Autoimmune Hemolytic Anemia in a 24-Year-Old Patient With COVID-19 Complicated by Secondary Cryptococcemia and Acute Necrotizing Encephalitis: A Case Report and Review of Literature

Abstract

Since the initial reported outbreak of coronavirus disease 2019 (COVID-19), many unique case reports have been published in the medical literature. Here we report a complicated clinical course of a young patient with COVID-19 who presented initially with recurrent autoimmune hemolytic anemia (AIHA). He subsequently developed bilateral pulmonary emboli, and ultimately succumbed to encephalitis and cryptococcemia in the context of being treated with high dose immunosuppression for the AIHA. Combining immunosuppression with active COVID-19 infection presents some truly challenging diagnostic and management scenarios which this case summarizes and highlights very well. Based on this case, we propose some strategies on how to approach these difficult decisions while also recognizing the significant gaps that exist in such an evolving topic. Lastly, this case also represents a potentially novel presentation of secondary fungal infection of the central nervous system (CNS) related to COVID-19.

COVID-19-associated opportunistic infections: a snapshot on the current reports

“…Likewise, disseminated cryptococcosis [190], meningitis [191], invasive aspergillosis [192], CMV pneumonitis [193], and tuberculosis [194] were reported in patients who received tocilizumab (Table 2). In COVID-19 patients, different cases with cryptococcosis [24,65,[71][72][73], aspergillosis [88], strongyloidiasis [175], PCP [88], CMV [135], and HSV [143] infections were reported following tocilizumab use (Table 3). Inhibition of the JAKs pathway (ruxolitinib [195][196][197], baricitinib [198,199], and tofacitinib [200]), TNFα (infliximab [201,202]), IL-1 (Anakinra [203,204] and Canakinumab [205,206]), and GM-CSF (Mavrilimumab [207]) was also used for mitigating the CSS in COVID-19 patients (Table 1).…”

“…However, it seems that future studies are needed for standard diagnosis and new treatment options of these infections in COVID-19 patients (Table 4). [31,88] Candidiasis [43] Mucormycosis [60] Cryptococcosis [24,65,[71][72][73] Pneumocystis jiroveci (carinii) pneumonia [76,81,88,89] Histoplasma capsulatum [95,96,98] Coccidioides immitis [101,102] Strongyloidiasis [175,176] CMV [130,132,135,136] HSV [143] IL-6 blocker (Tocilizumab)…”

“…Cryptococcosis [24,65,[71][72][73] Pneumocystis jiroveci (carinii) pneumonia [88] Aspergillosis [88] Strongyloidiasis: [175] CMV: [135] HSV: [143] Limitations of the study…”

“…Meningoencephalitis due to C. neoformans was reported in a 73-year-old woman who received azithromycin and dexamethasone after COVID-19 infection [70]. Other cases were reported from COVID-19 patients with several underlying diseases who received immunosuppressive therapy (e.g., corticosteroids and tocilizumab) [24,[71][72][73]. Like other fungal infections, early detection and treatment can improve the outcome of infection in COVID-19 patients.…”

SARS-CoV-2 and Autoimmune Cytopenia

“…Relapse of hemolysis was seen in one patient with CAD and one with Evan's syndrome, and was successfully treated with transfusion and steroids [36]. An unfortunate case of recurrent warm autoimmune hemolytic anemia in the setting of COVID-19 infection complicated by lethal cryptococcal sepsis and encephalitis in the setting of immunosuppression with cyclophosphamide and steroids has been reported as well [37].…”