Since the beginning of COVID-19 vaccination in New Jersey in December 2020, we have observed multiple cases of undetectable adaptive immunity, post-vaccination or post-COVID-19 infection, in patients using immunosuppressants. Here, we present three cases of patients using immunosuppressants: mycophenolate and tacrolimus for renal transplant; ocrelizumab for multiple sclerosis and rituximab for peripheral ulcerative keratitis. All three patients were admitted for acute respiratory distress syndrome (ARDS) from COVID-19 pneumonia; two patients reported having received full COVID-19 vaccination prior to admission and one unvaccinated patient required readmission. Our findings showed that these patients tested negative for SARS-CoV-2 IgM spike and CoV-2 IgG nucleocapsid antibodies. All three patients were treated with standard-of-care remdesivir, dexamethasone and convalescent plasma; two recovered successfully and one patient died from respiratory failure secondary to worsening ARDS from COVID-19 pneumonia. We highlight the challenges of treating immunosuppressed patients with COVID-19 pneumonia, in an era where dissemination of such information is paramount to helping doctors standardise and improve the quality of care for these patients.
Introduction: Primary hyperparathyroidism (PHPT) is rarely diagnosed in pregnancy and if left untreated has the potential to lead to serious maternal and neonatal complications. We describe a case of PHPT with associated complicated pre-eclampsia. Clinical Case29-year-old primigravida admitted at 33 + 6 weeks with fatigue, 10lbs weight gain and elevated BP. Labs revealed potassium 2.9 (3.5-5.2mmol/L), corrected serum calcium (Ca)11.62 (8.4-10.2mg/dL), ionized calcium 1.69 (1.15-1.33mmol/L), PTH 163.9 (15-65pg/mL) and vitamin D 24.6 (30-100ng/mL). Other labs were normal. Urine studies showed 315mg/24h proteinuria and urine calcium of 129.5 mg/24hrs (100-300mg/24hrs). She was started on magnesium sulphate along with labetalol for BP control, given betamethasone for stimulation of fetal lung maturity as well as potassium repletion. Hypercalcemia (HCa) was initially managed with fluids and Lasix intravenously. At 34 + 2 weeks she developed SOB, orthopnea, headaches with new 9lbs weight gain over 5 days and sustained BP elevation. Urgent C-section was done for pre-eclampsia with severe features. Post-operatively, she suffered from postpartum hemorrhage, managed with transfusion of packed red cells and transient placement of a Bakri balloon. Her HCa worsened with Ca 12.56 and cinacalcet was started after delivery. This coincided with gradual improvement of her BP and Ca to 10.8. She declined additional work-up and was discharged in stable condition. Clinical LessonPHPT often goes undiagnosed in pregnancy, with symptoms of fatigue and constipation mimicking common complaints of pregnancy. Studies have also suggested that up to 25% of patients with PHPT during pregnancy present with hypertension and pre-eclampsia and that there is an association between preeclampsia and the presence of parathyroid adenomas. The pathophysiology is unclear but is thought to be due to endothelial dysfunction triggered by hypercalcemia as well as abnormal placentation. No clear guidelines exist for the management of PHPT during pregnancy, with observation and rehydration being the preferred initial options. The use of cinacalcet as well as curative surgical parathyroidectomy when Ca levels persist >11 in the second trimester have also been described. Our patient presented similarly, with severe pre-eclampsia needing urgent C-section, further complicated by persistent severe HCa. Early diagnosis of PHPT, along with treatment including cinacalcet improved her Ca. It is therefore important that PHPT be considered in patients presenting like ours, progressing to severe pre-eclampsia as early reduction of serum calcium may reduce morbidity and mortality. ReferencesMcCarthy, A., Howarth, S., Khoo, S., Hale, J., Oddy, S., Halsall, D., ... & Samyraju, M. (2019). Management of primary hyperparathyroidism in pregnancy: a case series. Endocrinology, diabetes & metabolism case reports, 2019(1).
Giant cell arteritis (GCA), previously referred to as temporal arteritis, continues to pose significant diagnostic challenges to clinicians as it could have unusual and atypical presentations. We present the case of a 69-year-old Caucasian male who had presented with painful scrotal swelling and bilateral arm pain and was eventually diagnosed with GCA based on histological findings. His symptoms resolved completely with the initiation of high-dose steroids. It is important to note that some clinical manifestations of GCA could be subtle, atypical, and maybe entirely extracranial. A high index of suspicion is helpful when diagnosing patients who present with non-specific or constitutional symptoms as delay in diagnosis or treatment in these patients could result in severe adverse outcomes.
INTRODUCTION: Dyspnea with hypoxia warrants prompt evaluation. Anemia is an uncommon cause of hypoxia. We describe a case of unearthing elusive anemic hypoxia following bariatric surgery. CASE PRESENTATION: A 62 year old woman post gastric bypass surgery presented with 2 years of progressive exertional dyspnea, lightheadedness and recurrent syncope. 6 minute walk test showed SpO2 96 % at rest,74% with activity and improving to 97% with 2 L/ min oxygen(O2). Labs showed Hb 9.0g/dL, MCV 85.7 FL, B12 < 159 pg/mL, ferritin 7.5 ng/mL, TSAT 5% & iron 25 UG/DL and normal folate, TIBC, renal & hepatic function panels. Chest CT angiogram showed no pleural, parenchymal or embolic disease. VQ scan showed no perfusion or ventilation defects or intracardiac shunt. PFTs showed no obstructive or restrictive disease .Echocardiogram showed normal left ventricular systolic function and no wall motion abnormalities. Cardiac MRI showed increased right ventricular thickness and CT coronary angiogram showed coronary atherosclerosis without significant stenosis. Right heart catheterization revealed arterial desaturation with limited exercise/stress with maximal heart rate < 90 and normal pulmonary artery pressures and mild elevation with exertion. PCWP was normal at rest, but moderately elevated with exercise and mixed venous O2 saturation (SvO2) was 54% (normal 60-80%).Her vitamin deficiencies were replaced orally with eventual resolution of dyspnea and normal saturations.DISCUSSION: Extensive hypoxia evaluation of this patient showed increased O2 extraction and high O2 consumption. Normal O2 delivery involves an intricate relationship between the cardiac & respiratory systems & as reflected by Fick principle, is influenced by the O2 carrying capacity of blood & the metabolic activity at the level of tissues. In a hypoxic patient, once cardiac & pulmonary pathologies are explored & ruled out, the presence of anemia should raise the possibility of anemic hypoxia. This results from a decrease in blood O2 carrying capacity eliciting several systemic & microcirculatory physiologic adjustments. These result in increased cardiac output & O2 extraction ratio. This is reflected by decreased venous O2 content indicating the body's attempts at addressing inadequate O2 needs. In our patient, this is shown in the low SvO2. Additionally, during severe anemia there is a right shift of the O2 dissociation curve resulting in decreased Hb affinity for O2 thus improving O2 availability to tissues. Anemia, particularly due to iron & vitamin B12 deficiencies, is common post bariatric surgery due to decreased absorptive surface & chronic inflammatory changes. Studies demonstrate this finding up to 2 years post operatively, however, anemia uncommonly progresses to anemic hypoxia years after surgery.CONCLUSIONS: Anemic hypoxia is a rare complication of bariatric surgery and generally resolves with correction of anemia and it's underlying etiology.
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