COVID-19 has been declared a pandemic since March 2020 and it has been responsible for millions of deaths worldwide. The SARS-CoV-2 causes a spectrum of diseases mainly affecting the respiratory system. It can also complicate other systems causing thromboembolic phenomena and myocardial ischaemia. An entity of hypoxia has been described in these patients which show no clinical signs and symptoms of respiratory distress despite being extremely hypoxic. This is called silent or happy hypoxia. The exact mechanism for this is not known. We report 4 cases which had similar presentations of silent hypoxia but had different course of illness and different outcomes. All 4 patients did not show any signs of respiratory distress, but had oxygen saturation less than 82%. 3 of them needed intensive care unit support for oxygen therapy and subsequently needed noninvasive ventilation. Only one required invasive ventilation. The fourth patient did not require intensive care support. The patient who required invasive ventilation succumbed due to severe COVID pneumonia whereas the other 3 patients were discharged from the hospital. Silent hypoxemia can go undetected in COVID-19 patients particularly in the time of a pandemic. This case series highlights the importance of meticulous clinical examination including oxygen saturation measurements in suspected or confirmed patients with COVID-19. The course of illness can be different in different populations, and this needs further clinical evidence.
IntroductionAcquired haemophilia A is a rare life- and limb-threatening bleeding disorder if left untreated. Autoimmune thyroiditis is an autoimmune disorder that can be rarely associated with acquired haemophilia. Here we report a case of a 60-year-old woman presenting with cutaneous and muscle haematomas secondary to acquired haemophilia A in association with autoimmune thyroiditis, who was successfully treated with recombinant activated factor VII and immunosuppression.Case presentationA 60-year-old Sri Lankan woman with a background of longstanding hypothyroidism, diabetes mellitus, hypertension, hyperlipidaemia and bronchial asthma developed spontaneous cutaneous purpura and a limb-threatening intramuscular haematoma. Initial coagulation screening revealed prolonged activated partial thromboplastin time of 66.4 seconds (normal range 26 to -36 seconds) and time-dependent inhibitors against factor VIII. She had positive antinuclear antibody and antithyroid peroxidase (microsomal) antibody titre of over 1/80 and 1000IU/mL respectively. The diagnosis was therefore made of acquired haemophilia A in association with autoimmune thyroiditis. Acute limb-threatening bleeding was managed with recombinant activated factor VII (NovoSeven®). Immunosuppressive treatment consisting of oral prednisone 60mg/day and cyclophosphamide 100mg/day was administered in order to remove the factor VIII inhibitor. This treatment led to normalisation of her haemostatic parameters. This case illustrates a very rare association of acquired haemophilia and autoimmune thyroiditis as well as the importance of considering acquired haemophilia as a differential diagnosis of spontaneous bleeding.ConclusionsAcquired haemophilia should be considered in the differential diagnosis of unexplained bleeding in adults. Treatment of the acute coagulopathy with recombinant activated factor VII and immunosuppressive therapy was successful in this case.
A very few cases with Coronavirus disease inducing Diabetic ketoacidosis in non-diabetic patients are reported. Hyperglycaemia caused by transient damage to pancreatic cells by the virus and cytokine storm is identified as the underlying pathophysiology. Here, we present a patient who presented with transient Diabetic ketoacidosis while being treated for COVID-19 pneumonia and is the first reported case in Sri Lanka as per literature. We highlight the approach to diagnosis, monitoring and management of this patient which was challenging for the treating physician.Case: A 34-year-old previously well Sri Lankan male presented with severe covid pneumonia. He was found to have diabetic ketoacidosis and managed as per protocol with fluid and insulin. His glycosylated haemoglobin was normal. Even though his Covid pneumonia worsened leading to death, he recovered from diabetic ketoacidosis and did not require exogenous insulin later in the course of the illness. Conclusion:Transient hyperglycemia with ketoacidosis, such as in our patient, associated with Covid infection has been reported very rarely in the literature. The treating physician should have a high index of suspicion to diagnose these types of patients and to manage them timely. Otherwise, it will be an added but a preventable factor to increase mortality in patients with Covid pneumonia.
Background: The spreading of COVID 19 pandemic in Dengue endemic tropical countries such as Sri Lanka has increased the risk of dual outbreaks as well as the risk of Dengue and COVID 19 coinfection. Such coinfections are clinically challenging as Dengue and COVID 19 show similarities in symptoms and laboratory findings. Case presentation: This is a case series of four patients presented to a COVID 19 treatment hospital, Sri Lanka. All four patients were diagnosed to have Dengue and COVID 19 coinfection, while two of them were complicated with Dengue Hemorrhagic Fever. Fluid resuscitation according to the dengue management guideline and supportive treatments improved their clinical symptoms and all recovered fully. Conclusion: Here, we emphasize the similar clinical symptoms and laboratory findings in COVID 19 and Dengue infections and the importance of extensive diagnostic workup and timely management. Raising awareness among health care providers as well as the public is necessary to face upcoming challenges during the COVID 19 pandemic especially in dengue-endemic countries. Keywords: COVID 19; dengue; SARS-CoV-2; covid -19; co-infection.
As of February 2021, cumulative high-certainty data shows that Tocilizumab decreases the risk of mechanical ventilation in hospitalized patients with Covid-19 [1]. COVID-19 patients receiving tocilizumab may have a theoretical risk of acquiring a secondary infection due to immunosuppression [2]. Here we present a series of chest radiographs of a patient presented with severe Covid pneumonia who improved rapidly with tocilizumab but died of secondary infection later on.
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