Dear Friends of EJCRIM,
we know that the COVID-19 epidemic is giving you a hard time. Please keep on fighting this virus, your efforts and work are irreplaceable in this very moment.
In order to spread awareness of the various COVID-19 manifestations, EJCRIM is now offering a Fast Track and the waiver of the publication fee for case reports and case series that touch this particular topic. The reports will be quickly peer-reviewed and published for free upon acceptance, so that the all internists and acute medicine doctors can take advantage of the immediate, shared knowledge.
Case reports are the quickest mean to share and to have your peers benefit from (vicarious) experience. Share yours.
The program will be in place until June, 1 2020. COVID-19 articles will be treated as fast track but not all submitted articles will be elegible for the fee waiver. Priority will be given to articles coming from the new epicentre, South America, as per WHO news conference held on Fri 22 May.
Please do not hesitate to reach out to the Editorial Office in case of doubts.
Treatment strategies for patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to be heavily researched and ever-changing. Recent data has suggested that combination therapy with dexamethasone, remdesivir and baricitinib could decrease the severity and length of illness in patients with severe SARS-CoV-2. However; the data regarding the safety and side effects related to this combination therapy are limited to case reports. The purpose of this case report is to highlight a potentially life-threatening side effect of one or all medications mentioned above.
Tacrolimus is commonly used as a prophylactic against acute rejection in transplant patients. Tacrolimus toxicity has numerous presentations that have been well documented in the literature and can be induced by a wide variety of agents. We present a novel case of tacrolimus toxicity in a cardiac transplant patient induced by outpatient treatment for COVID-19 pneumonia with ritonavir-nirmatrelvir, which was successfully treated with phenytoin therapy.
Introduction: mRNA COVID-19 vaccines are very safe, but rare adverse events such as transverse myelitis have been reported after COVID-19 vaccination.
Case Description: We report the case of 50-year-old man who presented with progressive lower extremity weakness, back pain and urinary retention after his second dose of the Pfizer COVID-19 vaccine. MRI of the spine revealed longitudinally extensive transverse myelitis (LETM). He recovered completely after treatment with intravenous methylprednisone and physical therapy.
Discussion: This case highlights the rare association between LETM and COVID-19 vaccines and encourages clinicians to maintain a high index of suspicion for prompt diagnosis and treatment.
Introduction: Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome is a leading cause of maternal mortality. The emergence of Coronavirus disease 2019 (COVID-19) has led to challenges in diagnosing HELLP syndrome due to overlapping clinical and laboratory presentations. We report a case of HELLP syndrome complicated by COVID-19 infection.
Case Description: An otherwise healthy pregnant 31-year-old female presented with fever, myalgia, and headache. She was found to be COVID-positive with laboratory signs of HELLP syndrome. Symptoms and laboratory findings trended toward normal post-partum confirming the diagnosis of HELLP syndrome.
Discussion: A prompt diagnosis of HELLP syndrome is essential to avoid maternal and fetal complications. Clinicians should be aware of the similarities in presentation between HELLP syndrome and COVID-19 for timely diagnosis and treatment.
We describe four cases of COVID-19 infection during the Omicron wave, in patients treated with anti-CD20 monoclonal antibodies. All cases follow a similar biphasic clinical course consisting of respiratory deterioration, which occurred a few weeks after convalescence from initial mild to asymptomatic infection. Possible explanations are discussed.
Introduction: Several immune-mediated side effects have been reported with COVID-19 vaccines, including myocarditis.
Case description: A 27-year-old woman with a past medical history of mild COVID-19, developed adult-onset Still’s disease (AOSD) with salmon-pink flagellate erythema, polyarthritis, a sore throat, myocarditis and haemophagocytic lymphohistiocytosis after receiving two doses of the BNT162b2 vaccine (Pfizer®, BioNTech®). Despite the initial efficacy of high-dose pulses of methylprednisolone, inflammatory markers rose as soon as de-escalation of corticosteroids was attempted, warranting initiation of biologics targeting the interleukin (IL)-1/6 axis, which allowed sustained remission of the disease despite withdrawal of corticosteroids.
Discussion: To our knowledge, this is the first case of AOSD with both haemophagocytic lymphohistiocytosis and cardiac magnetic resonance imaging-proven myocarditis triggered by COVID-19 vaccination, successfully treated with steroids and biologics targeting the IL-1/IL-6 axis. The pathophysiological process by which COVID-19 vaccination can lead to AOSD is still unknown, although it has been reported that the spike protein may act as a pathogen-associated molecular pattern and thus induce an overproduction of pro-inflammatory cytokines of the innate immune system (e.g., IL-1, IL-6 or IL-18).
Conclusion: Targeting the IL-1/6 axis is effective for the treatment of severe steroid-refractory BNT162b2 vaccine-induced adult-onset Still’s disease. At a population level, the favourable benefit/risk ratio of COVID-19 vaccination remains indisputable.
Secondary bacterial pneumonia infection is frequent in COVID-19 patients. Nocardia are responsible for opportunistic pulmonary infections especially after steroid treatment. We describe a case of pulmonary nocardiosis following critical COVID-19 pneumonia in an 83-year-old male. Two weeks after initiation of dexamethasone 6 mg/L, the patient developed a new episode of acute dyspnea. The sputum cultures identified Nocardia cyriacigeorgica. In spite of intravenous imipenem and cotrimoxazole treatment the patient died. Physicians should be aware of the possibility of nocardiosis in case of deterioration of respiratory status of severe COVID-19 inpatients and perform Nocardia evaluation. This evaluation requires prolonged culture.
Platypnoea-orthodeoxia syndrome (POS) is a condition characterized by dyspnoea and hypoxaemia while sitting or standing, which improves during decubitus. It is usually caused by intracardiac right-to-left shunting through a patent foramen ovale but may also occur due to pulmonary ventilation-perfusion mismatch of other aetiologies. A new cause of POS was recently described: SARS-CoV-2 pneumonia. We report the case of a 62-year-old man admitted for SARS-CoV-2 pneumonia with respiratory failure. Chest computed tomography angiography showed pulmonary thromboembolism and parenchymal lung changes compatible with COVID-19. He had worsening dyspnoea in a sitting position, relieved by assuming the dorsal position. He was diagnosed with POS after other causes were excluded. POS is an underdiagnosed complication of COVID-19 and is manageable with respiratory rehabilitation.
Introduction: Viral infections can induce autoimmune diseases in susceptible patients. SARS-CoV-2 has been associated with the development of rheumatic disease, especially small vessel vasculitis and arthritis. Typically, onset occurs days to weeks after the antigenic challenge and in patients with mild COVID-19. We report a case of large vessel vasculitis (LVV) temporally related to SARS-CoV-2 infection.
Case description: An otherwise healthy 19-year-old woman presented with fatigue, malaise, and chest and low back pain. The symptoms had begun 5 weeks earlier and 1 month after mild SARS-CoV-2 infection. Serological work-up revealed a marked proinflammatory state and anaemia without signs of infectious or autoimmune disease. Computerized tomography revealed thickening and blurring of the perivascular fat of the descending thoracic and abdominal aorta, progressing along the proximal iliac and renal arteries. Fluorodeoxyglucose positron emission tomography confirmed inflammatory activity. Symptoms and laboratory values normalized after prednisolone treatment.
Discussion: Recent SARS-CoV-2 infection may be a trigger for LVV, including Takayasu arteritis, as well as other rheumatic diseases. A prompt and thorough differential diagnosis is essential to exclude aortitis and LVV mimickers. Moreover, physicians should be aware of the potential spectrum of systemic and autoimmune diseases that could be precipitated by SARS-CoV-2 infection. This will allow timely diagnosis and treatment, with significant improvement in prognosis.
Background: Massive haemoptysis is a rare symptom ofcoronavirus disease 2019 (COVID-19). Management can be very challenging due to the lack of clear recommendations.
Case description: We report a case of massive recurrent haemoptysis in a young patient who tested positive for COVID-19 with successful management using endovascular embolization.
Discussion: Life-threatening massive haemoptysis has rarely been reported as the only manifestation of COVID-19. Embolisation was the therapeutic option chosen to manage this emergency.