Coronavirus disease 2019 (COVID-19) is associated with coagulation activation and high incidence of venous thromboembolism (VTE) in severe patients despite routine thromboprophylaxis. Conflicting results exist regarding the epidemiology of VTE for unselected anticoagulated COVID-19 patients hospitalized in general wards. The aim of this study was to evaluate the prevalence of asymptomatic deep venous thrombosis (DVT) in unselected patients with COVID-19 recently hospitalized in general wards. We performed a systematic complete doppler ultrasound (CDU) at a median 4 days after admission in 42 consecutive COVID-19 patients hospitalized in general wards of our university hospital, irrespective of D-Dimer level, and retrospectively collected clinical, biological and outcome data from electronic charts. Thromboprophylaxis was systematically applied following a French national proposal. In our population, the prevalence of asymptomatic DVT was 19% (8/42 patients), with distal thrombosis in 7/8 cases and bilateral DVT in 4/8 cases. Symptomatic pulmonary embolism was detected in 4 (9.5%) patients, associated to DVT in one case. Compared to patients without DVT, patients with DVT were older and experienced poorer outcomes. In conclusion, prevalence of asymptomatic DVT is high in the first days of hospitalization of unselected COVID-19 patients in general wards and may be related to poor prognosis. Individualized assessment of thromboprophylaxis and early systematic screening for DVT is warranted in this context. Electronic supplementary material The online version of this article (10.1007/s11239-020-02246-w) contains supplementary material, which is available to authorized users.
Objective: Orthostatic hypotension (OH) is a common disease in the elderly, associated with an increased risk of falls and cardiovascular morbi-mortality. Its reproducibility in clinical setting is low. A recent, single-center study has shown the feasibility of home blood pressure monitoring (HBPM) for the detection of OH in subjects older than 65 years referred for a memory complaint, and reported a prevalence of 12% and 42% of HO in the office and ambulatory settings respectively. The prevalence of masked OH detected with HBPM in treated hypertensive elderly subjects is still not known. Design and method: 42 hypertensive patients older than 65 years without office OH were included in 8 specialized hypertension centers. Their treatment has not been changed for at least 1 month. An ambulatory OH was sought according to the following protocol: 3 measurements in sitting position at 1 minute intervals after 5 min of rest, followed by 3 measurements in standing position at 1 minute intervals, every morning and evening for 3 consecutive days, recorded by an automated device with humeral cuff. HBPM was considered valid if more than 4 out of 6 series of measurements were completed. Ambulatory OH was defined as a fall of more than 20mmHg in SBP between one of the 3 measurements in orthostatism compared to the average of the 3 measurements taken while sitting. Results: 100% of HBPM sessions were considered valid. The main characteristics of the patients were: 72 ± 6 years, 39% women, SBP/ DBP: 149 ± 20/82 ± 10 mmHg, 2.4 ± 0.9 antihypertensive drugs, 9.3% history of falls. 20 (47.6%) included patients had a masked OH according to the protocol detailed above, with an average of 2 ± 1.2 episodes and a maximum of 5 episodes. 86% of patients had at least one episode in the morning, and 57% in the evening. In multivariate analysis, no factor identified in the study was significantly associated with the existence of a masked OH. Conclusions: OH detection with HBPM in treated hypertensive elderly subjects is feasible and reveals a significant prevalence of masked OH. Prospective studies are needed to clarify the prognostic value of masked OH.
Objective: Drug hypersensitivity syndrome or “Drug Reaction with Eosinophilia and Systemic Symptoms” (DRESS) is a severe form of cutaneous drug eruptions that combines skin manifestations and systemic damage. More than 50 drugs have been associated with this syndrome. Amlodipine is a long-acting calcium channel antagonist of type L (DHP), used as an antihypertensive drug. Peripheral edema remains one of the most common side effects of this drug, while dermatological events are very rare (1/100,000). We report a patient with DRESS syndrome who appeared under amlodipine treatment. Design and method: An 84-year-old hypertensive patient with eradicated chronic hepatitis C, chronic renal failure, idiopathic thrombocytopenia and dyslipidaemia was hospitalized with a febrile rash. Treatment with amlodipine 5 mg/d is prescribed for hypertension and then stopped by the patient after 15 days. Resumption of treatment is an accompanied at 4 weeks by a diffuse and infiltrated erythematous skin rash (initially suggestive of a large mesh livedo), associated with facial edema and fever at 39°. EKG is normal. The biological parameters: progressive hypereosinophilia up to 9 G/l, lymphopenia at 0,9 G/l with hyperbasophilic activated T lymphocytes (TL), hepatic cytolysis, HHV6 PCR is positive. The autoimmune test remains negative. The skin biopsy shows an inflammatory infiltrate, rich in eosinophils, with a few rare necrosis areas leading to cutaneous drug eruption. There is no vasculitis. The RegiSCAR score was 4. The discontinuation of amlodipine and high-dose dermocorticoids allowed the rash and hypereosinophilia is reduced within a few weeks until complete disappearance. The pharmacovigilance survey retained this diagnosis with proscription from this drug class. Results: The pathogenesis of DRESS syndrome is still very controversial. A hypersensitivity cytokine mediation of TL, and the reactivation of HHV6 are involved. The RegiSCAR score (European register of Serious Adverse Skin Reactions) is used to categorize the imputability to a drug. Amlodipine remains an exceptional cause but should be known because of the very common frequency of prescribing this treatment. Conclusions: DRESS syndrome is a rare but serious side effect of calcium channel blockers. Lack of knowledge can leaf to diagnostic errors and unnecessary additional examinations.
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