SÍNDROME DE EVANS COMO UMA MANIFESTAÇÃO TARDIA DA COVID-19

Relato de caso

Paciente de 70 anos, sexo masculino, branco, hipertenso, diabético e portador de insuficiência cardíaca sistólica e doença renal crônica em tratamento por hemodiálise. Durante internação hospitalar por artrite séptica o paciente desenvolveu sintomas gripais e dispneia, com teste reação em cadeia da polimerase em tempo real  (RT-PCR) em aspirado de nasofaringe positivo para  COVID-19. Permaneceu hospitalizado, desenvolvendo diarreia e hipóxia, tratada com altas doses de oxigênio por máscara facial. Após recuperação completa do quadro clínico de COVID-19, apresentando saturação normal de oxigênio em ar ambiente,  passou a apresentar equimoses em extremidades inferiores, em sítios de punção venosa e subcutânea, associada a diminuição progressiva na contagem de plaquetas (57.000/μL). Foram suspensos todos os medicamentos em uso, inclusive heparina dose profilática, frente a hipótese de plaquetopenia induzida por medicamentos. Apesar da medida, na próxima semana houve piora progressiva do quadro clínico e a contagem de plaquetas atingiu 2.000/μL. Foi iniciado tratamento com Metilprednisolona endovenosa e transfusão de plaquetas, considerando o quadro como Púrpura Trombocitopênica Idiopática (PTI). Houve piora progressiva do quadro clínico, mantendo plaquetopenia grave com alto consumo após transfusão, somado a queda progressiva da hemoglobina (6,6 g/dL). Investigação laboratorial revelou sorologias para HIV e HBV negativas, Coombs indireto positivo, alteração de enzimas hepáticas, presença de esferócitos em esfregaço sanguíneo e lactato desidrogenase (LDH) elevado (835u/L), apontando para quadro de hemólise associada. Considerando a possibilidade de síndrome de Evans, foi iniciada infusão de imunoglobulina endovenosa. Não houve resposta satisfatória as intervenções e o paciente evoluiu para óbito duas semanas após o início do quadro hematológico.

Discussão

A COVID-19 é uma doença recente, com novas manifestações clínicas e laboratoriais descritas a cada dia. O termo “Long Covid”foi criado para representar as manifestações tardias da COVID-19. Esse relato de caso descreve uma manifestação hematológica, Síndrome de Evans, iniciada após a recuperação de um quadro moderado de COVID-19. A Síndrome de Evans é uma doença rara, caracterizada pela presença concomitante de duas citopenias imunomediadas, mais comumente a PTI e a anemia hemolítica, essa doença apresenta um difícil diagnóstico e um pior prognóstico em relação a outras citopenias isoladas.

Conclusão

Espera-se que a partir do conhecimento de que a Síndrome de Evans é uma possível manifestação do COVID-19, eventualmente de forma tardia, o professional da saúde apresente capacidade de realizar esse diagnóstico e tratamento de forma mais precoce e possivelmente mudar o prognóstico do paciente acometido.

Comparative efficacy and safety of lock solutions for the prevention of catheter-related complications including infectious and bleeding events in adult haemodialysis patients: a systematic review and network meta-analysis

BACKGROUND

Central venous catheters are used extensively as temporary or permanent vascular access for haemodialysis patients. Catheter-related bloodstream infections are the main complication of central venous catheters and increase morbidity and mortality in haemodialysis patients.

OBJECTIVES

The aim was to assess the most appropriate lock solution for central venous catheters to prevent catheter-related bloodstream infections and other complications.

DATA SOURCES

Medline, Embase and the Cochrane Central Register of Controlled Trials from the date of their inception to August 2018 were used as data sources. The reference lists of eligible studies and relevant reviews were also checked.

STUDY ELIGIBILITY CRITERIA AND PARTICIPANTS

Randomized controlled trials (RCTs) comparing different lock solutions for the prevention of central venous catheter-related infectious and bleeding complications for adult dialysis patients were included.

INTERVENTIONS

Interventions were lock solutions for haemodialysis catheters.

METHODS

The primary outcomes were catheter-related bloodstream infections and bleeding events. The secondary outcomes were catheter malfunction, exit-site infection, and all-cause mortality. We estimated summary risk ratios (RRs) using pairwise and network meta-analysis. We assessed the risk of bias of individual studies with the Cochrane risk of bias tool.

RESULTS

Forty-nine trials (7020 patients) were included for this study. Compared with heparin 5000 U/mL, antibiotic locks (antibiotics with trisodium citrate (TSC), ethylenediamine tetraacetic acid (EDTA), heparin 5000 U/mL, low-dose heparin or urokinase) and ethanol locks were more effective in preventing catheter-related bloodstream infections. Antimicrobial agents plus low-dose heparin (500-2500 U/mL), TSC and low-dose heparin locks had lower risk of bleeding events than heparin 5000 U/mL. None of the lock solutions reduced rates of catheter malfunction and all-cause mortality compared with heparin 5000 U/mL. In summary, antibiotics plus low-dose heparin was ranked as the best lock solution. The overall results were not materially changed in sensitivity analyses.

CONCLUSIONS

Taking into account both efficacy and safety, antibiotics plus low-dose heparin (500-2500 U/mL) may be the preferred lock solution.

(+)-Angchibangkine, a new type of bisbenzylisoquinoline alkaloid, and other dimers from Pachygone dasycarpa

Analysis of the alkaloidal fraction of the stem bark extract of Pachygone dasycarpa (Menispermaceae) resulted in the isolation of 10 known bisbenzylisoquinolines, (+)-tetrandrine, (+)-penduline, (+)-fangchinoline, (+)-atherospermoline, (+)-N-methyl-7-O-demethylpeinamine, (+)-daphnoline, (4-)-isotrilobine (1), (+)-cocsuline (2), (+)-tricordatine (3), (+)-2'-norcocsuline, and the new alkaloid (+)-12-O-methyltricordatine (4). The last bisbenzylisoquinoline alkaloid isolated, (+)-angchibangkine (5), is the first member of this alkaloid class found to possess three diphenyl ether bridges in the 7-6',8-7', and 11-12' positions. Structure elucidation of these alkaloids and of (+)-O-methylangchibangkine (6) was achieved by analysis of spectral data. Compounds 4-6 show antiplasmodial activity against Plasmodium falciparum.

Costaricine, a new antiplasmodial bisbenzylisoquinoline alkaloid from Nectandra salicifolia trunk bark

A MeOH extract of Nectandra salicifolia trunk bark, obtained during a diversity-based plant collection in a lower montane rainforest in Costa Rica, showed activity in an in vitro antiplasmodial assay measuring incorporation of [3H]-labeled hypoxanthie by Plasmodium falciparum. In addition to 15 known alkaloids isolated from samples of trunk bark, roots, and leaves/twigs of this species, a new bisbenzylisoquinoline alkaloid (+)-costaricine [(+)-12-O-methyllindoldhamine] (1) was isolated from bark (0.038% yield) and from roots (0.001%). (+)-Costaricine was active in the antiplasmodial assay, with IC50 values of 50 ng/mL vs. the chloroquine-sensitive D6 clone and 294 ng/mL vs. the chloroquine-resistant W2 clone of P. falciparum.