COVID-19 vaccination associated severe immune thrombocytopenia

Background Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has emerged as a deadliest global pandemic after its identification in December 2019 in Wuhan, China resulting in more than three million deaths worldwide. Recently FDA issued emergency authorization for three vaccines for prevention of COVID-19. Here in, we report three cases of severe immune thrombocytopenia (ITP) following COVID-19 vaccination and their clinical course. Case presentations Case #1: 53 year old male with past medical history of Crohn’s disease was admitted for myalgias and diffuse petechial rash 8 days after receiving second dose of Pfizer-BioNTech COVID-19 vaccine. A complete blood test showed a platelet count of 2 × 109/L. Patient did not have a prior history of thrombocytopenia and other causes of thrombocytopenia were ruled out by history and pertinent lab data. He received two doses of intravenous immunoglobulin and oral dexamethasone for 4 days resulting in normalization of platelet counts. Case #2: 67 year male with past medical history of chronic ITP in remission was admitted for melena 2 days after receiving his first dose of Pfizer-BioNTech COVID-19 vaccine. A complete blood test showed a platelet count of 2 × 109/L. Physical exam showed generalized petechiae. There was no history of recent flares of ITP and patient had normal platelet counts following his splenectomy 4 years ago. He received two doses of IVIG and oral dexamethasone for 4 days with gradual improvement in platelet counts. Case #3: 59 year old female with past medical history of chronic ITP secondary to SLE was admitted for bloody diarrhea 2 days after receiving her first dose of Johnson and Johnson COVID-19 vaccine. Physical exam was unremarkable. A complete blood test showed platelet count of 64 × 109/L which dropped to 27 × 109/L during hospital course. She received oral dexamethasone for 4 days with improvement in platelet counts. Conclusion COVID-19 vaccination induced ITP has been recently acknowledged. However, given very few cases and limited data, currently there are no guidelines for management of ITP caused by COVID-19 vaccine as well as vaccination of people with predisposing conditions.

Comparative study of oral and IV dexamethasone premedication in the prevention of docetaxel induced allergic reactions

Background The hypersensitivity reactions after docetaxel administration is a main concern in this study. The aim of this study is to check the incidence of hypersensitivity reactions (HSRs) after receiving a single dose of intravenous dexamethasone before docetaxel administration Method In this retrospective study, 1 year data from Jan 1st 2018 to Dec 31st 2018 was retrieved from hospital information system (HIS). We examined 210 patients who visited hospital during the last 12 months during their cancer treatment and took dexamethasone orally 3 days prior to docetaxel administration or 20 mg intravenously before 15 minutes of docetaxel. Results Out of 210 patients, only 50 patients were taking IV dexamethasone injection prior to docetaxel constitutes only 23.5% while patients who were taking oral dexamethasone were found to be 160 which constitutes 75%. There was no hypersensitivity reaction with oral and IV dexamethasone before docetaxel administration. Majority of the patients were without taking oral dexamethasone before docetaxel administration which not only saved time but also improve patient compliance. Conclusion No hypersensitivity reaction had been found either in oral or intravenous dexamethasone prior to docetaxel administration by using patient data from Hospital Information System (HIS). However, intravenous dexamethasone not only improve patient compliance but also reduce the risk of hypersensitivity reactions but the cost of intravenous dexamethasone is higher than the cost of oral dexamethasone. In conclusion, single dose of intravenous IV dexamethasone is preferred treatment option.

Successful live birth in a Chinese woman with P450 oxidoreductase deficiency through frozen-thawed embryo transfer: a case report with review of the literature

Background Congenital adrenal hyperplasia (CAH) caused by P450 oxidoreductase deficiency (PORD) in 46, XX patients is characterized by genital ambiguity, primary amenorrhea, absent or incomplete sexual maturation, infertility, skeletal malformations and so on. But few pregnancies have been reported from these female patients with PORD. Case description A 29-year-old Chinese woman with PORD due to the compound heterozygous mutation (c.1370G > A/c.1196_1204del) in the P450 oxidoreductase (POR) gene had suffered from primary amenorrhea and infertility. She had one cancelled cycle of ovulation induction due to low serum estradiol(E2), high progesterone(P) levels and thin endometrium, then in vitro fertilization (IVF) was recommended. At the first IVF cycle, 4 oocytes were retrieved and 4 viable embryos were cryopreserved due to thin endometrium associated with low E2 and prematurely elevated P after ovarian stimulation, even though oral dexamethasone were used to control adrenal P overproduction at the same time. When basal P fell to < 1.5 ng/ml after the therapy of oral dexamethasone, artificial endometrial preparation and frozen embryo transfer were performed, resulting in a twin pregnancy. She delivered a healthy boy and a healthy girl by caesarean section at 37 weeks and 2 days of gestation. After the literature search in PORD women, no spontaneous pregnancy has been reported and only two previous case reports of 3 successful pregnancies through IVF were summarized. Conclusions It is the third report that successful pregnancy was achieved in a CAH woman caused by a compound heterozygous POR mutation, with primary amenorrhea and disorders of steroidogenesis. It seemed that disorders of steroidogenesis caused by PORD didn’t impair the developmental potential of oocytes. IVF and frozen embryo transfer after adequate hormonal control and endometrial preparation should be an effective infertility treatment for PORD women.

Successful live birth in a Chinese woman with P450 oxidoreductase deficiency through frozen-thawed embryo transfer: a case report with review of the literature

Background: Congenital adrenal hyperplasia (CAH) caused by P450 oxidoreductase deficiency (PORD) in 46,XX patients is characterized by genital ambiguity, primary amenorrhea, absent or incomplete sexual maturation, infertility, skeletal malformations and so on. But few pregnancies have been reported from these female patients with PORD. Case Description: A 29-year-old Chinese woman with PORD due to the compound heterozygous mutation (c.1370G>A/c.1196_1204del) in the P450 oxidoreductase(POR) gene had suffered from primary amenorrhea and infertility. She had one cancelled cycle of ovulation induction due to low serum estradiol(E2), high progesterone(P) levels and thin endometrium，then in vitro fertilization (IVF) was recommended. At the first IVF cycle, 4 oocytes were retrieved and 4 viable embryos were cryopreserved due to thin endometrium associated with low E2 and prematurely elevated P after ovarian stimulation, even though oral dexamethasone were used to control adrenal P overproduction at the same time. When basal P fell to <1.5ng/ml after the therapy of oral dexamethasone, artificial endometrial preparation and frozen embryo transfer were performed, resulting in a twin pregnancy. She delivered a healthy boy and a healthy girl by caesarean section at 37 weeks and 2 days of gestation. After the literature search in PORD women, no spontaneous pregnancy has been reported and only two previous case reports of 3 successful pregnancies through IVF were summarized.Conclusions: It is the third report that successful pregnancy was achieved in a CAH woman caused by a compound heterozygous POR mutation, with primary amenorrhea and disorders of steroidogenesis. It seemed that disorders of steroidogenesis caused by PORD didn’t impair the developmental potential of oocytes. IVF and frozen embryo transfer after adequate hormonal control and endometrial preparation should be an effective infertility treatment for PORD women.

Is Standard Oral Dose Dexamethasone (6mg Once Daily) Prescribed For COVID-19 Pneumonitis Treating Autoimmune Haemolytic Anaemia Associated with COVID-19? A Case Series of Five Patients Providing Us with the Answer

Initially originating as an epidemic respiratory illness in Wuhan, China, COVID-19 eventually spread around the world and has now been declared as a global pandemic disease by the WHO. Our understanding of the pathophysiology of SARS-CoV-2 is evolving with each passage of days. Previously thought to be a respiratory illness resulting in pulmonary complications such as pneumonia, respiratory failure, and acute respiratory distress syndrome now have been found to be causing multiple extra-pulmonary pathologies which includes various degree of autoimmune disorders. Certain group of patients have been found to have autoimmune haemolytic anaemia triggered by COVID-19. We report a case series of five patients who developed COVID-19 induced AIHA which responded dramatically to oral dexamethasone (6mg once daily) initially prescribed for the deteriorating pulmonary function. Therefore, our intuition is dexamethasone prescribed for COVID-19 pneumonitis is beneficial for the rapid recovery of AIHA associated with COVID-19.

Adjunctive treatment with oral dexamethasone in non-ICU patients hospitalised with community-acquired pneumonia: A randomised clinical trial

BackgroundAdjunctive intravenous corticosteroid treatment has shown to reduce length of stay (LOS) in adults hospitalised with community-acquired pneumonia (CAP). We aimed to assess the effect of oral dexamethasone on LOS and whether this effect is disease severity dependent.MethodsIn this multicentre, stratified randomised, double-blind, placebo-controlled trial, immunocompetent adults with CAP were randomly assigned (1:1 ratio) to receive oral dexamethasone (6 mg once daily) or placebo for 4 days in four teaching hospitals in the Netherlands. Randomisation (blocks of four) was stratified by CAP severity (pneumonia severity index class I–III and IV-V). The primary outcome was LOS. This study is registered with ClinicalTrials.gov (NCT01743755).ResultsBetween December 2012 and November 2018, 401 patients were randomised to receive dexamethasone (n=203) or placebo (n=198). Median LOS was shorter in the dexamethasone group (4.5 days (95% CI 4.0–5.0)) than in the placebo group (5.0 days (95% CI 4.6–5.4); p=0.033). Within both CAP severity subgroups, differences in LOS between treatment groups were not statistically significant. Secondary ICU admission rate was lower in the dexamethasone arm (5 (3%) versus 14 (7%), p=0.030), 30-day mortality did not differ between groups. In the dexamethasone group rate of hospital readmission tended to be higher (20 (10%) versus 9 (5%); p=0.051) and hyperglycaemia (14 (7%) versus 1 (1%); p=0.001) was more prevalent.ConclusionOral dexamethasone reduced LOS and ICU admission rate in adults hospitalised with CAP. It remains unclear for which patients the risk-benefit ratio is optimal.