MO101: Atypical Haemolytic Uremic Syndrome Associated with COVID-19: Case Report

Abstract

BACKGROUND AND AIMSRenal manifestations are common in hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We report here the case of a patient with confirmed SARS-CoV-2 infection with the clinical picture of atypical haemolytic uremic syndrome (aHUS).METHODCase reportRESULTSOur case is a 31-year-old man with a nasopharyngeal swab with real-time reverse-transcriptase polymerase chain reaction (RT-PCR) for SARS-CoV-2 positive, who was hospitalized in the Clinic of Infectious Diseases. His medical history had a respiratory illness of 7-day evolution characterized by cough, fever, dyspnoea, muscle pain, nausea, vomiting and non-bloody diarrhoea, and decreased urine output with dark colour urine. The chest computed tomography (CT) scan showed few rounded ground-glass opacities.Laboratory tests at admission revealed the following: (i) acute kidney injury stage 3 with a serum creatinine of 3.85 mg/dL (basal value 0.9 mg/dL); serum urea 221 mg/dL. His urinary volume in the first 24 h of hospitalization was 800 mL. (ii) Severe haemolytic anaemia with haemoglobin (Hgb) level of 3.7 g/dL, and peripheral smear showing large number of schistocytes, haptoglobin <10 mg/dL and indirect bilirubin 9.7 mg/dL, direct coombs testing was negative; reticulocyte count 8.9%. (iii) Severe thrombocytopaenia with platelet count of 25 000/µL, prothrombin time 45%, international normalized ratio 1.7, D-dimer 1082 ng/dL and fibrinogen 880 mg/dL.Increased blood levels of enzymes and inflammatory markers were present: lactate dehydrogenase 1867 U/L and protein C reactive 9.1 mg/dL. Electrolyte disturbances characterized by hyperkalaemia, hyperphosphatemia, hypocalcaemia and severe metabolic acidosis. Dynamic changes of laboratory data are presented in Table 1.Table 1.Dynamic changes of laboratory dataLaboratory dataDay 0Day 3Day 7Day 11Day 15Day 19Total serum bilirubin (mg/dL)16.454.8625.8914.69.74.2PT (%)455867889999LDH (U/L)55218671704768667455Serum urea (mg/dL)22121579635645Serum creatinine (mg/dL)3.851.570.70.60.50.6RBC ×106/µL1.221.611.723.233.763.98Hgb (g/dL)3.75.26.58.99.19.3PLTs (K/µL)2533395698178WBC (K/µL)11.224.522.316.214.511.3D-dimer (ng/dL)108246456893423035001800PCR (mg/dL)8.579.117.625.234.451.62Serum fibrinogjen (mg/dL)880647556550450450PT, prothrombin time; LDH, lactate dehydrogenase; RBC, red blood cell; Hgb, haemoglobin; PLT, platelet cell count; WBC, white blood cell; PCR, protein C reactive.The usual liver panel tests, alkaline phosphatase, γ-glutamyl transferase and albuminemia were normal. Toxic hepatitis was excluded. Hepatobiliary and spleen imaging (ultrasonography) was normal.ELISA serologic tests for HIV, hepatitis B, hepatitis C virus and cytomegalovirus were negative. Serological and virological tests for hepatitis A, B, C, HIV and CMV were negative. Stool was negative for Shiga toxin-producing Escherichia coli (STEC).The results of antinuclear antibodies and anti-smooth-muscle antibodies were negative, C3 serum level was mildly depressed (82 mg/dL; normal range 88–201 mg/dL) and C4 serum level was normal (20 mg/dL; normal range 10–44 mg/dL). ADAMTS13 activity was 90% on day 10.He was treated with broad spectrum antibiotics, intravenous dexamethasone and supportive therapy. One week from admission, renal function recovered, and 1 week after intravascular haemolysis and thrombocytopaenia recovered. The patient was hospitalized for 21 days.CONCLUSIONClose monitoring and early intervention can help for a better outcome of SARS-CoV-2 patients complicated with aHUS.