with a 5 day history of progressive diffuse myalgias and weakness in her bilateral thigh muscles that progressed to her bilateral upper extremities and neck. Following the COVID-19 infection, she was treated for myalgia and fatigue with a multimodal pain regimen. When her myalgias and fatigue continued to progress, she returned to the ED at which time her WBC was 19.2 cells/mm3 with left shift, ESR 65 mm/hr, CRP 12.8 mg/dl however ANA and RF were negative. She was started on prednisone and was discharged with improved symptoms. Several days later, she returned to the ED with diffuse muscular weakness. WBC count was 71.9 cells/mm3, steroid therapy was held, ESR increased 90 mm/hr and CRP increased to 44.7 mg/dl with normal CK. Autoimmune workup was unremarkable (including anti-MDA5 antibody). MRI of bilateral thighs demonstrated severe generalized myositis. CT chest did not show interstitial lung
disease and TTE was unremarkable. Rheumatology was consulted, and muscle biopsy of her right thigh revealed minimal myopathic changes and no morphologic evidence of vasculitis. She developed extensive muscle weakness including trismus and was re-started on high-dose steroids. Her IgA was low, so she was not a candidate for IVIG. She continued to improve slowly over the following year. Discussion: The rapidly progressive nature of post-COVID myositis draws parallels with Clinically Amyopathic Dermatomyositis (CADM) which is associated with high risk for progression to interstitial lung disease, and is anti-MDA5 positive. Our patient’s presentation was atypical given her high degree of leukocytosis and normal CK, however given her rapidly progressive symptoms sharing similarities to anti-MDA5-positive patients, the underlying cause was likely post-COVID or vaccine myositis.
SARCOIDOSIS AND WORSENING LYMPHADENOPATHY- SARCOIDOSIS FLARE? THINK AGAIN!! Manush Sondhi, Anusha Vuppala, Madiha Tariq; Department of Medicine, Louisiana State University, Shreveport, LA.
Introduction: Patients with active sarcoidosis already have suppressed cell-mediated immunity. Doses of steroids and immunosuppressive medications further exacerbate this immunosuppression increasing the risk for atypical/opportunistic infections Case: A 62-year-old male with long-standing sarcoidosis diagnosed in 1997 with muscle biopsy from the thigh. Patient was stable without treatment until 12/2017, when he presented with symptoms of cough and shortness of breath with CT chest showing worsening of pulmonary nodules. Patient was started on mycophenolate mofetil, but later escalated to Rituximab due to worsening symptoms of joint pain and sinusitis with significant clinical improvement. Later around October 2021, he presented with worsening symptoms of chest pain, shortness of breath and fevers. CT chest showed worsening hilar, mediastinal adenopathy and GGO bilaterally. Bronchoscopy was done with prelim reports consistent with granulomas and negative microbiological stains. He was treated with antibiotics and steroids for possible sarcoidosis flare and superimposed infection with transient improvement.
Unfortunately, he was admitted again in November 2021 due to worsening abdominal pain. He was noted to have pancytopenia, hepatosplenomegaly, bilateral adrenal lesions and lung nodules on CT scan. HIV test was negative. Bone marrow biopsy showed hypercellular marrow with multiple non-caseating granulomas and special stain GMS showed fungal spores with rare budding forms consistent with Histoplasma species. Culture from bronchoscopy done in October 2021 also later resulted in Histoplasmosis. Amphotericin was administered followed by oral itraconazole with improvement. Discussion: Histoplasmosis can present clinically in varied forms, ranging from asymptomatic infection, acute or chronic pulmonary infection, mediastinal fibrosis or granulomas or as chronic disseminated histoplasmosis. There is a significant overlap in clinical, pathological and radiologic presentations of histoplasmosis and sarcoidosis. Clinicians should consider possibility of opportunistic infection when exacerbation of symptoms occur in a patient of Sarcoidosis.
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