key: cord-1043331-fbx08dgc
authors: Mansour, Ephraim; Olayiwola, Ayoola; Muzaffarr, Zuleikha; Singh, Anita
title: KEEPING A BROAD DIFFERENTIAL DIAGNOSIS AMIDST A PANDEMIC
date: 2020-10-31
journal: Chest
DOI: 10.1016/j.chest.2020.08.1746
sha: 5573bd2b910c046ec2d01dc809a84b330c2ff568
doc_id: 1043331
cord_uid: fbx08dgc

nan

A 54 year old male with a history of well controlled HIV (CD4þ > 400, undetectable viral load), Kaposi's Sarcoma, and recent travel within the United States in the past month, presented to the ICU with fever, dry cough, and shortness of breath for two weeks. He presented febrile (T Max 101F), tachycardic, and hypoxic requiring high flow nasal cannula. Physical exam was notable for cervical lymphadenopathy, diffuse rhonchi, and hepatosplenomegaly. Laboratory data revealed WBC 8k with lymphopenia, elevated inflammatory markers (Ferritin 2740, CRP 157), D-Dimer 8.4, LDH 222. There was high clinical suspicion for COVID-19, however, the patient had 2 negative tests. CT chest showed bilateral ground glass opacities with numerous pulmonary nodules up to 1cm with diffuse hilar and mediastinal lymphadenopathy and massive splenomegaly. The patient underwent excisional biopsy of a cervical lymph node with pathology revealing interfollicular areas with mature plasma cells positive for CD138, kappa, and lambda light chains. Lymphoid follicles contained small clusters of CD20 and HHV-8 positive, lambda light chain plasmablasts consistent with the diagnosis of HHV-8 MCD. The patient was started on chemotherapy with Doxorubicin and Rituximab.

DISCUSSION: Patients with HHV-8 MCD often manifest with constitutional symptoms, lymphadenopathy, hepatosplenomegaly and pulmonary manifestations. This is caused by upregulation of pro-inflammatory cytokines particularly IL-6 and TNF-alpha, similar to the dysregulation associated with poorer outcomes in COVID-19 patients. Our case demonstrates that established treatments of pro-inflammatory illness such as MCD may play a role in managing COVID-19 patients. The shared aspects of the clinical presentations of COVID-19 and MCD further emphasize the importance of developing a broad differential.

CONCLUSIONS: Our patient represents a common presentation of a rare disease during a global health crisis. We maintain the importance of resisting inherent biases when formulating a differential diagnosis.

Multicentric Castleman disease: Where are we now?

Weathering the COVID-19 storm: Lessons from hematologic cytokine syndromes

DISCLOSURES: No relevant relationships by Ephraim Mansour, source¼Web Response No relevant relationships by Zuleikha Muzaffarr, source¼Web Response No relevant relationships by Ayoola Olayiwola, source¼Web Response No relevant relationships by Anita Singh

American College of Chest Physicians