Arnaldo Lopez-Ruiz, MD
Doctor
AdventHealth Orlando, United States
Disclosure information not submitted.
Title: Microangiopathic Hemolytic Anemia Complicated by Bacteremia in a Postpartum COVID-19 Patient
Introduction: Severe sepsis, HELLP (hemolysis, elevated liver enzymes, and low platelets), and severe preeclampsia can all present with microangiopathic hemolytic anemia. A timely and accurate diagnosis is undoubtedly lifesaving. Here, we describe a case involving HELLP complicated by severe sepsis superimposed on COVID-19 pneumonia.
Description: A 36-year-old female on POD #2 status post emergent C-section at 33 weeks due to preeclampsia presented to the ICU secondary to acute hypoxic respiratory failure due to COVID-19 pneumonia. She was noted to have severe anemia with a drop in hemoglobin from 11.3 mg/dL to 5.0 mg/dL after deliver. Additionally, she developed severe thrombocytopenia, acute kidney injury, confusion, and lactic acidosis. Her peripheral smear showed schistocytes. Her LDH/AST ratio was < 22. PLASMIC score was consistent with high probability for TTP. ADAMSTS-13 was sent and plasmapheresis was initiated. Over the course of 24 hours, she developed profound transaminitis consistent with HELLP. ADAMSTS-13 returned at 63%. Her respiratory status continued to worsen and she was intubated. Shortly after intubation, she suffered cardiac arrest though ROSC was obtained after two minutes of CPR. On hospital day 3, blood cultures resulted showing Serratia marcescens bacteremia resulted. She developed oliguric acute kidney injury and continuous renal replacement therapy was initiated. She continued with supportive care and continued to improve. She was extubated on hospital day 12. Her renal function returned and hemodialysis was stopped upon hospital discharge on day 30. She returned home to her husband and newborn and has since had few complications.
Discussion: In this case, emergent delivery of the fetus in addition to plasma exchange was crucial. Eculizumab was not initiated as blood cultures had not yet resulted. At the time of diagnosis, the role of complement inhibitors in acute COVID-19 infection let alone pregnant patients with COVID-19 was completely unknown. Additionally, no COVID-19 vaccines were available and no American College of Obstetrics and Gynecology existed on best practices. Regardless, timely recognition of overlapping clinical syndromes is essential in critical care medicine.