scholarly journals EP10 Hyperinflammatory syndrome in a patient with rheumatoid arthritis and COVID-19

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Melissa Ong ◽  
Mark Gibson ◽  
Gerald Coakley
Keyword(s):  
Rheumatoid Arthritis ◽  
Case Report ◽  
High Resolution ◽  
Critically Ill ◽  
Inflammatory Markers ◽  
Ground Glass ◽  
Successful Outcome ◽  
Biological Therapies ◽  
Oxygen Requirement

Abstract Case report - Introduction Severe acute respiratory coronavirus 2 (SARS-CoV-2) is a novel virus that can lead to an excessive immune activation and cytokine response known as Coronavirus disease 2019 (COVID-19) which predominantly affects the lungs. Patients with chronic inflammatory disease on biological immunosuppressive treatments may be at a higher risk of contracting SARS-CoV-2. However, it is yet to be determined whether immunomodulatory medications used in inflammatory diseases have protective capabilities against severe outcomes. Case report - Case description A 51-year old female with a 13-year history of rheumatoid arthritis (RA) presented to hospital with fever, exertional breathlessness, and a non-productive cough. She was diagnosed with seropositive erosive RA at the age of 38 and was on 6-monthly Rituximab infusions and Leflunomide on admission. She had relatively stable pulmonary fibrosis (diagnosed in 2010). Her chest CTs in 2010 and 2018 noted bilateral basal subpleural ground glass change with limited honeycombing and spirometry study revealed FEV1 of 2.2 (82% predicted), VC of 2.7 (87% predicted), DLCO of 7.0 (78% predicted) and kCO of 1.6 (78% predicted). On admission in March 2020, she was hypoxic (oxygen saturation of 88% in room air) and had raised inflammatory markers (CRP 341mg/dL, d-Dimer 914ng/ml, Ferritin 3141ng/ml, LDH 672U/L). Her last Rituximab infusion was 3 months prior and leflunomide was withheld on admission. SARS-CoV-2 PCR nasopharyngeal swab was positive, and she was recruited to the RECOVERY trial, being randomized to Lopinavir-Ritonavir for 10 days. Her oxygen requirements increased, and a CT pulmonary angiogram excluded pulmonary embolism but revealed ground glass changes and extensive multilobar consolidation. She was eligible for recruitment into RECOVERY-2 (tocilizumab) given the ongoing oxygen requirement and elevated CRP, but she was randomised to usual care. She was commenced on 80mg of IV methylprednisolone, a dose chosen because of its proven effectiveness in Acute Respiratory Distress Syndrome. She clinically improved and was discharged from hospital 20 days after starting Methylprednisolone with a CRP of 17mg/dL. Two months after discharge, the patient had repeat spirometry study which noted FEV1 of 1.4 (57% predicted), VC of 1.5 (52% predicted), DLCO of 2.4 (28% predicted) and kCO of 1.0 (47% predicted). A repeat high-resolution chest CT reported significant improvement of peripheral ground glass changes and consolidation, but she is still fatigued and more breathless than previously. Case report - Discussion The RECOVERY trial concluded that Dexamethasone reduced mortality in intubated patients and in hospitalised patients with COVID-19 with a high oxygen requirement. The results were published after this patient was discharged. A hyperinflammatory response to COVID-19 is seen in a subset of patients, and our own hospital data suggest that this condition affects around 5% of admitted COVID-19 patients, but that extreme hyperferritinaemia above 10,000 is extremely rare. Similar responses (known as Haemophagocytic Lymphohistiocytosis [HLH]) are seen with a variety of viral and bacterial infections, in malignancy and in inflammatory rheumatic diseases (Macrophage Activation Syndrome [MAS]), but typically HLH and MAS patients have ferritin > 10,000. It appears unlikely that true HLH is a significant manifestation of COVID-19 infection, but moderate hyperferritinaemia is not uncommon and the results of this study, taken together with case reports and series from China and Italy suggest that similar treatments to those used in HLH may transform the prognosis for COVID-19 patients in this subset. It is unknown whether the recent Rituximab infusion had a role in reducing the “cytokine storm” and delaying progression to severe COVID-19. However, it may be argued that the remaining T cells in B cell depleted patients are sufficient for viral clearance. The long-term impact of SARS-CoV-2 on pulmonary function is still unclear. Our patient had a major deterioration in her lung function when compared to her baseline. There was severe reduction in gas transfer post COVID-19. However, her repeat high resolution CT chest reported substantial improvement in ground glass changes and consolidation. The long-term prognosis is still uncertain. Initial fears that patients on DMARDs and biological therapies for inflammatory rheumatic disease would be extremely vulnerable to COVID-19 have not been confirmed, but patients with extra-articular manifestations on combinations of DMARDs and biological therapies may be a subset at higher risk. Case report - Key learning points Our Intensivist colleagues, early in the COVID-19 outbreak, were understandably cautious about using heavily immunosuppressive treatments for a life-threatening viral infection. Using a multi-disciplinary approach at a time when knowledge of how to treat this condition was rudimentary, along with informed consent from an intelligent and thoughtful patient, we were able to plot a middle path to suppress hyperinflammation without using massively immunosuppressive doses of steroid, with a successful outcome. This patient illustrates one aspect of the hyper-inflammatory response seen in a subset of the most critically ill patients with COVID-19. At the time of writing, the RECOVERY 2 trial is yet to be published, but the rapid improvement in inflammatory markers including CRP and Ferritin, along with a dramatic improvement in clinical state, suggest that relatively modest doses of parenteral steroid have life-saving potential at far lower cost and greater worldwide availability than biological therapies such as Tocilizumab or Anakinra. Trials of Tocilizumab in RECOVERY2 and of Anakinra coordinated by the Hyperinflammation Histio UK Haemophagocytosis Across Specialty Collaboration (HASC), as well as international randomised controlled trials will be critical in determining the optimal treatment strategy for this subset of critically ill COVID-19 patients. The experience of our patient suggests that one arm of such studies should include a relatively modest dose of parenteral steroid, be that Dexamethasone or Methylprednisolone, particularly given that COVID-19 is affecting countries across the developing, as well as the developed, world.

scholarly journals Rheumatoid arthritis onset after COVID-19 infection: a case report

2021 ◽  
Vol 9 (12) ◽  
pp. 3713
Author(s):  
Thafar S. A. Safar ◽  
Karmen B. Katay ◽  
Reem H. Khamis
Keyword(s):  
Rheumatoid Arthritis ◽  
Case Report ◽  
Pathological Condition ◽  
Primary Health Care Centre ◽  
Short Term ◽  
Health Care Centre ◽  
Immune Mediated ◽  
Small Hand ◽  
History Of

At the end of 2019, coronavirus disease (COVID-19) outbreak is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Worldwide researchers and physician try to explore the mechanisms of damage induced by virus, they focus on the short-term and long-term immune-mediated consequences induced by the virus infection. Every day discover a new pathological condition induced by virus and new symptoms and disease may occur after recovery from disease. Our case report is 41 years old, Indian lady who presented to our primary health care centre complaining of multiple small hand joints pain, both elbows and knees pain with swelling of them and prolonged morning stiffness, diagnosed seropositive rheumatoid arthritis (RA) (arthritis, positive rheumatoid factor (RF), and X-ray changes) after 1 month recovery from COVID-19 infection. She did not have any joint pain and she had negative RF before COVID-19 infection with no family history of RA.

scholarly journals Cost-effectiveness analysis of treatment sequences containing tofacitinib for the treatment of rheumatoid arthritis in Spain

2020 ◽  
Vol 39 (10) ◽  
pp. 2919-2930 ◽  
Author(s):  
F. Navarro ◽  
J. M. Martinez-Sesmero ◽  
A. Balsa ◽  
C. Peral ◽  
M. Montoro ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Cost Effectiveness ◽  
Cost Saving ◽  
Inadequate Response ◽  
Concomitant Treatment ◽  
Biological Therapies ◽  
Biological Drugs ◽  
Line Therapy ◽  
Treatment Sequences

Abstract Objective To assess the cost-effectiveness of tofacitinib-containing treatment sequences versus sequences containing only standard biological therapies in patients with moderate-to-severe rheumatoid arthritis (RA) after the failure of conventional synthetic disease-modifying antirheumatic drugs (csDMARD-IR population) and in patients previously treated with methotrexate (MTX) who show an inadequate response to second-line therapy with any tumour necrosis factor inhibitor (TNFi-IR population). Methods A patient-level microsimulation model estimated, from the perspective of the Spanish Public NHS, lifetime costs and quality-adjusted life years (QALY) for treatment sequences starting with tofacitinib (5 mg twice daily) followed by biological therapies versus sequences of biological treatments only. Concomitant treatment with MTX was considered. Model’s parameters comprised demographic and clinical inputs (initial Health Assessment Questionnaire [HAQ] score and clinical response to short- and long-term treatment). Efficacy was measured by means of HAQ score changes using mixed treatment comparisons and data from long-term extension (LTE) trials. Serious adverse events (SAEs) data were derived from the literature. Total cost estimation (€, 2018) included drug acquisition, parenteral administration, disease progression and SAE management. Results In the csDMARD-IR population, sequences starting with tofacitinib proved dominant options (more QALYs and lower costs) versus the corresponding sequences without tofacitinib. In the TNFi-IR population, first-line treatment with tofacitinib+MTX followed by scAbatacept+MTX➔rituximab+MTX➔certolizumab+MTX proved dominant versus scTocilizumab+MTX➔scAbatacept+MTX➔rituximab+MTX➔certolizumab+MTX; and tofacitinib+MTX➔scTocilizumab+MTX➔scAbatacept+MTX➔rituximab+MTX versus scTocilizumab+MTX➔scAbatacept+MTX➔rituximab+MTX➔certolizumab+MTX was less effective but remained a cost-saving option. Conclusions Inclusion of tofacitinib seems a dominant strategy in moderate-to-severe RA patients after csDMARDs failure. Tofacitinib, as initial third-line therapy, proved a cost-saving strategy (€− 337,489/QALY foregone) in moderate-to-severe TNFi-IR RA patients. Key points• Therapeutical approach in rheumatoid arthritis (RA) consisted in sequences of several therapies during patient lifetime.• Treatment sequences initiating with tofacitinib followed by biological drugs provided higher health effects in csDMARDs-IR population, compared with sequences containing only biological drugs.• In both csDMARD-IR and TNFi-IR RA populations, initiating treatment with tofacitinib was associated to lower treatment costs for the Spanish National Health System.

scholarly journals EP13 A case of candida albicans septic sacroiliitis complicating severe COVID-19 infection

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Ioana Onac ◽  
Saadia Ali ◽  
Arti Mahto ◽  
Andrew Rutherford ◽  
James Galloway ◽  
...  
Keyword(s):  
Candida Albicans ◽  
Case Report ◽  
Inflammatory Markers ◽  
Candida Glabrata ◽  
Fungal Infections ◽  
Multidrug Resistant ◽  
Sacroiliac Joints ◽  
Gram Negative ◽  
Septic Sacroiliitis

Abstract Case report - Introduction Bacterial and fungal infections are recognised complications of viral pneumonia, particularly in patients who are critically ill. We describe a case of fungal sacroiliitis complicating severe COVID-19 pneumonia following a prolonged intensive care unit (ICU) admission. Candida albicans sacroilitis is a rarely reported infection with few case reports in the literature. Candida osteoarticular infections can present as septic arthritis, with knee involvement in 75% of cases, or osteomyelitis. The latter presentation differs based on age - vertebral involvement (51%) is more common in adults while children are more likely to present with infection in the long bones, ribs, or sternum. Case report - Case description A 48-year-old Afro-Caribbean gentleman with a history of hypertension and obesity was admitted to the ICU with clinical, laboratory and radiographic features of COVID-19 infection despite persistently negative swabs. Whilst in ICU he required mechanical ventilation. His stay was further complicated by multiple infections, pulmonary emboli, and the presence of a cavitating lesion in the left lung. Cultures from bronchoalveolar lavage and a central venous catheter line grew Serratia Mascense, candida glabrata and pseudomonas were isolated from his urine. He was treated with multiple antibiotics including meropenem, tazocin, ceftazidime and avibactam. After 61 days in the ICU he was transferred to the ward. He developed severe pain in his right hip which was worse on movement. This was followed by urinary incontinence and sensory deficit in the right L2/L3 dermatome. He underwent magnetic resonance imaging (MRI) of his spine and sacroiliac joints which showed right sided sacroiliitis and oedema around the iliopsoas muscle. He was started on vancomycin, later changed to ceftazidime avibactam and metronidazole. An echocardiogram did not show any vegetations. He underwent a biopsy of his sacroiliac joints which confirmed the presence of leucocytes, extended cultures yielded candida albicans in one out of two biopsy specimens. Considering ongoing pyrexia, pain and inflammatory markers, intravenous fluconazole was added to his antibiotic regimen which resulted in a marked improvement in mobility. After four weeks, ceftazidime, metronidazole and avibactam were stopped, and fluconazole was administered as oral tablets. 6 days later he became febrile and IV fluconazole was restarted. A repeat chest CT showed resolution of the cavity but ongoing changes suggestive of organising pneumonia. A repeat MRI of the sacroiliac joints revealed minor improvement. Intravenous Fluconazole was continued for a total of 8 weeks and was changed to tablets for complete a total of 12 weeks. Case report - Discussion This is a severe case of COVID-19 infection who despite 9 negative PCR tests, on day 53, had positive IgG for SARS-CoV-2 infection, confirming our clinical suspicion. Particularly in the ICU setting, individuals are approximately ten times more likely to have secondary bacterial/fungal infections with more frequent detection of multidrug-resistant Gram- negative pathogens. This case highlights several difficulties. Urine cultures had confirmed candida albicans, likely to be related to catheter related urinary tract infections, and a possible source for our patient but also a resistant pseudomonas aeruginosa species. Furthermore, cultures were positive for Serratia Mascense, candida glabrata. He had also already been treated with prolonged, broad spectrum antimicrobial treatment. Considering this, establishing the aetiology of the septic sacroiliitis was challenging. The rarity of candida sacroiliitis and presence of the organism in just one specimen made this more difficult. This led to the decision of a repeat sacroiliac biopsy to supply sufficient samples for further microbial analyses such as 16S, 18S and mycobacteria culture, all of which were negative. He became febrile after the discontinuation of antimicrobials and a switch to oral fluconazole therapy. He was extensively re-investigated and despite resolution of the lung cavity, there were changes which could have been consistent with an organising pneumonia. At this point he was neutropenic, mildly eosinophilic, and therefore a drug reaction was also considered. Repeat MRI revealed resolving muscle inflammation and minimal change at the bone site, with erosions and possible reactive bone marrow oedema. Following discussion with microbiology the decision was made to persist with intravenous Fluconazole. He continued to improve, and his inflammatory markers normalised after 8 weeks of treatment. Prednisolone was started for COVID-19 related pneumonitis. Long-term antifungal treatment is advisable, and we aim to complete 12 weeks of treatment. Case report - Key learning points  Patients with SARS-CoV-2 infection, particularly those requiring ICU admission were at risk of developing superinfections with multidrug-resistant Gram-negative bacteria or fungal infections.Candida albicans sacroiliitis is rare therefore early aspiration/biopsy is essential for the management.Longer treatment is needed in osteoarticular candida infections, even up to 6 or 12 months, therefor long-term close monitoring of this patients is essential.The utility and timing of reimaging patients following such infections is still unclearClose multidisciplinary and interdisciplinary team collaboration is essential in the management of this complex patients

scholarly journals P11 Multiple insufficiency fractures in rheumatoid arthritis

2021 ◽  
Vol 5 (Supplement_1) ◽  
Author(s):  
Qurat Ul Ain Amjad ◽  
Spencer Ellis
Keyword(s):  
Rheumatoid Arthritis ◽  
Vitamin D ◽  
Case Report ◽  
Treatment Failure ◽  
Fracture Risk ◽  
Inflammatory Markers ◽  
Disease Duration ◽  
Stress Fractures ◽  
Insufficiency Fractures ◽  
History Of

Abstract Case report - Introduction Rheumatoid arthritis (RA) is an autoimmune inflammatory arthropathy with systemic manifestations. It is 4-times more common in females. RA is recognised to induce bone loss and decrease in bone mineral density (BMD). Management may include corticosteroids (CS) for new presentations, acute flares, and more rarely longer-term management, which increases bone fragility. Patients are at 30—50% increased risk of developing osteoporosis with a 30% increase in fracture risk. This risk rises with the level of persistent disease inflammation. We present a case of a lady with longstanding RA, who sustained multiple bone fractures without significant osteoporosis on bone density scanning. Case report - Case description Our patient is a 64-year-old headteacher who took early retirement due to reduced mobility after 20 years of seropositive RA. She had received multiple disease modifying drugs (DMARDs) and biologics therapies, requiring repeated alterations primarily due to treatment failure. She was commenced on alendronic acid due to osteopaenia of the hip but 2 years later sustained a fractured neck of femur and was switched to risedronate. A year later she presented with acutely painful and swollen right foot and ankle without history of trauma. X-rays showed progressive degenerative change whilst inflammatory markers were normal. Ultrasound demonstrated sub-clinical synovitis. Her medication was optimised but the ankle swelling persisted, rendering her wheelchair-reliant. MRI revealed multiple stress fractures involving calcaneum, talus and 5th proximal phalanx. She was treated with 16 weeks of an Aircast boot. An old right upper medial tibial fracture was also identified. Repeat dual energy X-ray absorptiometry (DEXA) scan showed osteopaenia but with improvement from the previous scan (T score of -2.1 total hip and -1.6 lumbar vertebra). She smoked 1 cigarette a day, did not drink alcohol and there was no parental history of fractures. No evidence of malabsorption or endocrine disorder was identified. Unusually, she had received tamoxifen in her late 20s for cancer prevention based on breast fibroadenosis and she experienced early menopause aged 36 years. Inflammatory markers, calcium, parathyroid hormone, and immunoglobulins were normal. Vitamin D3 levels were insufficient at 40.3 nmol/l and replacement was initiated, following which she was switched to intravenous zoledronic acid. After one infusion of zolendronate, she twisted her right ankle and sustained a new malleolar fracture. She was converted to 6-monthly denosumab injections along with calcium and vitamin D, which has been continued. Her RA remains active, and she has recently commenced JAK2 inhibitors. Case report - Discussion Inflammatory arthropathies such as RA predispose to significant morbidity and disability. An earlier age of diagnosis poses a longer inflammatory response in body, with a higher incidence of bone health complications. A treat-to-target strategy in RA aids optimal disease management and reduces fracture risk. Studies have shown the risk of osteoporosis in RA is not just disease dependent but also affected by certain medications. Treatment challenges arise when a patient sustains fracture despite a BMD above osteoporosis risk criteria, leading us to consider other variables. She was further investigated for secondary causes of osteoporosis, including endocrine causes, and was found to be vitamin D insufficient, which was replaced prior to further antiresorptive treatment. Our case also highlights a diagnostic dilemma given that our patient presented with a single swollen joint assumed to be due to active RA. Multiple insufficiency fractures were only identified after MRI was performed. As per EULAR criteria, our patient had difficult to treat RA with a long disease duration. She showed intolerance to a several DMARDs and treatment failure with multiple biologic therapies. She had required local joint injections and repeated short courses of oral steroids. These factors are likely to have played a considerable role in her fracture development. RA is an independent risk factor for fracture in both men and women with disease duration and CS use being important clinical variables. Bisphosphonates are considered vital in fracture risk reduction. The compliance is an important factor for both primary and secondary prevention of fracture. They are associated with decreased bone remodelling and have been well studied for atypical femoral fractures; however, whether there is any link with stress fractures in the feet requires further studies. Long-term use (>5years) hasn’t shown to be beneficial in preventing hip fractures. Case report - Key learning points

scholarly journals AB0651 CASE-REPORT: ORGANIZING PNEUMONIA IN A PREGNANT WOMAN WITH RHEUMATOID ARTHRITIS DURING COVID-19 PANDEMIC

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1358.2-1359
Author(s):  
A. Cornillie ◽  
C. Grivegnee
Keyword(s):  
Rheumatoid Arthritis ◽  
Case Report ◽  
Pregnant Woman ◽  
Clinical Condition ◽  
Lung Biopsy ◽  
Clinical Case ◽  
Chest Ct ◽  
Ground Glass ◽  
Organizing Pneumonia ◽  
Systemic Inflammatory Disease

Conclusion:Case-report: Organizing pneumonia in a pregnant woman with rheumatoid arthritis during Covid-19 pandemicCORNILLIE Alexia, GRIVEGNEE Camille, CHU Charleroi Marie-CurieIntroductionRheumatoid arthritis (RA) is a systemic inflammatory disease characterized by destructive polyarthritis and extra-articular organ involvement. Lungs are one of the most commonly affected organ in RA, and the lung involvement in RA results in a various clinical features including interstitial lung disease (ILD) and organizing pneumonia (OP).OP is a histologic term characterized by the presence of buds of granulation tissue in bronchioles and alveoli. OP can be either idiopathic (cryptogenic organizing pneumonia) or secondary to underlying disease such as infection, drugs or connective tissue disease including RA.Lung biopsy is usually recommended for the diagnosis, but the following criteria fulfilled by patients can lead to the diagnosis: (1) specific radiological manifestations (nonsegmental randomized consolidation with/without ground grass opacities in chest CT), (2) no causative infectious agent, (3) no response to antibiotics and (4) good response to corticosteroid therapy.We describe here the case of organized pneumonia discovered in a pregnant woman with known rheumatoid arthritis during COVID-19 pandemic.Case descriptionA 39-year old moroccan woman, gravida 4, para 1, was admitted during COVID-19 pandemic at 30 weeks’ gestation to maternity hospital with a 1-week history of cough, dyspnea and fever. Her medical history included rheumatoid arthritis and gestational diabetes. She was treated with 5mg of prednisolone daily for her RA. Blood sample showed white blood cell count and C reactive protein at a level of 6860/mm3 and 42mg/L respectively. Chest CT performed at her admission revealed diffuse irregular nodular condensations associated with ground glass infiltrates and a right lower lobe parenchymal condensation with airbronchogram in favor of superinfection. Given circumstances, she was tested twice for SARS-Cov-2 48 hours apart by PCR on nasopharyngeal sample and results came back negative. She was treated empirically with ceftriaxone and azithromycin during the first week and described an improvement in her clinical condition but symptoms reappeared 4 days after stopping treatment. During the 2 following months, until the delivery, the patient remained subpyretic with a nonproductive cough and moderate dyspnea. 5 days after the delivery, due to persistant dyspnea and fever, a new chest CT was performed and revealed similar image findings but some of the irregular nodular condensations showed a reversed halo sign and had a migrating character. Considering this typical image findings, the absence of causative infectious agents (excluded by bronchoalveaolar lavage performed after delivery) and the absence of response to antibiotics, we concluded with a diagnosis of OP secondary to RA without performing lung biopsy samples. A treatment with 48mg of methylprednisolone (and 100mg of azathioprine a few weeks later) was initiated. One month later, she showed a spectacular improvement in her clinical condition. A new chest CT highlighted disappearance of the majority of the ground glass areas and of all the condensations previously described. Methylprednisolone was then progressively tapered.ConclusionOP is a common pulmonary complication that can develop in RA. However, despite ou research, we have not found any other clinical case describing this disorder during pregnancy with RA. Since OP is a non-specific inflammatory response to an aggression of the organism, could we consider that the pregnancy is a state of aggression capable of causing such a response?In addition, this clinical case illustrates the diagnostic challenge of this pathology during the Covid-19 pandemic.Disclosure of Interests:None declared.

scholarly journals Case Report on Steroid Induced Cushing Syndrome

2019 ◽  
Vol 9 (4-s) ◽  
pp. 598-600
Author(s):  
Shaik Salma
Keyword(s):  
Rheumatoid Arthritis ◽  
Case Report ◽  
Cushing Syndrome ◽  
Allergic Diseases ◽  
Term Effect ◽  
Long Term Effect ◽  
Oral Hypoglycemics ◽  
Steroid Drugs ◽  
Buffalo Hump

Glucocorticoids are the effective steroid drugs which reduce the inflammation & most commonly glucocorticoids are used in diseases such as asthma, allergic diseases such as psoriasis, eczema and rheumatoid arthritis. Long term effect of corticosteroids leads to the symptoms of moon face, buffalo hump, pink stretch marks, and weight gain. In this we are going to report a case of 30 yrs female patient with representing the long term use of corticosteroids; Prednisolone leads to cushing syndrome. Eventually she was treated with oral hypoglycemics and diuretics and the use of steroid had stopped temporarily and the dose of prednisolone was tapered. Keywords: glucocorticoids, prednisolone, Cushing syndrome

scholarly journals Immunomodulatory and Anti-fibrotic Effects Following the Infusion of Umbilical Cord Mesenchymal Stromal Cells in a Critically Ill Patient With COVID-19 Presenting Lung Fibrosis: A Case Report

2021 ◽  
Vol 8 ◽  
Author(s):  
Kátia Nunes da Silva ◽  
Priscila Carvalho Guedes Pinheiro ◽  
André Luiz Nunes Gobatto ◽  
Rogério da Hora Passos ◽  
Bruno Diaz Paredes ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Case Report ◽  
Cell Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Lung Inflammation ◽  
Lung Fibrosis ◽  
Mesenchymal Stromal Cell ◽  
Stromal Cell

Background: The patients with coronavirus disease 2019 (COVID-19) associated with severe acute respiratory distress syndrome (ARDS) may require prolonged mechanical ventilation which often results in lung fibrosis, thus worsening the prognosis and increasing fatality rates. A mesenchymal stromal cell (MSC) therapy may decrease lung inflammation and accelerate recovery in COVID-19. In this context, some studies have reported the effects of MSC therapy for patients not requiring invasive ventilation or during the first hours of tracheal intubation. However, this is the first case report presenting the reduction of not only lung inflammation but also lung fibrosis in a critically ill long-term mechanically ventilated patient with COVID-19.Case Presentation: This is a case report of a 30-year-old male patient with COVID-19 under invasive mechanical ventilation for 14 days in the intensive care unit (ICU), who presented progressive clinical deterioration associated with lung fibrosis. The symptoms onset was 35 days before MSC therapy. The patient was treated with allogenic human umbilical-cord derived MSCs [5 × 107 (2 doses 2 days interval)]. No serious adverse events were observed during and after MSC administration. After MSC therapy, PaO2/FiO2 ratio increased, the need for vasoactive drugs reduced, chest CT scan imaging, which initially showed signs of bilateral and peripheral ground-glass, as well as consolidation and fibrosis, improved, and the systemic mediators associated with inflammation decreased. Modulation of the different cell populations in peripheral blood was also observed, such as a reduction in inflammatory monocytes and an increase in the frequency of patrolling monocytes, CD4+ lymphocytes, and type 2 classical dendritic cells (cDC2). The patient was discharged 13 days after the cell therapy.Conclusions: Mesenchymal stromal cell therapy may be a promising option in critically ill patients with COVID-19 presenting both severe lung inflammation and fibrosis. Further clinical trials could better assess the efficacy of MSC therapy in critically ill patients with COVID-19 with lung fibrosis associated with long-term mechanical ventilation.

Long-Term Successful Outcome of Severe Hand Ischemia Using Arterialization With Reversal of Venous Flow: Case Report

2008 ◽  
Vol 33 (7) ◽  
pp. 1048-1051 ◽  
Author(s):  
George D. Chloros ◽  
Zhongyu Li ◽  
L. Andrew Koman
Keyword(s):  
Case Report ◽  
Successful Outcome ◽  
Venous Flow ◽  
Hand Ischemia ◽  
Flow Case

scholarly journals T-Cell Subsets in Rheumatoid Arthritis Patients on Long-Term Anti-TNF or IL-6 Receptor Blocker Therapy

2017 ◽  
Vol 2017 ◽  
pp. 1-19 ◽  
Author(s):  
Sonja Dulic ◽  
Zsófia Vásárhelyi ◽  
Florentina Sava ◽  
László Berta ◽  
Balázs Szalay ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
T Cells ◽  
T Cell ◽  
T Cell Subsets ◽  
Cell Phenotype ◽  
Healthy Controls ◽  
Biological Therapies ◽  
Cd8 Cells ◽  
The Impact

Data on the impact of biological therapies on the T-cell phenotype in rheumatoid arthritis are limited. Here, we prospectively measured the percentages of 15 circulating T-cell subtypes using flow cytometry. We obtained transversal and longitudinal data in 30 anti-TNF responders, 19 secondary anti-TNF nonresponders, and 43 IL-6R antagonist responders, before, 8 weeks and at least 6 months after biological therapy. Untreated RA patients and healthy controls were also included. The important findings are the following: (1) the proportion of regulatory T-cells (Tregs) which are decreased in untreated RA patients becomes normal in all long-term-treated groups; (2) in anti-TNF responders as well as in nonresponders, the frequencies of naïve CD4+ and CD8+ cells are lower, whereas those of proinflammatory Th1, Th2, and Th17 cells and HLA-DR+-activated cells are higher than those in untreated RA or healthy controls; (3) in IL-6R responders, Th1 proportion is decreased, while that of Th2 and Th17 is increased as compared to that in anti-TNF-treated patients and controls; (4) pending confirmation, a CD4CD69 ratio < 2.43 at baseline, could be useful to predict a good therapeutic response to anti-TNF therapy. This study provides comprehensive information regarding the long-term impacts of those biological therapies on the ecotaxis of T-cells in RA. The ClinicalTrials.gov registration number of our study is NCT03266822.

Sign in / Sign up

Export Citation Format

Share Document