled out by serial negative blood cultures and a negative transthoracic echocardiogram. Several medical specialties were involved and the initial working diagnosis was ANCA vasculitis (oeosinophilic granulomatosis with polyangiitis). Early administration of intravenous steroids clouded our judgement further and sarcoidosis was not thought as a possible differential. We illustrate the immensely challenging and complicated clinical course involving multiple specialties and investigations. In the end, a complete steroid wean was required to reach an accurate histological diagnosis.
Subject(s)
Granulomatosis with Polyangiitis , Sarcoidosis , Brain Infarction/diagnostic imaging , Brain Infarction/etiology , Diagnosis, Differential , Female , Granulomatosis with Polyangiitis/diagnosis , Hemorrhage , Humans , Middle Aged , Sarcoidosis/complications , Sarcoidosis/diagnosis , Sarcoidosis/drug therapyABSTRACT
Cutaneous polyarteritis nodosa (CPAN) is a rare diagnosis which is distinct from polyarteritis nodosa (PAN). PAN is a medium-vessel vasculitis which can affect multiple organs and classically produces microaneurysms in the vasculature. CPAN is limited to the skin mainly affecting small vessels. There is an absence of microaneurysms in CPAN and it does not affect internal organs. However, the histopathological findings on the skin are similar to PAN. CPAN rarely progresses to PAN but relapses more often. We will illustrate a challenging case of a patient with CPAN who developed gangrenous infarcts despite initial immunosuppressive treatment with high-dose steroids and azathioprine. His treatment had to be escalated to intravenous cyclophosphamide which induced disease remission.
