COVID-19 with Rapid Progression to Hypoxemia Likely due to Imbalance between Ventilation and Blood Flow: A Case Report.

BACKGROUND: In COVID-19 pneumonia, cases of severe hypoxemia in the early stage and cases of sudden deterioration in respiratory status due to silent hypoxia leading to death, have been reported. CASE SUMMARY: A 70-year-old Japanese man with essential hypertension, dyslipidemia, chronic kidney disease and emphysema was hospitalized with the novel coronavirus disease. He had hypoxemia that was disproportionate to the severity of pneumonia indicated by computed tomography (CT), along with coagulation abnormalities. We speculated that there was a high possibility that he had developed ventilation and blood flow imbalance due to pulmonary intravascular coagulopathy (PIC) or hypoxic pulmonary vasoconstriction (HPV). In this case, early, short-term combination therapy with remdesivir, nafamostat mesylate and low-dose dexamethasone (Dex) was successful. CONCLUSION: In COVID-19 patients with multiple comorbidities who have hypoxemia and coagulation abnormalities that are disproportionate to the severity of pneumonia on CT, it is important to commence antiviral and anticoagulant therapy as soon as possible, followed by use of a low dose of Dex.

Irrelevant B-type natriuretic peptide levels in patients with mechanical prostheses in the mitral position presenting with congestive heart failure.

BACKGROUND: Plasma B-type natriuretic peptide (BNP) level is reported to be a strong marker of congestive heart failure (CHF). Heterogeneity of the BNP levels among individuals with CHF, however, can cause confusion in interpreting the results. The influence of mitral mechanical prostheses on BNP levels in patients presenting with CHF is not well known. METHODS AND RESULTS: In the present study 214 consecutive patients with CHF diagnosed using the Framingham criteria were enrolled and divided into 2 groups with and without mitral mechanical prostheses (prosthesis group, n=31; native group, n=183). The plasma BNP levels were measured, and clinical examinations including echocardiography were performed at the same time to assess cardiac performance. There was no difference in the left ventricular ejection fractions between the 2 groups. Despite having a lower body mass index, larger prevalence ratio of atrial fibrillation and larger size of the left atrium, the prosthesis group had a significantly lower logBNP level than the native group (prosthesis group vs native group: 5.12+/-1.01 vs 6.21+/-0.92, P<0.001; BNP level: 167+/-324 pg/ml vs 498+/-380 pg/ml). On multivariate analysis the presence of a mitral mechanical prosthesis was extracted as an independent predictor for decreased BNP level in patients with CHF. CONCLUSIONS: Plasma BNP level cannot correctly reflect the severity of CHF in patients with mechanical prostheses in the mitral position.

[Multiple atrial ball thrombi with stalk mimicking myxoma without valve disease: a case report].

A 77-year-old man with atrial tumors was admitted to our hospital. He had no history of dyspnea, palpitation, or chest pain. He had a history of hypertension and atrial fibrillation without valve disease. Transthoracic and transesophageal echocardiography showed floating ball tumors with stalks from the right atrium (28 X 31 mm), the interatrial septum (16 X 11 mm), and the left atrial appendage (14 X 8 mm). The tumors were surgically removed and histologic examination of these tumors confirmed organization thrombus. This case of multiple atrial ball thrombi illustrates the problems with differentiation of myxoma and thrombus.