Haemophagocytic Lymphohistiocytosis in COVID-19

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COVID-19
Peripheral blood smear showing the presence of schistocytes (Leishman stain, 1000x).

Haematological manifestations of COVID-19

Cases of haemophagocytic lymphohistiocytosis has surfaced as an uncommon complication of COVID-19, in addition to rare incidences of thrombotic thrombocytopenic purpura. This article highlights the case of a 21-year-old man who developed both these complications while he was at the hospital recovering from COVID-19. He initially presented with fever and bilateral COVID-19 related pneumonia, for which he required invasive ventilation. During his hospitalisation tenure, he also developed pneumothorax, ventilator-associated pneumonia, thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis.

Doctors put the patient on supportive care and prescribed remdesivir, IVIG, steroid, fresh frozen plasma.

The 21-year-old presented to the emergency of King George’s medical university, Lucknow with a history of fever of 2 weeks. He had high-grade fever for 7 days accompanied with symptoms of dry cough and high-grade fever. There were no other symptoms of skin rash, haemoptysis, expectoration, chest pain, rigour or chills. His medical history was clear of addiction, tuberculosis and any other known illnesses or comorbidities.

Physical examination showed that the patient was severely breathless despite being conscious oriented. The patient’s built appeared to be thin and cachexic with a body mass index (BMI) of 15 kg/m2. His blood pressure was 118/70 mm Hg with a pulse rate of 104/min and respiratory rate of 24/min. Further findings showed pallor with no icterus, oedema or lymphadenopathy. Chest examination was consistent with bilateral diffuse crackles, whereas abdominal examination showed splenomegaly 3 cm below the left costal margin. Other examinations including cardiovascular and neurological examination were normal.

Doctors initially advised the patient with noninvasive ventilation but it was inadequate for maintaining oxygen saturation.

He developed multiple episodes of seizures, requiring intubation and invasive ventilation. Although the seizures subsided after administering of antiepileptic medications, he suffered from altered sensorium with sensorium of E2VTM5 on Glasgow Coma Scale. His COVID-19 test results came back positive and he was to the COVID-19 intensive care unit (ICU) setup.

On the 3rd day of his admission, despite ventilatory support, he was not maintaining oxygen saturation. Examination showed absent breath sounds on the right side. The patient’s X-ray confirmed the possibility of right-sided pneumothorax, allegedly because of barotrauma. Intercostal drainage was done urgently after which his vitals stabilised. Treatment included invasive ventilation, antiepileptic medications and broad-spectrum antibiotics. He showed improvement for a limited time period and passed away after a prolonged stay at the hospital for 2 months.

References

Complicated case of COVID-19 disease with overlapping features of thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis https://casereports.bmj.com/content/14/5/e242202

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Dr. Aiman Shahab is a dentist with a bachelor’s degree from Dow University of Health Sciences. She is an experienced freelance writer with a demonstrated history of working in the health industry. Skilled in general dentistry, she is currently working as an associate dentist at a private dental clinic in Karachi, freelance content writer and as a part time science instructor with Little Medical School. She has also been an ambassador for PDC in the past from the year 2016 – 2018, and her responsibilities included acting as a representative and volunteer for PDC with an intention to make the dental community of Pakistan more connected and to work for benefiting the underprivileged. When she’s not working, you’ll either find her reading or aimlessly walking around for the sake of exploring. Her future plans include getting a master’s degree in maxillofacial and oral surgery, settled in a metropolitan city of North America.

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