Case 31-2021: A 21-Year-Old Man with Sore Throat, Epistaxis, and Oropharyngeal Petechiae

Clinical Signs and Treatment of New-Onset Bone Marrow Failure Associated SARS-CoV-2 Infection in Children: A Single Institution Prospective Cohort Study

Background

Viral infections can cause direct and indirect damage to hematopoietic stem cells. The objectives of this study were to identify the frequency and severity of aplastic anemia in children infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as well as recognize the response to treatment.

Methodology

13 children with newly diagnosed severe aplastic anemia were enrolled in this prospective clinical trial. Blood samples were obtained from all patients to detect SARS-CoV-2 antibodies, and nasopharyngeal swabs were collected for reverse-transcription Polymerase Chain Reaction to detect SARS-CoV-2 viruses. According to the laboratory results, patients were classified as having SARS-CoV-2 positive antibodies and SARS-CoV-2 negative antibodies. Both groups received combined cyclosporine (CsA) + Eltrombopag (E-PAG). The hematological response, either complete response (CR) or partial response (PR), no response (NR), and overall response (OR) rates of combined E-PAG + CsA treatment after 6 months were evaluated.

Results

Four children were recognized to have aplastic anemia and SARS-CoV-2 positive antibodies. Two patients fulfilled the hematological criteria for CR and no longer required transfusion of packed red blood cells (PRBCs) or platelets, and one had PR and was still PRBC transfusion-dependent but no longer required platelet transfusion. The remaining patient showed NR, and he had died before reaching the top of the HSCT waiting list. Moreover, six patients in the SARS-CoV-2 negative antibodies group had CR, while three patients had PR. The difference in ANC, Hg, and platelet counts between both groups was not significant.

Conclusion

The SARS-CoV-2 virus is added to several viral infections known to be implicated in the pathogenesis of aplastic anemia. Studies are needed to establish a definitive association and determine whether the response of bone marrow failure to standard therapy differs from that of idiopathic cases.

Manifestation of Pancytopenia Associated with COVID-19 as Paroxysmal Nocturnal Hemoglobinuria (PNH) and Aplastic Anemia (AA)

We report two cases of pancytopenia in patients after recovering from a mild COVID-19, now presenting as paroxysmal nocturnal hemoglobinuria (PNH) and aplastic anemia. These cases illustrate a common pathway whereby a viral trigger causes the clonal expansion of a hematological disorder. Although the association of both cases with COVID-19 is temporal and COVID-19 may be an incidental diagnosis, the growing evidence related to the hematological effects of SARS-CoV-2 infection highlights the need for further investigation into the hematological consequences of COVID-19, particularly in the post-pandemic era.

A Case of Acquired Aplastic Anemia after Severe Hepatitis- Probably Induced by the Pfizer/BioNTech Vaccine: A Case Report and Review of Literature

INTRODUCTION

An important but rare adverse effect of vaccines is their association with autoimmune events, including hepatitis and aplastic anemia (AA). In this paper, we report a case of hepatitis followed by AA that occurred after the COVID-19 vaccine was administered.

CASE REPORT

This paper focuses on a 30-year-old female who presented with acute hepatitis three weeks after receiving the second dose of the coronavirus Pfizer/BioNTech vaccine. After an extensive diagnostic evaluation was conducted that did not discover a specific cause, the Pfizer/BioNTech vaccine was suspected and the patient was treated with corticosteroids. One week after the onset of a liver disorder, the patient presented with gum bleeding and pancytopenia, and the diagnosis of AA was established via laboratory testing and bone marrow biopsy. After the diagnosis, the patient received immunosuppressive therapy using anti-lymphocyte serum (ATGAM) and CYCLOSPORINE A with progressive improvements in cytopenia. The important issue is whether AA is related to acute hepatitis or the coronavirus vaccine.

CONCLUSION

Clinicians should be aware of the risk of both the possibility of acute hepatitis, AA, or both after receiving the COVID-19 vaccination. It is very hard to distinguish the cause of AA between vaccine- and hepatitis-related AA. Predicting who develops hepatic or myelo-complications after vaccination is difficult.

Oral mucosa lesions in confirmed and non-vaccinated cases for COVID-19: A systematic review

This systematic review purposed to investigate reports of oral lesions in confirmed COVID-19 patients summarizing clinical characteristics, histological findings, treatment and correlation of oral lesions and COVID-19 severity. Electronic search was conducted on November 2021 using seven databases to identify case reports/series describing lesions in oral mucosa in COVID-19 confirmed cases. A total of 5,179 studies were found, being 39 eligible from 19 countries, totalling 116 cases. It was observed only COVID-19 non-vaccinated cases and no sex or age predilection. The oral lesions presentation was mostly single location (69.8%), commonly in the tongue, lips, and palate, being ulcer the main clinical presentation. According to severity index for COVID-19, the reports were more frequent in patients with mild and moderate symptoms, being 75.8% in acute phase. The oral lesion appearance in post-acute COVID-19 were described after 14 to two months after patient recovery. Histologically, keratinocytes with perinuclear vacuolization, thrombosis and mononuclear inflammatory infiltrate were also described with the presence of the virus in keratinocytes, endothelial cells, and minor salivary glands. In conclusion, health care professionals should consider COVID-19 association when patient present ulcerated oral lesions and mild to moderate symptoms for COVID-19 or had acute-COVID-19.