Therapeutic plasma exchange and intravenous immune globulin in the treatment of heparin-induced thrombocytopenia: A systematic review.

BACKGROUND: Immunomodulatory strategies in heparin-induced thrombocytopenia (HIT) include the use of intravenous immune globulin (IVIG) and therapeutic plasma exchange (TPE). The optimal application of these therapies is unknown and outcomes data are limited. We investigated treatment categories and laboratory and clinical outcomes of IVIG and/or TPE in HIT with a systematic literature review. STUDY DESIGN AND METHODS: We searched MEDLINE, Embase, and Web of Science through December 2019 for studies combining controlled vocabulary and keywords related to thrombocytopenia, heparin, TPE, and IVIG. The primary outcome was treatment indication. Secondary outcomes were platelet recovery, HIT laboratory parameters, heparin re-exposure, and post-treatment course. Case-level data were analyzed by qualitative synthesis. RESULTS: After 4241 references were screened, we identified 60 studies with four main categories of IVIG and/or TPE use as follows: (a) treatment of refractory HIT (n = 35; 31%); (b) initial therapy (n = 45; 40%); (c) cardiopulmonary bypass surgery (CPB; n = 30; 27%); and (d) other (n = 2; 2%). IVIG was most commonly used for the treatment of refractory HIT while TPE was primarily used to facilitate heparin exposure during CPB. Both IVIG and TPE were equally used as initial therapy. Heparin re-exposure occurred without thrombotic event in 29 TPE-treated patients and three IVIG-treated patients. CONCLUSION: In patients with HIT, both TPE and IVIG are used for initial therapy or treatment of refractory HIT. However, TPE is more commonly used in patients undergoing CPB. Prospective studies may help clarify which treatment is indicated in HIT population subsets.

Psychosis secondary to COVID-19 in pediatric sickle cell disease.

Key Clinical Message: COVID-19 psychosis is a potential long-term sequela of COVID-19. Vulnerable populations, such as individuals with sickle cell disease, are at high risk for psychosis. Given the limited number of cases, more investigations in the etiopathology and management of this new disease is needed. Abstract: We report a case of a 15-year-old female with a past medical history of depression who developed psychosis post-SARS-CoV-2 infection (COVID-19). After an initial moderate COVID-19 infection, the patient appeared to recover and was discharged home. Four weeks later, she presented with symptoms of psychosis and symptoms of cognitive impairment. Imaging studies did not show any evidence of stroke and toxicology studies were negative. She was treated with antipsychotics and required inpatient neuropsychiatric rehabilitation. Acute psychotic syndrome resolved after 3 weeks, antipsychotics were weaned, and an antidepressant was initiated. Mild cognitive impairment with significant memory loss persisted for about 1 year. Thereafter, she returned to her baseline but remains on an antidepressant. Some studies have previously reported the occurrence of psychosis in individuals with COVID-19. This report is the first outline of severe prolonged post-COVID-19 psychosis in a child with sickle cell disease. Given the neurologic vulnerability of children with sickle cell disease, these individuals should be monitored for neuropsychiatric symptoms post COVID-19.