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Table of Content - Volume 18 Issue 2 - May 2021
A case series of Response to Intravenous immunoglobulin in patients with worsening multisystem inflammatory syndrome adults associated with SARS-COV2 infection
S Jaganathan1, M Ganeshmoorthy2*, G Arthi3
1HOU Intensive Care, 2,3Consultant, ICU, Dr.Mehta’s Hospitals, Chennai, Tamil Nadu, INDIA. Email: jaganmmc@gmail.com, m.ganeshmoorthy@gmail.com, arthi85med@gmail.com
Abstract Background: In recent times covid 2019 and cytokine release syndrome associated with it poses a great challenge in treatment. We present the cases of 10 patients with severe covid 19 disease 2019 who failed to improve with initial supportive treatment and steroids. IVIG 1g/kg in divided doses for 2 days were given along with steroids and improvements in cytokine release syndrome was noted. Severity of the disease decreased with reduction in oxygen requirement, improved clinical condition and reduced ICU stay. Severity of the disease and hyperinflammation was observed more with male patients. Starting from early 2020, patients with SARS–COV2 have been described to have multisystem inflammatory syndrome – adults. Criteria’s were defined to diagnose Multisystem inflammatory syndrome – Adults which included 1.Severe illness requiring hospitalization with age >21. 2.A positive test for SARS-COV2 within 12 weeks. 3.Severe dysfunction of one or more extrapulmonary organs 4. Lab evidence of severe inflammation. 5.Absence of severe respiratory illness(r/o hypoxia). Key Word: multisystem inflammatory syndrome, SARS-COV2 infection.
INTRODUCTION COVID-19 patients requiring intensive care treatment have high morbidity and mortality. Patients usually deteriorate very fast and almost all of them have hyper-inflammation as common pathway. In addition to steroids we treated ten sick COVID-19 patients having hyper-inflammation with 1gm/kg IVIG in two divided doses for two days and report the improvement in inflammatory markers and clinical condition of the patients.
CASE REPORT Based on our case reports we suggest that patients who have severe hyper-inflammation, clinical deterioration, decreasing spo2 and increasing oxygen requirement when started early with 1g/kg IVIG in divided doses halts disease progression due to hyperinflamation and improve clinical condition by improving oxygenation.2,4,6 Severity of the disease and hyper-inflammation is more among male patients.
DISCUSSION Demographic characteristics We report 10 cases treated at our hospital with intravenous immunoglobulin who had worsening Multisystem Inflammatory Syndrome-Adults. Age of the patients range from 39 to 80. Nine out of ten patients were male, all belong to Asian ethnicity. Eight out of ten patients had respiratory symptoms before MIS-A(Multisystem inflammatory syndrome - Adults). Two out of Ten patients were initially treated in outside hospital and then referred here. Table 1
CRP- c reactive protein, IVIG - intravenous immunoglobulin, MIS-A - multisystem inflammatory syndrome adults,RT-PCR - real time polymerase chain reaction, LDH - Lactatae dehydrogenase,IL6 - Interleukin 6
Comorbid illness Four of the ten patients had no co morbid illness. One patient was obese. Five patients had Diabetes mellitus, of which one was poorly controlled and needed insulin infusion. Three had systemic hypertension and two had CAD and two had hypothyroidism Clinical presentation Seven of the ten persons had more than 24 hrs fever. One patient presented with anosmia and one presented with burning micturition. Two patient presented with dyspnea. Laboratory markers All the patient had elevated markers of inflammation including CRP - C Reactive Protein, Ferritin, D-dimer. All ten patients had RTPCR(Real time polymerase chain reaction) positive and as per our hospital protocol antibody testing not done as RTPCR is positive.
TREATMENT All the patients received corticosteroids initially and when worsening MIS-A(multisystem inflammatory syndrome – adult) happened they were started on 1g/kg intravenous immunoglobulin in two divided doses. All the patients received low molecular heparin. CONCLUSION From the case reports it is clear that MIS-A can present in all age groups in adults. Though the average time duration from the onset of fever and worsening MIS-A was unclear, our case reports indicates worsening MIS-A occurred between 8 and 13 days from the onset of illness. Hyper-inflammation and clinical deterioration with decreasing spo2 and increasing oxygen requirement occurred in almost all patients ,but only three patients required mechanical ventilation support. Two of the patients who required mechanical ventilator support had decreasing trend in inflammatory markers but had secondary hospital acquired infection(HAI) and the third patient had massive pulmonary embolism. Extrapulmonary involvement of SARS-COV-2 is a well-known phenomenon. Most common pathophysiology being endothelial dysfunction, hypercoagulation and Dysregulated immune response. Dysregulated immune response was the important pathway in hyperinflamation and intravenous immunoglobulin prevents hyper-inflammation by regulating immune system by multimodal ways.7,8,12 We used it in patients who are already getting treated with corticosteroids and has worsening MIS-A due to hyperinflamation .Worsening MIS-A was confirmed with raising lab parameters (CRP, FERRITIN , d-DIMER) , requiring more oxygen, clinical deterioration and secondary organ involvement.1,3,5 Ten patients received IVIG 1gm/kg in two divided doses. Seven patients recovered and were discharged. Two patients declared dead. Of the two one patient presented very late, 21st day of illness and IVIG was tried as rescue therapy since patient came in a late stage with HAI(hospital acquired infection), AKI(acute kidney injury), Poor GCS and severe hemodynamic instability. Other patient was declared dead after hemodynamic instability due to acute massive pulmonary embolism, though patient was on therapeutic dose of anticoagulants from the first day of admission. All patients who showed improvements in inflammatory markers in 48 hrs, also showed clinical improvement with improvement in spo2 and decreased oxygen requirement.
REFERENCES
1Tsinghua-Peking Center for Life Sciences, School of Medicine, Tsinghua University, Beijing, China 2Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China| https://doi.org/10.3389/fimmu.2020.01660
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