COVID-19 ASSOCIATED RESPIRATORY FAILURE COMPLICATING A

PERICARDIAL EFFUSION IN A PATIENT WITH SIDEROBLASTIC

ANEMIA

Dipresentasikan oleh :
Heru Sigit Pramono

 Pembimbing :
dr. Ismiranti Andarini, Sp.A, M.kes.
   
 PROGRAM PENDIDIKAN DOKTER SPESIALIS
PULMONOLOGI DAN ILMU KEDOKTERAN RESPIRASI
FK UNS/RSUD Dr. MOEWARDI
SURAKARTA
2021
 PENDAHULUAN
• Anemia sideroblastik ditandai dengan adanya cincin
sideroblas yang mengandung besi di sumsum tulang.

• Varian dalam YARS2 telah dikaitkan dengan miopati,

asidosis laktat, dan anemia sideroblastik 2 (MLASA2)

• Efusi perikardial dan neutropenia telah dilaporkan

pada pasien yang menunjukkan varian YARS2
2
 PENDAHULUAN

Insidensi
Rendah

Multikomplikasi Data
dengan bidang tatalaksana
kardiovaskular masih terbatas

Covid-19 dan
kardiovaskula

3
 Data Diri
LAPORAN KASUS Diagnosis
Anemia sideroblastik
Seorang anak laki- kongenital dengan
laki berusia tiga belas mutasi YARS2 dengan
tahun riwayat transfusi kronis
yang terinfeksi COVID-
Pemeriksaan Fisik 19 isertai efusi
perikardial.
Normotensif, Saturasi
Keluhan
oksigen adalah 96% pada
posisi tegak, dan 91% Sesak napas, jantung
pada posisi terlentang berdebar, batuk tidak
disertai dengan dispnea produktif, pucat, dan
dan ortopnea lesu selama 8 hari.
4
PEMERIKSAAN PENUNJANG

Pemeriksaan Hasil
Hb 6,4 g/dl
Leukosit 2,97× 103 g/dl
Neutrofil absolut 120
Trombosit 81 x 103/μ
Ferritin 8606 ng/dl
D-dimer 0,44 g/ml
Fibrinogen 186 mg/dl
 PEMERIKSAAN PENUNJANG
Pemeriksaan Hasil
Epstein-Barr (EBV) Negatif
Cytomegalovirus (CMV), Negatif
antibodi IgM Mycoplasma Negatif
Turunan protein murni Negatif
(PPD
 Ro Thoraks
Infiltrat konfluen di tengah kiri dan lapangan paru bawah

Siluet jantung yang membesar

 EK
G Echo
fungsi
Efusi
Sinus perikardial
sistolik
Septum Tekanan
takikardi Pelebaran ventrikel
berlobus interventrik arteri
ringan kiri ukuran
a dan ST melingkar
arteri dan fungsi
ular sedikit pulmonalis
elevasi sedang medorong adalah ~ 40
pulmonalis ventrikel
difus hingga ke kiri mmHg
kanan
besar
normal.
 Ct- Scan Thoraks
Konsolidasi lobular dan area kekeruhan ground-glass di lobus
kiri atas dengan efusi perikardial sedang dengan ketebalan
maksimal 3 cm

9
 TERAPI
1 Remdesivir 5 mg/kg/dosis per hari
Enoxaparin 1 mg/kg/dosis per 12 jam

2 Meropenem 1g setiap 8 jam

Teicoplanin 300 mg setiap 12 jam
3
Colchicine 0,5 mg per oral per 24 jam
solumedrol intravena 1mg/kg per 12 jam
4
Transfusi PRC 2 kolf dan oksigen nasal
kanum 1 lpm

10
 PERIKARDIOSENTESIS TELAH DIBAHAS TETAPI DITUNDA
PADA SAAT ITU KARENA PASIEN STABIL SECARA
HEMODINAMIK, TIDAK MEMILIKI TANDA-TANDA TAMPONADE,
DAN TERDAPAT PENINGKATAN RISIKO PERDARAHAN
PERIPROSEDURAL KARENA TROMBOSITOPENIA DAN TERAPI
ANTIKOAGULANNYA
Sehari kemudian, pasien mulai
memburuk. Dia mengalami
hipoksemia akut, hiperkapnia,
gagal napas yang refrakter
terhadap terapi oksigen
tambahan.
Pasien terintubasi mode kontrol volume
dengan volume tidal (TV) 8 cc/kg,
tekanan akhir ekspirasi positif awal
(PEEP) 6 cm H2O, dan fraksi oksigen
inspirasi (FiO2) 100%

01 02 03

Pasien dipindahkan ke ICU

6
PEMERIKSAAN PENUNJANG EVALUASI

Pemeriksaan Hasil
pH 7,29
PCO2 78
PO2 117
HCO3 37.5
 Ro Thoraks
Radio opaq yang memenuhi di sisi paru kiri disertai efusi
pleura minimal di lobus bawah
 Ct- Scan Thoraks
Efusi perikardial persisten dengan hipertensi pulmonal yang
memburuk (55 mmHg)

15
TERAPI TAMBAHAN
Tocilizumab (IL-6 216 pg/ml)
1
Inhalasi Nitric oxide dipertimbangkan
2 tetapi ditunda karena kekhawatiran
tentang cedera ginjal akut.

3 Oksigenasi membran ekstrakorporeal

(ECMO) tidak tersedia

16
PADA HARI YANG SAMA, PASIEN MENGALAMI HENTI JANTUNG
SETELAH PENURUNAN SATURASI OKSIGEN DAN BRADIKARDIA
YANG CEPAT DIIKUTI DENGAN PENGHENTIAN AKTIVITAS
LISTRIK DAN MEKANIK JANTUNG
 METHODS
Search on PubMed Data was then
and Google Scholar narratively
for papers synthesized

All the references judged

Key WOrd to have relevant
“severe asthma” AND information about
“COVID-1900 OR prespecified questions
“SARS-CoV-2” were included
18
 SARS-CoV-2 infection: immunology and respiratory
pathology

About 20% of the infected patients

About 80% of the infected
patients, the disease will be mild
and mostly restricted to the
upper and conducting airway.
will progress and develop pulmonary
infiltrates and some of these might
develop very severe disease.
7
RESULTS Interrelationship of severe asthma endotypes
and COVID-19 disease mechanisms

Type2-high endotype

The major immune-

Type2-low endotype Inflammatory pathway
involved

Mixed endotype

8
TYPE2-HIGH ASTHMA / COVID-19

T helper (Th) 2 cells,

IL-4-secreting nature type-2 B cells, group 2
killer and natural innate
killer T cells, lymphoid cells, type-2
macrophages
Basophils,
eosinophils,
and
mast cells.

The type-2 immune 9

 ALLERGIC ASTHMATIC SUBJECTS SEEM TO BE
LESS LIKELY TO BE INFECTED BY THE SARS-COV-2

01 02
EFFECT OF THE INHALED CORTICOSTEROIDS
REDUCED ACE2
EXPRESSION

03 04
IMUNE RESPONS SMOKING STATUS

10
 TYPE2-LOW ASTHMA / COVID-19
Increased severity and remodeling and less
satisfactory response to anti-inflammatory treatment

Dysregulated innate immune response, including

intrinsic neutrophil abnormalities, the inflammasome
pathway and the activation of the IL-17 pathway

A type 2-low endotype can be an aggravating factor

to COVID-19 severity
1141
MIXED ENDOTYPES ASTHMA
/ COVID-19
Bye friends!

12
13
SEVERE ASTHMA EPIDEMIOLOGY AND COVID-19

This is the rolling 7-day

average per 100 people in
the total population

0-0.03 0.03-01 0.1-0.3 0.3-1 1-3

14
 SEVERE ASTHMA EPIDEMIOLOGY AND COVID-19
42 asthmatic patients identified,
patients on GINA 4/5 and those not
adequately treated were considered at
higher risk(Caminati et al )
asthmatic patients using ICS plus
long-acting beta2-agonists admitted
to an intensive care unit was higher
(57.9%) than those using ICS alone
(Chibba et al )
None of the patients required
intensive care (Hauron-Diaz et al ) 15
 SEVERE ASTHMA EPIDEMIOLOGY AND COVID-19
Asthma with recent use of an oral
corticosteroid) was associated
with COVID-19 related death
(Kow et al )

Inhaled and oral corticosteroid

treatment were not identified as
risk factor (Calmes D. et al.)
16
Biologics for severe asthma in the context of
COVID-19
CONCLUSIONS

Mercury is the closest planet to the

Sun and the smallest one in the Solar
System—it’s only a bit larger than the
Moon
The planet’s name has nothing to do
with the liquid metal, since it was
named after the Roman messenger
god, Mercury

17
 Biologics for severe asthma in the context of
COVID-19
Theoretically reasonable that mAbs targeting type-2 asthma
inflammation can be associated with increased risk for COVID-19

Patients treated with anti-IL-5 mAbs had a considerably higher

(71%) compared to those with anti-IgE (29%)
Ideas about the role of mAbs in modulating the risk of COVID-19
are speculations and need further evidence.

Major respiratory recommend continuing the biologic treatment,

preferably in a self-administered home program. 18
DISCUSSION
 DISCUSSION

At the present moment, no definitive

conclusions can be drawn as many confounding
factors might have influenced available evidence

Several aspects apart from the disease

itself start to be shown about the impact of
COVID-19 pandemic on severe asthma patient
19
 MYTHS AND FACTS

These pathophysiological and symptomatic

changes in long-COVID interact with severe
asthma is still uncertain

Severe asthma patients need proper

answers about their disease management
20
 SEVERAL QUESTIONS

What is the real dual

What are the role of steroids used What are the
long-term for severe asthma possible interactions
effects of past management in between mAbs
COVID-19 COVID-19 (cytokine directed for COVID-
infection on blocking versus 19 treatment and
asthma disease induction of corona mAbs for severe
progression? virus replication)? asthma treatment?21
CONCLUSIONS
CONCLUSIONS

Severe asthma management during the COVID-19

pandemic is now a challenge until herd immunity is
reached

Type2-high seems to have a protective role both in

SARS-CoV-2 infection and COVID-19 course. Type-2 low
increased risk of infection and severe disease forms.

Major respiratory societies recommend continuing the

biologic treatment
22
THANKS!