#pulmonary embolism | Explore Tumblr posts and blogs

jcsmicasereports · 2 months ago

Text

Coinfections and pulmonary embolism in a patient with onset of Leukemia concomitantly with COVID19- Case report by Evgenia Papakonstantinou in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract

The pandemic of COVID19 is ongoing, with the treatment of neoplastic diseases to be challenging. Patients with acute leukemia are vulnerable to many pathogens due to impaired immunity coming from their disease and simultaneous chemotherapy. Although the COVID19 disease evolves milder in children, concomitant treatment for leukemia may be fatal. We present a girl with COVID19 and Escherichia Hermannii infection at diagnosis for Acute Lymphoblastic Leukemia (ALL). This child suffered bilateral pulmonary embolism after initiation of treatment. We discuss the therapeutic challenges about the initiation of chemotherapy in the context of coinfections as well as the role of COVID19 and other predisposing factors to pulmonary embolism. We found that the slight delay in the antineoplastic treatment contributed to the remission of the acute infection and did not negatively impact the initial response to the leukemia treatment. Nevertheless, the resumption of the oncological treatment should remain among our priorities.

Keywords

Acute leukemia, COVID19, Escherichia Hermannii, pulmonary embolism

Introduction

Given the immunodeficiency due to their disease and chemotherapy, patients with cancer are vulnerable to infections and COVID19 infection is really threatening. We describe a successful management of a girl diagnosed with acute lymphoblastic leukemia (ALL) and COVID19 infection concomitantly with Escherichia Hermannii sepsis. The initiation of chemotherapy was slightly postponed, due to the danger of these severe infections until blood cultures were negative for E. Hermanii. Pulmonary thrombosis was added, as COVID-19 infection predisposes for developing cardiovascular complications, while our patient was under existing predisposing factors for thrombophilia, but with appropriate management had successful outcome.

Case History

A three-year-old girl who presented with a four-day fever, rhinitis, and cough, found positive for COVID19 infection without mutation, as all her family members. She had anemia (Hb: 2.9 g/dL), neutropenia (N: 371/μL), thrombopenia (PLT: 24 K/μL) while tachypnea (RR=31/min), tachycardia (HR=146/min), fever 38.6°C, air oxygen saturation 97%, were found on examination. Empirical antimicrobial treatment with Tazobactam-Piperacillin, Amikacin, Teicoplanin, and Micafungin were given for febrile neutropenia, transfusions (blood, platelets) for myelosuppression, Remdesivir (5 mg/kg) for COVID19. Blood culture yielded Escherichia Hermannii sensitive to receiving antibiotics, but therapy was upscaled to Meropenem due to elevated CRP (109mg/l) and persistent fever 40.6°C. The antibiotic treatment lasting 14-days ceased after two negative cultures. Baseline chest computed tomography (CT) scan showed small cloudy glass spots, areas of pulmonary thickening, atelectasis. Bone marrow aspiration, with 61% blasts, set the diagnosis of pre-B acute lymphoblastic leukemia (ALL) hyperdiploid, Central Nervous System (CNS) negative. Abdominal ultrasound showed hepatomegaly and splenomegaly. Examinations for thrombophilia revealed heterozygosity for factor V Leiden. Chemotherapy started while positive for COVID according to ALLIC 2009 protocol, standard risk arm, 15 days post diagnosis. Remained in COVID clinic until two negative PCR tests. The ALL re-examination showed good prednisolone response on Day 8, complete remission on Days 15, 33. On Day 40 from the initiation of chemotherapy, she had tachypnea with a value of D-dimer elevated at 2.145 ng/mL. Chest CT revealed subsegmental pulmonary embolism on both lower lobes of the lungs. She had not high oxygen requirements, hemodynamic instability requiring intubation, and was treated with low molecular weight heparin for 3 months. She continued chemotherapy without delays, with regular weekly tests for COVID19 and without reactivations, despite the use of corticosteroids and immunosuppressive therapy.

Discussion

The management of children with haematological malignancies and Sars-Cov 2 infection remains challenging since limited data about the impact of COVID 19 in these children are available. Main goal is to optimize the oncological treatment and avoid severe Sars-Cov2 infection due to immunosuppressive therapy. The Escherichia Hermanni bacteremia1 at diagnosis increased the risk of severe complications and led to slight delay of the chemotherapy initiation. The risk of virus transmission to the immunocompromised children in our department required a structured protocol regarding nursing care and isolation techniques. According to American Society of Hematology guidelines2, (January 2021), treatment for ALL patients is individualized, especially during the induction period. Reducing chemotherapy doses is not recommended since it may alter the expected therapeutic effect on ALL, while the severity of COVID19 does not seem to be affected. According to SFCE3 (French Society Committee for fight children and adolescents' Cancers), the main threat to children with ALL remains the ALL itself, even if life-threatening infections are emerging. We slightly delayed the chemotherapy initiation and prioritized treating the viral and bacterial infection since the type of leukemia of our patient was neither potentially life-threatening nor high risk (WBC<20.000, no HR cytogenetic findings, no CNS involvement). Our concern was that the co infections could be deteriorated if we had started induction chemotherapy and corticosteroids. The limited data available suggest a significant heterogeneity regarding the time till the first negative COVID19 PCR test in oncology patients (from four to 94 days). Bisogno et al. reported 19 patients with a mean time to negative PCR of 22 days and eight patients with 19 days4. Our patient demonstrated negative PCR testing for Sars-Cov2 on the 40th day of chemotherapy. As there is no standard therapy established for paediatric oncology patients with COVID19 yet, many centers follow the treatment strategy as in adults. Bisogno et al. treated nine out of 29 oncological patients suffering from COVID19 with Ritonavir, Hydroxychloroquine, and immune plasma. The Children's Hospital of Philadelphia (CHOP) reported their experience with the plasma administration to critically ill children5. Remdesivir is RNA polymerase inhibitor recommended in children with severe Sars-Cov2 infection and underlying medical conditions, especially in the early course of illness. According to a recent meta-analysis remdesivir has the most promising evidence that improves the time to recovery6. In our patient the seven-day lasting antiviral therapy was well tolerated, without any pathological findings. The reported cases of venous thromboembolism may be related to the systemic inflammatory response or a state of hypercoagulability8. Our patient had multiple coexisting risk factors predisposing for thrombophilia, such as administration of Asparaginase, use of a central venous catheter (Hickman), and heterozygous status for the factor V Leiden. In patients with ALL and COVID19, prophylactic administration of anticoagulants may have an impact, but there are not yet standardize recommendations. We need to maintain a high index of suspicion for pulmonary embolism in patients with COVID19 and leukemia and to measure D-dimers regularly. There is need for guidelines for prophylaxis with low molecular weight heparin for pulmonary embolism in patients with COVID-19 and existing risk factors for thromboembolism. The patient was treated successfully with three- month administration of low molecular weight heparin. She continued chemotherapy without delays, with regular weekly tests for COVID19 as some authors have reported reactivations, without reactivations, despite the use of corticosteroids and immunosuppressive therapy.

Acknowledgements

Dr Pappa A., Medical Biopathologist-Microbiologist, Professor of Microbiology, Aristotle University Thessaloniki, Dr. Polychronopoulou Sofia, Coordinating Director Department of Pediatric Hematology-Oncology Agia Sofia Children’s Hospital Athens.

#JCRMHS #COVID19 #Acute leukemia #Escherichia hermannii #pulmonary embolism #Journal of Clinical Case Reports Medical Images and Health Sciences submissions

3 notes · View notes

myrawjcsmicasereports · 7 days ago

Text

Outline of hospitalization due to venous thromboembolism in the state of bahia between 2010 and 2020 by Wagner Ramos Borges in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract

An important pathology that affects the cardiovascular system is venous thromboembolism (VTE), a disease characterized by the formation of clots in veins. VTE is divided into two clinical presentations: pulmonary thromboembolism (PT) and deep vein thrombosis (DVT). The general objective of the present work is to describe the profile of patients hospitalized for venous thromboembolism and other venous diseases, in the state of Bahia between the years 2010 and 2020. The specific objectives are the following: describe the demographic characteristics of hospitalized patients; describe the epidemiological trend of venous thromboembolism over the period. Based on data extracted from the SUS Hospital Information System (SIH/SUS), it was possible to analyze the following variables: annual frequency; race/color; sex; age range; health macro-region of the state of Bahia. Of the 21,450 hospitalizations for phlebitis, thrombophlebitis, embolism and venous thrombosis in Bahia, between 2010 and 2020, for patients from 20 years of age, it was noticed that 63.09% (13,533) are women, of which 42.14% (9,040) are self-declared as black or brown and that 43.39% (9,308) are concentrated in the East 2915 macro-region (NRS – SALVADOR). The profile of patients admitted between 2010 and 2020 was identified as being composed of brown women between 40 - 49 years old.

Keywords: Venous Thromboembolism; Pulmonary Embolism; Venous Thrombosis; Embolism and Thrombosis

Introduction

Diseases of the cardiovascular system have been seen for many years as important factors in the population's illness. According to data from the Ministry of Health, in 1999, such comorbidities led to approximately 1,100,000 hospitalizations through the Unified Health System 1. Within this scenario, Venous Thromboembolism (VTE) stands out, a pathological condition marked by the development of a clot in the veins, which leads to impairment of blood circulation.

The physiological changes that precede venous thromboembolism are grouped by Virchow's Triad, which encompasses endothelial lesions, stasis or turbulent blood flow, and blood hypercoagulability. Injury to the endothelial cell is a procoagulant factor, as it increases the expression of thrombomodulin, a thrombin modulating agent, stimulating platelet adhesion. Hemodynamic alterations, such as stasis and turbulence, by modifying normal blood flow, stimulate contact of platelets with the endothelium of vessels and reduce the elimination of coagulation factors, by decreasing flow. The state of hypercoagulability, which can have hereditary and genetic causes, also promotes an imbalance between clotting factors by activating procoagulant substances and inhibiting anticoagulants. two

VTE has two distinct clinical presentations, which are closely related: Deep Vein Thrombosis (DVT) and Pulmonary Thromboembolism (PTE) 3. DVT consists of the formation of clots in the deep veins of the lower limbs, which have the potential to reach the pulmonary circulation 3. This mechanism results in PTE, a condition marked by the migration of an embolus to the pulmonary circulation, which compromises the irrigation of this organ and is generally associated with a more serious situation 4.

Manifestations in Deep Vein Thrombosis are pain, heat, redness, swelling of the affected limb, cramps and, in some cases, greater predisposition to the formation of ulcers 2-5. The edema, due to the venous obstruction, is normally of the tense type, causing a swelling, only in the calf or in the whole affected leg. The redness, heat and pain at the site are caused by inflammation of the vessel wall. The pain may be permanent or be related to orthostasis or physical exertion, such as the Hormans Sign, in which the foot is dorsiflexed to assess whether there is severe pain in the calf 6. However, certain patients may not have symptoms or only some of them 5. Pulmonary embolism is characterized by distinct manifestations, namely: chest pain, usually of a pleuritic nature, tachypnea, dyspnea on exertion and in some cases cough 5. In more serious situations, dyspnea at rest, hypotension and syncope, due to low cardiac output and hypoxemia 5. Cases of pulmonary infarction are uncommon complications and, when they exist, are associated with extensive events and previous diseases or comorbidities, such as pulmonary infections and heart failure 7.

The diagnosis of venous thrombosis is complex, as no sign or clinical manifestation presented by the patient is predictive for confirmation or exclusion of condition 8. Thus, the patient is classified according to the pre-test probability (i.e. [suspected presence of a certain disease based on anamnesis, physical examination findings and epidemiology 9]) through validated risk assessment models for deep vein thrombosis or pulmonary embolism using the Wells or Geneva diagnostic criteria, which have similar diagnostic accuracy 10. These scores are important, as they eliminated situations of intermediate probability, dichotomously characterizing patients into situations of low probability (“probable PTE”) and high probability (“unlikely PTE”) 5,10.

This predictive model can be complemented using other tests such as D-dimer. Its values can be measured in whole blood or plasma, however it should be noted that complementary tests are only performed when it is not possible to confirm the suspicion of VTE with clinical examination, which occurs in most cases 11. As it is highly sensitive ( 95%) 10, but little specific (40%) 10 for VTE, its use is related to its high negative predictive value 5 (i.e. [probability of disease absence when the test is negative])9. Thus, if the result is negative, the diagnosis of VTE can be excluded in patients with a low to moderate pre-test probability of DVT or embolism 5. However, in situations where there are strong indications of a case of VTE , treatment can be started even without the results of complementary exams 12. Treatment consists of three main categories 13: medication (use of anticoagulants paying attention to the risk of bleeding 14) thrombolysis (through an injection of a substance into the bloodstream of the patient)15,16 and vena cava filter (the insertion of devices in the inferior vena cava, indicated for patients with DVT who cannot use anticoagulation)17.

Thus, the presentation of signs and symptoms, which are often nonspecific and common to other pathologies, as well as clinical diagnoses with specificity lower than 50%, lead to underreporting of the disease 18. As a result, knowledge of the disease is significantly hampered. real incidence of venous thromboembolism.

Due to this worldwide epidemiological problem, estimating the prevalence of VTE is a challenging task, and for this reason, the numbers are variable. In the United States (USA), for example, it is estimated that the prevalence of PTE is between 3.4% and 14.8%, while in Asia, this number is around 2.0% to 4. 7% 19. In Brazil, in turn, the numbers that characterize the epidemiology of VTE are also not very precise. According to certain references, the incidence of the disease is 1 to 2 episodes per 1000 inhabitants 18, while others describe it as 0.6 per 1000 inhabitants.20

The analysis of the relationships between VTE and different health variables also allows understanding the impacts of this disease on the Brazilian population. From an epidemiological study carried out at the Hospital das Clínicas of the Federal University of Uberlândia, MG, between September and December 2005, it was concluded that the most frequent risk factors found for VTE were prolonged surgery (85.2%), anesthesia general (46.2%), age equal to or above 60 years (42.3%), prolonged restriction to bed (27.4%) and age between 40 and 59 years (24.9%) 20. age and factors that promote immobility are crucial for the development of VTE. There are also the following variables intrinsically associated with the prevalence of VTE: obesity, increasing the risk by 2 to 3 times, in cases of BMI greater than 30Kg.m2; 21 neoplasms, with an increase in risk of 5 to 7 times 22; in addition to pregnancy (increase in risk by 10 times) and the puerperium (25 times).23

Objectives

Primary objective: to describe the profile of patients hospitalized for venous thromboembolism and other venous diseases in the state of Bahia between 2010 and 2020.

Secondary objectives:

Describe the demographic characteristics of hospitalized patients;

Describe the epidemiological trend of Venous Thromboembolism over the period

Methods

The present work constitutes a descriptive observational study of secondary data, extracted from the SUS Hospital Information System (SIH/SUS), available in the DataSUS database, referring to patients hospitalized in Bahia between the years 2010 to 2020, according to the ICD chapter -10: IX. Diseases of the circulatory system, in the category Phlebitis, thrombophlebitis, embolism and venous thrombosis.

The data obtained were then treated in Microsoft Excel software, where mean and median calculations were performed. This data can be verified through the TabNet portal, at the following access link: https://datasus.saude.gov.br/.

To describe the profile of hospitalizations, Venous Thromboembolism and associated conditions in Bahia, the variables used were:

Annual frequency;

Race/Color:

the White;

or Black;

the Brown;

the Yellow;

the Brown;

the Indigenous; It is

o No information.

Gender:

the Male;

the Feminine; It is

the Ignored.

Age range:

20 to 29 years old;

30 to 39 years old;

40 to 49 years old;

50 to 59 years old;

60 to 69 years old;

70 to 79 years old; It is

80 years and over.

Health macro-region of the state of Bahia:

the North;

the Center-north;

the Northeast;

the East;

the Central-East;

the West;

the Southwest;

the South; It is

the extreme south.

System

Public services

Private services

Results

Between 2010 and 2020, 21,450 hospitalizations for Phlebitis, Thrombophlebitis, Embolism and Venous Thrombosis were recorded throughout the state of Bahia, for patients aged 20 years and over. The macro-region 2915 East (NRS – SALVADOR) had the highest number of hospitalizations, totaling 9,308 (43.39%), followed by the regions 2910 South (NBS - ILHÉUS) and 2911 Southwest (NBS - VITÓRIA DA CONQUISTA) with 2,360 (11 %) and 2303 (10.74%), respectively.

There were also 880 deaths reported throughout the period, led by 2915 EAST - (NRS – SALVADOR) with 300 (Median (M) = 27; first quartile (Q1) = 23.5; third quartile (Q3) = 32.5) , followed by 2910 SOUTH (NBS – ILHEUS) with 123 (M = 11; Q1 = 9; Q3 = 14) and 2917 CENTER-EAST (NRS – FEIRA SANTANA) with 111 (M = 12; Q1 = 6.5; Q3 = 12.5). The trend of the curve in the period suggests stability, with an annual average of 80 deaths, with a peak of 97 deaths in 2019.

The general panorama of the period demonstrates a significantly higher number of women hospitalized for phlebitis, thrombophlebitis, embolism and venous thrombosis, so that of the 21,450 hospitalized patients, 63.09% (13,533) are women and 36.91% are men (7,917) . Men had M = 717, with Q1 = 692 and Q3 = 727, and women M = 1173, with Q1 = 1145 and Q3 = 1261, demonstrating the difference in the absolute value of cases.

The central tendency values also show the density of hospitalizations over the years, which indicates that there were no alarming fluctuations between groups or between individuals of the same sex, except for the year 2019. There were 2630 hospitalizations recorded, of which 905 were men (34 .41%) and 1725 women (65.58%), absolute numbers that differ from the general average, male and female, respectively, of 1950, 719.73 and 1230.27.

When evaluating the data according to the race/color criterion, of the patients who had this information collected, the black population stands out, since in this category self-declared black and brown patients are considered, which totaled 9,040 (42.14%) in the studied period , followed by the white population with 1027 (4.79%). However, there is a greater emphasis on patients whose race/color criterion was ignored, totaling 11,669 (54.4%) between 2010 and 2020.

The regime-based analysis revealed that the sum of hospitalizations for public services (7391) significantly exceeds those for private services (3564). The numbers of hospitalizations in which the type of regime was not registered were very expressive (11089). From 2010 to 2014, there were no records of hospitalizations classified as ignored. However, between 2016 and 2020, the nature of the regime was not distinguished in any hospitalization.

During the period in which the types of regimes were considered, the median number of admissions for the public regime was 1247.5, while for the private regime it was 611.5. During the same period, the average hospitalizations by the public and private regime were, respectively, 1231.8 and 594.

Distribution by age group revealed a higher incidence among patients aged 40 to 49 years, with an annual average of 404.18 patients. Then, the ranges from 50 to 59 years old (339.64) and 30 to 39 years old (327).

Discussion

Distribution by macro-regions reflects the impacts of disparities in sociodemographic factors, such as differences in income, access to health services, as well as the number of inhabitants in each region. According to the data obtained, the macro-region 2915 East (NRS – SALVADOR) stood out, in relation to the others, in terms of the number of hospitalizations, as well as the number of deaths (34%). This information is in line with results shown in the literature, which state that the Brazilian regions with the highest proportion of cases of VTE hospitalization (south and southeast) have the lowest mortality rate due to the disease 19. that, despite the disparities regarding access to health and income being important, the significantly higher number of inhabitants in the East macro-region (NRS - SALVADOR) was able to determine it as the leader in terms of the highest rates of hospitalization and death from illness.

The profile in relation to gender corroborates the literature, since women correspond to the majority of hospitalizations. Intrinsic factors may be favorable to this arrangement, such as the use of oral contraceptives, eventual pregnancy, puerperium or gynecological surgery, as well as greater search for health services by the female population compared to the male population 23, 24 . Regarding the use of oral contraceptives, although pills currently have a lower concentration of estrogen, especially ethinyl estradiol, their use increases the risk of VTE by up to six times compared to those who do not use hormonal contraceptives. The absolute risk, however, in women aged less than 35 years and without associated risk factors remains between low and moderate 25.

When analyzing the occurrence of this condition in relation to age, it is noted that the probability of involvement grows according to the patient's age, some authors consider that this growth is directly related to longevity, however the analysis showed that this pattern is not directly proportional to the age factor 19. In research carried out by other researchers, it is noted that from the age of 40 19 the occurrence rate increases considerably, with greater risk, but other authors consider that this occurs from 50 years 26. It is important to highlight that prophylactic methods are being developed with the objective of preventing the occurrence of DVT, since this is one of the causes of PE, a serious complication. Preventive diagnostic methods, especially in older patients and after surgical procedures, rely on tests such as: daily gammagraphy with fibrinogen labeled with I125 and Doppler ultrasonography, which is easier to perform, while the treatment uses anticoagulants, which have dubious efficacy. as they increase the chances of bleeding 27.

The body of evidence, including the results of this work, suggests that VTE is more frequent in the population of African ancestry 28. Epigenetic factors help justify this arrangement, such as obesity, which increases the risk two to three times, together with greater activity of the factor VIII in this ethnic group, which may favor thromboembolic events; 10% of healthy people have values above 228 IU/dl 29,30. However, the genetic basis of this increase in the population of African origin is still unknown.

During data collection, it was noticed that the studied MORB ICD-10 list does not distinguish notifications of phlebitis and thrombophlebitis from those of embolism and venous thrombosis. This bias may have compromised the analysis of the data obtained, by including phlebitis and thrombophlebitis in the analyzed variables.

Conclusion

Venous Thromboembolism is a recurrent condition in the in-hospital setting, and its complications are high-risk pathologies for the patient's health, with the associated risk factors being determinant for the patient's prognosis. The study indicates that the hospitalization profile in the Bahian population is mainly composed of brown women, aged 40 to 49 years. In the territory of the state, the Macro-region 2915 EAST - (NRS – SALVADOR) led the total number of assistances in the period. This secondary study, whose database comes from DataSUS, has limitations since it made them available from the grouping of four different pathologies into a single category, which allows data inaccuracy and impacts the epidemiological design of Venous Throboembolism in the population of Bahia .

#Venous Thromboembolism #Pulmonary Embolism #Venous Thrombosis #Embolism and ThrombosisJournal of Clinical Case Reports Medical Images and Health Sciences #jcrmhs

0 notes