Multiple infectious causes have been implicated with the development of secondary immune thrombocytopenic purpura (ITP). Nevertheless, new pathogens, including coronavirus disease 2019 (COVID-19), are recently being described in its development. A 41-year-old Hispanic male presented to the Emergency Department with a two-day history of bleeding gums and blood-tinged sputum. A severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) test was positive on admission. Initial laboratory studies showed severe thrombocytopenia of 3x10 9 /L (150-400x10 9 /L) with no abnormal platelets or schistocytes seen on peripheral blood smear, with normal prothrombin time/international normalized ratio (PT/INR), partial thromboplastin time (PTT) and fibrinogen levels. Secondary causes of thrombocytopenia were ruled out. One unit of single donor platelets was transfused and the patient was treated with intravenous dexamethasone for a total of five days and intravenous immunoglobulin (IVIG) for two days. One week after discharge the patient had a recurrence of epistaxis and hematuria requiring a second course of steroids and IVIG and the decision was made to start the patient on eltrombopag 50mg daily, which maintained his platelet counts within normal limits. COVID-19-associated ITP can be severe and life-threatening and hence warrants rapid and prompt management with steroids and IVIG. In refractory cases, thrombopoietin receptor agonists should be used.
BackgroundCoronavirus disease 2019 (COVID-19) infection is associated with troponin elevation, which is associated with increased mortality. However, it is not clear if troponin elevation is independently linked to increased mortality in COVID-19 patients. Although there is considerable literature on risk factors for mortality in COVID-19-associated myocardial injury, the Global Registry of Acute Coronary Events (GRACE), Thrombolysis in Myocardial Infarction (TIMI), and Sequential Organ Failure Assessment (SOFA) scores have not been studied in COVID-19-related myocardial injury. This data is important in risk-stratifying COVID-19 myocardial injury patients.
Subcutaneous emphysema is a rare complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia that should prompt immediate attention to find its cause. Herein, we describe three patients with SARS-CoV-2 pneumonia who were admitted to the ICU and developed subcutaneous emphysema and one with a concomitant pneumothorax. Three patients with diagnosis of SARS-CoV-2 pneumonia admitted to the ICU developed subcutaneous emphysema during the hospital admission. One of them who had concomitant pneumothorax required thoracostomy tube for treatment and the other two were monitored clinically without additional interventions. Two patients died during the first two to three weeks of their hospital course. One patient survived and was discharged after 63 days in the hospital. Subcutaneous emphysema is considered a non-life-threatening condition and is usually self-limited requiring supportive treatment in mild cases. For such cases, observation is appropriate. Patients with newly discovered SE life-threatening pathology, such as pneumothorax, esophageal rupture, and necrotizing infections, should be investigated depending on the clinical setting. This is one of the first paper that shows the development of subcutaneous emphysema in patients with SARS-CoV-2 pneumonia. This may represent a rare complication of the infection as well as may be attributable to other factors such as increased cough and mechanical ventilation. There is a need for studies on the clinical characteristics of a disease with still many unknown features and a wide clinical spectrum that is still being defined.
Multifocal pneumonia amidst this global pandemic is often attributed to COVID-19, resulting in missed diagnosis of other potentially fatal illnesses such as eosinophilic pneumonia. Eosinophilic pneumonia is often associated with antibiotics and non-steroidal anti-inflammatory drugs. A 65-year-old male presented to the emergency department for a four-day history of fatigue, cough, and worsening dyspnea; CT thorax showed extensive multifocal pneumonia, and COVID-19 was suspected. COVID-19 testing using reverse transcription polymerase chain reaction was negative, and complete blood count revealed peripheral eosinophilia, which is not expected in COVID-19. The patient was being treated concomitantly with daptomycin and ceftaroline for septic arthritis and methicillin-resistant Staphylococcus aureus bacteremia. We reconsidered our initial diagnosis and held daptomycin, after which the patient started to improve. Due to hypoxia, steroids were added, which resulted in a dramatic improvement of the patient's symptoms. Daptomycin can have toxic effects, resulting in the accumulation of eosinophils in the lung parenchyma. Symptoms usually arise by the third week and include dyspnea, peripheral eosinophilia, and infiltrates involving the outer one-third of the lung fields. FDA drug safety guidance helped to establish this diagnosis. The treatment options include the removal of offending agents and steroids in severe cases.
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