Severe progression of autoimmune hepatitis in a young COVID-19 adult patient: A case report

Rationale:The impact of COVID-19 in patients with autoimmune liver disease treated with immunosuppressive therapy has not been described so far.This case report describes the clinical course of a patient with autoimmune hepatitis(AIH)who developed COVID-19 and the features of cytokine syndrome leading to its deterioration in our intensive care unit.Patient’s Concern:A 28-year-old male presented with generalized anasarca for two weeks and chronic liver disease for 8 months.Diagnosis:AIH and Covid-19 with features of cytokine storm syndrome.Interventions:Intravenous furosemide,mannitol,syrup lactulose,steroids(prednisolone 40 mg),azathioprine 1 mg/kg body weight,rifaximin,vitamin K,and blood products.Outcomes:The patient had hepatic encephalopathy and AIH and died on the 10th day after admission despite ventilatory support,sustained low-efficiency hemodialysis,and resuscition.Lessons:The dramatic release of cytokines and the inflammatory‐immune responses not only alter the pathophysiology but also affects the onset and severity of disease progression in patients with AIH.

Sudden cardiac death in a case of Crohn's disease with COVID-19: A case report

Rationale:The mechanism of sudden cardiac death in COVID-19 can be multifactorial.Cardiac hypersensitivity to 5-ASA therapy leading to myocarditis has been reported in some cases.Cytokine storm syndrome and idiosyncratic reaction with mesalazine use may lead to sudden cardiac death in COVID-19.Use of immunosuppressants in hospitalized COVID-19 patients should be continued with caution,especially in patients with inflammatory bowel disease.Patient’s concern:A 75-year-old man who was tested positive for SARS-CoV-2 was admitted with a history of shortness of breath for the last two days.He was a known case of Crohn’s disease treated with mesalazine.Diagnosis:COVID-19 pneumonia with underlying Crohn’s disease leading to sudden cardiac death.Intervention:Remdesivir,antibiotics,steroids,low molecular weight heparin,tablet zinc,tab vitamin C,and other supportive treatment were started.Because of increased inflammatory markers,itolizumab was given to the patient on the 2nd day.Outcome:On the 5th day of the intensive care unit,the patient complained of sudden chest pain with respiratory distress leading to bradycardia and asystole and could not be resuscitated.Lessons:Causes for sudden cardiac death in COVID-19 pneumonia patients with Crohn’s disease is multifactorial.Although mesalazine may be a safe and effective drug in the management of inflammatory bowel disease,it can induce sytokine strom syndrome and idiosyncratic reactions that could be one of the reasons of sudden cardic death.Therefore,we should be aware of its serious and potentially life-threatening complications,especially in COVID-19 infected patients.

COVID-19 presentation as acute pancreatitis:A case report

Rationale:The gastrointestinal manifestations of COVID-19 include anorexia,nausea,vomiting,abdominal pain,and diarrhea.However,pancreatitis as the presentation of COVID-19 is rarely reported.Patient’s Concern:A 63-year-old COVID-19 patient presented with complaints of abdominal pain and difficulty breathing for 5 d.Diagnosis:Contrast-enhanced computed tomography of the abdomen suggested acute interstitial pancreatitis without any biliary tract obstruction.Interventions:The patient was resuscitated with intravenous fluids based on dynamic parameters of fluid responsiveness.The patient was started on enteral feeding,analgesics,antibiotics,dexamethasone,low molecular weight heparin,and supportive therapy.Outcomes:The patient developed severe acute respiratory distress syndrome and died 6 days after admission.Lessons:Management of COVID-19 in the presence of pancreatitis is challenging.Adequate early fluid resuscitation is an important aspect of medical management for COVID-19 patients with pancreatitis and restrictive strategies must be followed.Increased liver enzymes and renal dysfunction in acute pancreatitis can also limit the use of specific therapies like remdesivir.Dexamethasone,even though it has shown a beneficial effect in treating COVID-19,can have an additive effect in causing hyperglycemia in these cases.Clinicians should be aware of this atypical presentation of COVID-19 with pancreatitis and adjust their management strategies,keeping in mind the considerations for both diseases.

Does a staged treatment of high energy tibial plateau fractures affect functional results and bony union?A case series

Purpose:Tibial plateau fracture(TPF)is a devastating injury as it shatters lower articular surface of the largest joint.Apart from bony injury,TPF can lead to great soft tissue envelope compromise which affects the treatment plan and outcome.In the present study,clinical results were assessed in cases of high energy TPFs treated in staged manner.Methods:Twenty-three(20 males and 3 females)patients of high energy communited TPFs(Schatzker typeⅤandⅥ)were consecutively treated.1 All the patient had compromise of overlying skin conditions.They were all successively scheduled for staged treatment plan which comprised of application of bridging knee external fixator on the first day of admission and definitive internal fixation after skin and soft tissue overlying the fracture were healed.Schatzker typeⅠ,Ⅱ,ⅢandⅣwere excluded from the study.Primary survey was done and patient who had head injury,chest and abdominal injury,pelvic injury and contralateral limb injury and open fractures were excluded from the study.The patients were also evaluated in terms of wound complications,axial and rotary alignment of limb,fixation failure,articular congruity and range of motion of the knees and post injury employment.Statistical analysis was done using SPSS software.Results:Maximum follow-up period was 13 months.All the fractures were united at final follow-up.Clinical evaluation was done with the Tegner Lysholm knee scoring scale.2 Excellent results were found in 78%cases and good and fair results in 22%cases.There was significant correlation between range of motion and the Tegner Lysholm knee score(p<0.001,Pearson correlation coefficient=0.741).The correlation between the score and the radiographical union duration was significant(p=0.006,Pearson correlation coefficient=-0.554).Conclusion:A staged treatment plan allows healing of soft tissue envelope,with avoidance of dreadful complications such as compartment syndrome and chronic infection.In addition,a staged treatment strategy does not hamper the fracture reduction,bony union and the functional results.