There have been increasing reports of a rare hyperinflammatory syndrome seen in children following Coronavirus disease 2019 (COVID-19) with shared features of Kawasaki's Disease (KD). More recently, cases involving adolescents and young adults are emerging [1]. We present a case of severe multi-system inflammatory syndrome with myocarditis in a young adult. CASE PRESENTATION:A 20-year-old male with beta-thalassemia trait and a family history of Sjogren disease presented for screening after contact with a friend who tested positive for COVID-19. PCR testing confirmed COVID-19. He was asymptomatic at that time and was advised to quarantine at home.Five weeks later, he presented with a high-grade fever of 104 F, myalgias, difficulty breathing, chest pain, palpitations, hematuria, and hematochezia. Vital signs showed tachycardia (127 bpm) and hypotension (90/53 mmHg). Chest X-ray showed no infiltrates. Electrocardiogram (EKG) showed no ST abnormalities. Nasopharyngeal PCR was negative for COVID-19. Labs showed elevated C-reactive protein (CRP), creatinine phosphokinase (CPK), and lactate (8.0 mmol/L). Troponin T was elevated to 1.5 ng/L, and high sensitivity troponin was 12759 ng/L. Sequential Organ Failure Assessment (SOFA) score was 9. He was admitted to the intensive care unit (ICU) for cardiogenic vs distributive shock. Echocardiogram revealed new-onset reduced ejection fraction (EF) at 20%, with no wall motion abnormalities. He was anuric with rhabdomyolysis and acute tubular necrosis. He was treated with hemodialysis, intravenous N-acetylcysteine protocol, inotropic support, three doses of intravenous immunoglobulins (IVIG), corticosteroids, and aspirin. Serial blood cultures were negative. He had a high serum titer of COVID-19 antibody. Patient slowly improved following IVIG treatment and supportive care, with decreasing SOFA score. He was weaned off pressors and dialysis. Repeat echocardiogram showed recovered EF at 45%, and inflammatory markers improved to normal. After a 3-week hospital course, patient was near baseline with post-ICU deconditioning.DISCUSSION: Multisystem Inflammatory Syndrome in Adults (MIS-A) is a rare post-infectious sequela of COVID-19 with shared features of KD. Proposed mechanisms include direct hypoxic, ischemic injury, and post-viral immune-mediated vasculitis. Patients usually have limited respiratory involvement, evidence of recent COVID-19, and high antibody titers, which supports a post-infectious, immune-mediated etiology. Myocarditis is more common compared with Kawasaki disease, and both can have coronary artery aneurysms. Limited data from case series show good outcomes with IVIG, corticosteroids, and aspirin [2].CONCLUSIONS: MIS is a rare extrapulmonary complication of COVID-19 with a wide spectrum of presentation. Initially described in children, more cases are emerging in young adults. A multidisciplinary approach is essential in severe cases.
Autoimmune hemolytic anemia (AIHA) is a relatively rare disorder (1-3 per 100 000) characterized by antibody production against autologous erythrocytes [1]. We present a novel case of warm agglutinin, autoimmune hemolytic anemia associated with Epstein-Barr Virus (EBV). CASE PRESENTATION:A 79-year-old woman with hypothyroidism was referred from the outpatient clinic after labs showed hemoglobin (Hgb) of 6.7 mg/dL. She complained of fatigue and dyspnea for 5 days. She had yellowing of skin and dark urine for 2 days. Vitals showed a blood pressure of 87/27 mmHg with a heart rate of 87 bpm. Repeat Hgb was 4.7 g/dL associated with mean corpuscular volume 111.6 fL. White cell count was elevated at 18. Leukocyte Alkaline Phosphatase score was elevated at 50. Direct Coombs test was positive with IgG and anti-C3 with warm agglutins. Haptoglobin was <10mg/dL, Lactate dehydrogenase 900U/ L, and ferritin 1747. She received 3 units of packed red blood cells (RBC) and was started on corticosteroids. Peripheral blood smear showed left shift with increased bands, and megaloblastic granulocytes. Serum B12 level was 63ng/mL (N >200). Intrinsic factor was within normal limits. Ebstein Barr Virus IgG titers were elevated at 50 times limit upper limit of normal. All other tests for infectious causes of AIHA were negative. She was not on any medications known to cause AIHA. The patient reported resolution of symptoms by admission day 2. Hgb improved to baseline at 9.4 mg/dL and repeat MCV was 94.8 fL. The patient was subsequently discharged with B12 supplementation and continued to be symptom-free 4 weeks later.DISCUSSION: AIHA has a broad differential, with etiologies including medications, viruses, and hematological malignancies. EBV has a well-established connection with cold agglutin AIHA. IgM antibodies formed against EBV can cross-react against erythrocytes, reacting at 1-3 degrees Celsius, hence classified as cold agglutinin hemolytic anemia. However, it is not known if EBV can also induce warm agglutination. An extensive literature review returned a single report of fatal AIHA due to IgG warm agglutination exacerbated by EBV [2]. AIHA may have also be exacerbated by irregular erythropoiesis. Megaloblastic erythrocytes may have unique membrane antigens that present easier targets for circulating antibodies, thus driving hemolysis [3].Macrocytosis was likely due to B12 deficiency in this case, however other autoimmune diseases like pernicious anemia may be associated with AIHA, and warrant investigation. LAP score was also done to differentiate between reactive leukocytosis vs hematological malignancies such as chronic myelogenous leukemia, which also causes AIHA. CONCLUSIONS:EBV is classically associated with cold agglutin AIHA, although this case suggests that warm agglutination is possible. Macrocytic anemia may also worsen AIHA. Further studies are needed to delineate causation.
A 57-year-old woman with a history of hypertension, diabetes mellitus, obesity, asthma, and hemoglobin SC disease presented to the emergency department by her home health aide after she was found having altered mental status. According to her home health aide, the patient was responding with "Ok" to her questions for more than a day. The hemoglobin on admission was 8.5 g/dL. A magnetic resonance imaging (MRI) without contrast of the brain showed acute cortical infarcts superimposed on the old infarct zone. The patient received 1 unit of packed red blood cells and a session of exchange transfusion, in addition to aspirin, clopidogrel, and atorvastatin during the hospital stay. When a patient known to have sickle cell disease presents with acute neurological deficits, the first consideration is usually acute ischemic stroke due to vasoocclusion in the cerebral vessels. However, it is essential to not overlook other potential causes of acute neurological deficits.
A ação “@pandemiadenarrativas, movida pelo grupo de pesquisa Antropoéticas[1] através do Instagram[2], surgiu em 19 de abril de 2020 devido à premência de criar um território de refúgio e compartilhamento de vivências diárias alteradas pela pandemia da Covid-19, num período trágico com características de liminaridade. Ao demonstrarem as relações entre dramas social e estético, Turner (2008) e Dawsey (2005) enfatizam como o isolamento e a vulnerabilidade, próprios da condição liminar, que marca a fase intermediária dos processos rituais, tendem a gerar comunidades de aflição. Que grafias expressariam as experiências subjetivas deste drama social? Como uma antropologia sensível, mediada por formas expressivas, contribuiriam com um mundo em crise, externalizando inquietudes, tristeza, gritos abafados pelo isolamento? Como tais narrativas poderiam romper o silêncio e tornar-se contagiantes? Esses questionamentos nos conduziram a esta ação antropoética, via uma plataforma on line, visando reunir experiências vividas de maneiras diversas e criar vínculos afetivos como modo de resistência ao trágico dilaceramento de laços sociais. Atualmente, com 420 seguidores, média de 84 "curtidas" diárias e comentários, o material reunido no primeiro mês nos convida a pensar e proceder de acordo com uma “antropologia da vida” (INGOLD, 2015), cujas implicações mais profundas serão consideradas futuramente, visto que a ação segue acontecendo. Optamos, aqui, por apresentar resultados parciais, em forma de ensaio visual, apoiado no princípio da “montagem” (VERTOV, 1983; BENJAMIN, 1987), através de um processo colaborativo e rizomático que valoriza gestos, emoções e resistências expressas por múltiplas “grafias” (INGOLD, 2015). Tal como Rancière (2005), entendemos esse modo de produção do conhecimento sensível como um ato político, ético e poético - uma forma de resistência cotidiana, como propõe Scott (1990), percebida através de narrativas pungentes e simbólicas, que nos fazem apostar no “poder epidêmico” dessas imagens (DIDI-HUBERMAN, 2003). [1] Esta ação integra o projeto de pós-doutorado de Daniele Borges Bezerra, no âmbito do grupo de pesquisa Antropoéticas, do Laboratório de Ensino Pesquisa e Produção em Antropologia da Imagem e do Som (LEPPAIS)/ Universidade Federal de Pelotas. O LEPPAIS é coordenado por Daniele Borges Bezerra e Cláudia turra Magni, Laboratório do qual todas as autoras e os autores participam. [2] No Site de Rede Social (SRS) Instagram, os perfis são precedidos pela arrouba (@).
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