Bilateral adrenal haemorrhage with renal infarction after ChAdOx1 nCoV-19 AstraZeneca vaccination

Vaccine-induced thrombotic thrombocytopaenia (VITT) is a rare syndrome associated with the ChAdOx1 nCoV-19 (AstraZeneca) vaccine. We detail a case of vaccine-induced thrombotic thrombocytopaenia in a 47-year-old female who was found to have bilateral adrenal haemorrhage, renal vein thrombosis, renal infarction and pulmonary embolism 13 days post-vaccination with ChAdOx1 nCoV-19.

Anterior Minithoracotomy vs. Transcatheter Closure of Patent Ductus Arteriosus in Very Preterm Infants

Introduction: Patent ductus arteriosus (PDA) is common in preterm infants and contributes to morbidity and mortality. Several studies have shown the feasibility and safety of percutaneous PDA closure. Minimally invasive surgical ligation by anterior thoracotomy is an alternative, bedside technique for PDA closure in very low birth weight preterm infants. Our study aimed to compare short- and medium-term morbidity and mortality between anterior minithoracotomy and transcatheter PDA closure.Methods: From 2010 to 2020, 92 preterm infants <1,600 g underwent PDA closure in two centers: 44 surgical anterior minithoracotomies (center 1) and 48 transcatheter closures (center 2). Using a 1:1 propensity score match analysis, 22 patients in each group were included. The primary outcome was time to extubation after intervention.Results: Preoperative characteristics were similar in both groups after propensity matching (mean weight at procedure, 1,171 ± 183 g; p = 0.8). Mean time to extubation was similar: 10 ± 15 days in the surgical group vs. 9 ± 13 days in the transcatheter group (p = 0.9). Mean age at hospital discharge was 114 ± 29 days vs. 105 ± 19 days (p = 0.2). Two deaths occurred in the surgical group and one in the transcatheter group (p = 0.61). Five complications (pneumothorax n = 2, chylothorax n = 2, phrenic nerve injury n = 1) occurred in three patients after surgery. Three complications (chylothorax n = 1, endocarditis n = 1, renal vein thrombosis n = 1) occurred in two patients after percutaneous closure (p = 0.63).Conclusion: Equivalent efficiency and safety of surgical mini-invasive vs. transcatheter PDA closure in preterm infants <1,600 g are in favor of applying these alternative techniques according to centers' facilities and competences.

Renal arteriovenous malformation and venous thrombosis: a tumour-like presentation

Renal arteriovenous malformation is a primarily congenital renal vascular abnormality. It is usually diagnosed incidentally on imaging, and the most common subtype is ‘cirsoid’, consisting of multiple, enlarged arterial feeders interconnecting with draining veins. We present a 74-year-old woman with an incidental finding of what was at first considered a hypervascularised kidney tumour but turned out to be a left intrarenal arteriovenous malformation associated with a left renal vein thrombosis. Selective endovascular embolisation was performed. The cause-consequence relationship between the arteriovenous malformation and the thrombosis is unique. To our knowledge, no such case has ever been reported.

RENAL VEIN THROMBOSIS WITH INFRAHEPATIC INFERIOR VENA CAVA EXTENSION IN A CASE OF ANTI dsDNA ANTIBODY NEGATIVE LUPUS NEPHRITIS

Systemic Lupus Erythematosis (SLE) is a chronic autoimmune disease of unknown cause that can affect virtually any organ of the body. Anti dsDNA antibody has been considered as a marker of renal disease. Hence elevated levels are expected in patients with Lupus Nephritis (LN). But in a subset of these patients anti dsDNA antibody is negative and this heralds the development of burned out LN (stage 5 LN) which predisposes patients to thrombosis. Prophylactic anticoagulation plays an important role in the management of such patients. We describe a case of a 19 year old female with lupus nephritis and renal vein thrombosis that had extended into the inferior vena cava. Her serology was strikingly signicant for the absence of anti dsDNA antibody. The factors that predispose to the development of venous thrombosis in patients with Lupus Nephritis are discussed. In conclusion, negative anti dsDNA antibodies heralds the development of stage ve Lupus Nephritis which predisposes to thrombosis. Guidelines for prophylactic anticoagulation as per serum albumin levels are also discussed.

Renal Vein Thrombosis and Pulmonary Embolism Secondary to Vaccine-induced Thrombotic Thrombocytopenia (VITT)

The Medicines and Healthcare products Regulatory Agency (MHRA) of the UK has approved the use of three vaccines to combat COVID-19 (SARS-CoV-2). There have been rare reports of thrombosis after vaccination with the AstraZeneca vaccine. We present three cases of vaccine-induced thrombotic thrombocytopenia (VITT) in one UK district general hospital following administration of this vaccine. Two of the patients had asymptomatic pulmonary emboli, while the other is the first known case of both renal vein thrombosis and pulmonary embolism.

Clinico-etiological profile of hospitalized paediatric patients: COVID-19 and non-COVID-19 in a district hospital of Northern India during lockdown period

Background: With the sudden outbreak of coronavirus pandemic in 2020, there is a paucity of data on the clinical and epidemiological profile of COVID positive paediatric patients. Objective of the study was a retrospective analysis of both COVID-19 and non-COVID-19 cases admitted to a district Hospital of Northern India.Methods: A retrospective cross-sectional study was conducted in the Pediatric Emergency Department of Government Multi-speciality Hospital, Chandigarh from 22 March 2020 till 30 November 2020.Results: A total of 842 children were enrolled. Among neonates, 33% had sepsis as the major admitting diagnosis and SARI in children less than 1 year (excluding neonates) (33.5%) and in the 1-5 years age group (37.3%). In children more than 5 years, acute febrile illnesses were the main admitting diagnosis (50.4%). 204 patients (24.2%) were tested for COVID-19. 62 children (30.4%) were found to be positive. Asymptomatic children (74.2%) dominated the COVID-19 positive group. The most common symptom included fever (87.5%) with no reported mortality. Atypical symptoms (56.1%) were more common than respiratory symptoms. The majority of children had mild COVID-19 symptoms (62.6%). The unusual presentation of COVID-19 was in the form of acute appendicitis (6.2%) and renal vein thrombosis (6.2%) in the symptomatic group.Conclusions: For children with COVID-19, most of them were infected via family clustering, were asymptomatic, and had mild symptoms with an overall good prognosis. However, for atypical cases, a high suspicion of COVID-19 associated multisystem inflammatory syndrome should be kept in mind for early diagnosis.

MO322VENOUS THROMBOEMBOLISM AND NEPHROTIC SYDROME: A FAMOUS BUT STILL SURPRISING COUPLE

Background Venous thromboembolism (VTE) is a multifactorial disorder, accounting for high morbidity and mortality rates, due to a complex interplay of several variables classifiable as inherited (mutated Leiden V factor, prothrombin, protein C, protein S and antithrombin) and acquired (lupus anticoagulants, pregnancy, major surgery procedures, cancer and inflammatory diseases) risk factors. The association of VTE with the nephrotic syndrome, particularly deep vein and renal vein thrombosis (DVT and RVT, respectively) is tightly established. This risk is particularly high in patients with idiopathic membranous nephropathy. In fact, thromboembolic events occur with a frequency between <10% and 45% in this disease. The reason(s) underlying the hypercoagulable status in nephrotic patients are not clearly understood. Multiple hemostatic abnormalities have been described, including decreased levels of antithrombin and plasminogen (due to urinary losses), increased platelet activation, reduced plasminogen activation, overproduction of fibrinogen and factors V and VIII as a compensatory response to hypoalbuminemia. The risk of thrombosis seems to be related to the severity and duration of the nephrotic status and seems to be particularly increased with serum albumin concentrations ≤2.0 g/dl (20 g/L). Case report We report the case of a 28 year-old male with nephrotic syndrome due to membranous nephropathy positive for serum anti-phospholipase-A2 receptor antibody. The patient was asymptomatic for VTE, but abdominal ultrasound showed endoluminal obstruction of both renal veins. Abdominal Computer Tomography confirmed the extensive bilateral renal vein thrombosis and also revealed an extension of the thrombosis to the inferior cava vein and the left common iliac vein. He was treated with low-molecular weight heparin for six months. According to our internal protocol, a complete Thrombophilia Molecular Study was performed and showed a normal Leiden V factor, but a rare homozygous mutation of the G20210A gene encoding for prothrombin. The prevalence of this is less than 5% in the general population, but is highly variable with ethnicity. The G20210A mutation confers a mildly increased thrombotic risk that is amplified by the presence of other risk factors, such as nephrotic syndrome. Conclusions In our case report, the association of a nephrotic syndrome secondary to a primitive membranous glomerulonephritis and the mutation in homozygous of the G20210A prothrombin, a rare mutation associated with a high thrombotic risk, led to a severe VTE in an still asymptomatic 28-year-old patient. Based on this experience, we would highlight the importance of the genetic screening for polymorphisms associated with inherited thrombophilia in nephrotic patients complicated with VTE.