Patient: Male, 19-year-old Final Diagnosis: COVID-19 Symptoms: Cough • diarrhea • fever • shortness of breath Medication: — Clinical Procedure: — Specialty: Immunology • Infectious Diseases • Pulmonology Objective: Rare co-existance of disease or pathology Background: Since the emergence of coronavirus disease 2019 (COVID-19), patients with the illness have presented with considerable variation in severity. Some infected individuals present mild or no symptoms, while others present severe illness with some fatal outcomes. Multiple lines of management have been suggested for critically ill patients, such as intravenous immunoglobulin (IVIG) and steroids. IVIG is the main treatment for patients with X-linked agammaglobulinemia. Multiple studies have reported that these patients have excellent outcomes when they contract COVID-19. This report describes the clinical course of COVID-19 pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a 19-year-old man on IVIG replacement therapy for X-linked agammaglobulinemia (XLA). Case Report: A patient with XLA receiving a monthly dose of IVIG and having bronchiectasis managed by prophylactic azithromycin presented with fever, shortness of breath, productive cough, and diarrhea. He was admitted to our hospital with SARS-CoV-2 infection. His treatment course for COVID-19 was uncomplicated and had excellent results. He completed a 10-day course of piperacillin/tazobactam and his symptoms resolved 3 days after admission, without complications, oxygen supplementation, or intensive care unit admission. Conclusions: Patients with XLA have weakened immunity and therefore may present with an infection as a first symptom. This report describes the mild course of COVID-19 pneumonia in an immunologically vulnerable patient with XLA who presented with SARS-CoV-2 infection while undergoing IVIG replacement therapy. Currently, IVIG is one of many supportive immune therapies undergoing clinical evaluation in patients with severe COVID-19.
Facial skeletal changes associated with hyperparathyroidism assume three radiographic patterns: osteitis fibrosa cystica, fibrous dysplasia, and leontiasis ossea. The 3rd pattern is unique to renal osteodystrophy. Renal osteodystrophy frequently affects the spine, ribs, long bones, and skull. Findings of renal osteodystrophy in facial and cranial bones are rare. However, it's most severe osseous complication is characterized by massive thickening of the cranial vault and facial bones, called uremic leontiasis ossea (ULO), with only few cases reported in the literature. The uremic leontiasis ossea causes significant aesthetic and functional changes. It is important to recognize features of leontiasis ossea, as it may result in life threatening upper airway obstruction and compressive cranial neuropathy while after parathyroidectomy, facial changes can be stabilized or improved mildly. We report a case of uremic leontiasis ossea with a history of gradual enlargement of the facial bones over a period of one year. Significant hypertrophy of the maxilla and clavarial bone is most significant CT finding with serpiginous tunneling within the bone and poor visualization of the cortical bone. Nuclear medicine scans are also useful for demonstrating parathyroid adenoma. Ultimately, the diagnosis of uremic leontiasis ossea can be made non-invasively through a combination of clinical parameters and imaging findings, as described in this article.
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