Canelas Mendes Cristiana, Howell Monteiro Patrícia, Madeira Lopes João, Pais de Lacerda António
Internal Medicine 2, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, PRT.
Cureus. 2023 Oct 9;15(10):e46723. doi: 10.7759/cureus.46723. eCollection 2023 Oct.
Severe coronavirus disease 2019 (COVID-19) is known to manifest in two phases, with a potential worsening in the second week. The pathophysiology of the first phase is expected to be heavily influenced by viral replication while the second phase is thought to be primarily characterized by systemic inflammation. We present the case of a 42-year-old man hospitalized for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with a history of Philadelphia-positive chronic myeloid leukemia, diagnosed seven months earlier, proposed to bone marrow allotransplantation after refractory imatinib and dasatinib treatment. After an initial clinical and laboratory improvement, the patient got worse. A pulmonary CT scan showed worsening ground-glass opacities and multiple bilateral consolidations. Neutropenia was resolved, and on the same day, the patient developed progressive respiratory failure with rapidly increasing oxygen demand and distributive shock, requiring mechanical ventilation. Acute respiratory distress syndrome (ARDS) induced by paradoxical COVID-19 immune reconstitution inflammatory syndrome (IRIS) following chemotherapy-induced aplasia was equated. High-dose corticosteroid therapy was rapidly effective. IRIS occurs in patients with severe immunosuppression in response to rapid immune reconstitution and results in an uncontrolled inflammatory response to infectious agents that cause tissue damage. The inflammation associated with both IRIS and COVID-19 shares a common path in terms of immunological response. We hypothesize that in our patient, a hyperinflammation overlap exerted a synergistic effect, leading to the worsening of the disease.
已知重症2019冠状病毒病（COVID-19）表现为两个阶段，在第二周可能会恶化。第一阶段的病理生理学预计受病毒复制的严重影响，而第二阶段则主要以全身炎症为特征。我们报告一例42岁男性病例，该患者因严重急性呼吸综合征冠状病毒2（SARS-CoV-2）感染住院，有费城染色体阳性慢性髓性白血病病史，7个月前确诊，在伊马替尼和达沙替尼治疗无效后拟进行异基因骨髓移植。在最初的临床和实验室检查有所改善后，患者病情恶化。肺部CT扫描显示磨玻璃影加重和双侧多发实变。中性粒细胞减少症得到缓解，同一天，患者出现进行性呼吸衰竭，氧需求迅速增加并伴有分布性休克，需要机械通气。化疗诱导的再生障碍性贫血后，由矛盾的COVID-19免疫重建炎症综合征（IRIS）诱发的急性呼吸窘迫综合征（ARDS）被认为与之相关。大剂量皮质类固醇治疗迅速起效。IRIS发生在严重免疫抑制患者中，是对快速免疫重建的反应，导致对引起组织损伤的感染因子产生不受控制的炎症反应。与IRIS和COVID-19相关的炎症在免疫反应方面有共同的途径。我们推测，在我们的患者中，过度炎症重叠发挥了协同作用，导致病情恶化。
