Heterotopic ossification post COVID-19: Report of two cases

Aziz, Amany; Choudhari, Rishabh; Alexander, Anup Jacob; Allam, Emad

doi:10.1016/j.radcr.2020.12.002

Cited by 23 publications

(23 citation statements)

References 9 publications

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“…We argue that tissue damage caused by post-COVID-19 syndrome might be the potential trigger of our patient’s notable disease progression, as well as the associated elevation of inflammatory cytokines. Notably, several instances of non-FOP-related HO after severe forms of COVID-19 have been reported, which further supports our hypothesis [ 12 , 13 ].…”

Section: Discussionsupporting

confidence: 89%

Post-COVID-19 exacerbation of fibrodysplasia ossificans progressiva with multiple flare-ups and extensive heterotopic ossification in a 45-year-old female patient

et al. 2021

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Fibrodyplasia ossificans progressiva (FOP) is a rare hereditary disease, which has a variable course characterized by occasional flare-ups of heterotopic ossification (HO) in soft tissues that are followed by swelling, stiffness, pain and warmth. Here, we report for the first time a case of a 45-year-old female patient with known FOP recovering from COVID-19 with disease progression potentially linked with the viral illness. In December 2020 the patient contracted a mild form of COVID-19 infection without need for hospital admission. Since January 2021, the patient felt unwell, with occasional abdominal pain which progressively intensified. In March 2021 she presented with new onset of HO, complaining of pain, swelling and thickening sensation in the lower abdomen and left part of the neck. Computerized tomography (CT) and cytokine analysis were performed. CT scan revealed new heterotopic bone formation in multiple soft tissue areas of the neck indicating clear radiological progression. Radiotherapy, which has proven to be an efficient tool to control HO in this patient, was not able to halt HO formation after COVID-19 infection. Cytokine analysis of a plasma sample obtained during a flare-up after COVID-19 infection showed a significantly elevated pro-inflammatory cytokines compared to a flare-up panel prior to infection. Of the 23 analyzed levels of cytokines, a staggering number of 21 were above normal levels. This case is the first confirmation of uncontrolled post-COVID-19 effects in a FOP patient, which manifested with flare-ups followed by progressive HO, possibly caused by a thus far, never described form of post-COVID syndrome.

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Section: Discussionsupporting

confidence: 89%

Post-COVID-19 exacerbation of fibrodysplasia ossificans progressiva with multiple flare-ups and extensive heterotopic ossification in a 45-year-old female patient

et al. 2021

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“…The described pathway underlying ARDS, activated by cytokines, induces the production of Activin A in skeletal muscle, resulting in skeletal muscle atrophy. Surprisingly, a small number of patients with severe COVID-19 appear at higher risk for developing HO [23], suggesting that the pro-in ammatory state found in COVID-19 could be detrimental in patients with FOP. Aziz et al highlighted the prevalence of shoulder HO in two female subjects (with a history of hypertension and type 2 diabetes, and hypertension, respectively) after their COVID-19 infection [23].…”

Section: Introductionmentioning

confidence: 99%

“…Surprisingly, a small number of patients with severe COVID-19 appear at higher risk for developing HO [23], suggesting that the pro-in ammatory state found in COVID-19 could be detrimental in patients with FOP. Aziz et al highlighted the prevalence of shoulder HO in two female subjects (with a history of hypertension and type 2 diabetes, and hypertension, respectively) after their COVID-19 infection [23]. A few months following hospitalization, the subjects reported shoulder pain/discomfort, which was identi ed as ossi cation.…”

Section: Introductionmentioning

confidence: 99%

Social and Clinical Impact of COVID-19 on Patients with Fibrodysplasia Ossificans Progressiva

Kou

Kile²,

Kambampati

et al. 2021

Preprint

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Background COVID-19, caused by the SARS-CoV-2 virus, is a severe inflammatory condition. Patients with pre-existing conditions including diabetes, hypertension, and cardiovascular disease are at particularly high risk of complications. Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare and debilitating genetic disorder that is characterized by a pro-inflammatory state, which leads to progressive heterotopic ossification and complications after trauma, including intramuscular vaccinations. To better understand the impact of COVID-19 on patients with FOP, we first examined the social impact of the pandemic using data from the FOP Registry managed by the International FOP Association. We also identified patients with FOP who were exposed to or contracted the SARS-CoV-2 virus, or who received a COVID-19 vaccine, to investigate if patients with FOP were at increased risks of complications from SARS-CoV2 exposure. Results Data from 326 individuals in 69 countries were examined in the International FOP Association FOP Connection Registry using patient-reported outcomes measurement information system (PROMIS) global health scale scores. Twenty-six (28.9%) participants aged ≥ 15 years old rated their satisfaction with their social activities and relationships as poor in 2020, which was an increase from 18 (18.9%) in 2019, prior to the SARS-CoV-2 outbreak. Similar trends were noted for physical and mental health in the pediatric population. Frequency of physician visits was not changed, but a larger portion of patients reported missing dental visits in 2020 compared with 2019 (31.5% vs. 41.7%). A second cohort with 32 subjects was tracked after SARS-CoV-2 exposure or vaccination. Ten subjects were positively diagnosed with COVID-19, 15 received a COVID-19 vaccine, and seven had high-risk SARS-CoV-2 exposure but either did not have a confirmed clinical diagnosis or tested negative. Subjects who tested positive for the virus showed no major complications or increased FOP disease activity, though our sample size is very limited. Among the 15 subjects who received a COVID-19 vaccine, using the International Clinical Council on FOP guidelines for prophylaxis with ibuprofen or acetaminophen, only one person experienced flare activity at the injection site. Conclusions Patients with FOP showed a significant decrease in social activities that was reflective of the isolation and mobility changes in this debilitated population. In our limited cohort, the majority of the patients with FOP who tested positive for COVID-19 showed no major complications. Also, although limited in sample size, the majority of patients who received a COVID-19 vaccination and followed guidelines from the FOP International Clinical Council tolerated vaccination well. Only one person experiencing flare activity following their injection. Thus, the risks and benefits of COVID-19 vaccination needs to be discussed carefully so as to support informed decisions.

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“…There are few published cases in the current literature of hospitalized patients after severe SARS-CoV-2 infection who have presented heterotopic ossification as a complication. In an article published by Meyer et al [4] cases were collected of patients who presented heterotopic calcifications (3 of them in the hips and 1 in the shoulder) as a complication of severe SARS-CoV-2 infections that prized mechanical ventilation [5,6] . It is not understood by what process these calcifications have developed on the posterior aspect of the hip joint, although some authors (Denormandie et al) have described the association between the posterior location of ossification, as in our case, with cerebral anoxia [7] .…”

Section: Discussionmentioning

confidence: 99%

Bilateral heterotopic ossification of the hip in a patient COVID19: A case report

Valero¹,

Picó²,

Bueno³

et al. 2021

Int. J. Case Rep. Orthop.

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We present the case of a 62-year-old man who, after suffering a severe COVID infection, spent 45 days in the intensive care unit. He developed bilateral heterotopic calcifications in his hips and within a few months a complete joint ankylosis. The surgery consisted of resection of most of the heterotopic ossification using a posterolaterally surgical approach in the right hip until restoring mobility to the joint intraoperatively. It is necessary to develop studies to determine if heterotopic ossifications are related to the viral infection itself, hypoxia, the need for invasive mechanical ventilation, immobility, or other causes in order to establish a prevention strategy for this type of complications.

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Heterotopic ossification post COVID-19: Report of two cases

Cited by 23 publications

References 9 publications

Post-COVID-19 exacerbation of fibrodysplasia ossificans progressiva with multiple flare-ups and extensive heterotopic ossification in a 45-year-old female patient

Post-COVID-19 exacerbation of fibrodysplasia ossificans progressiva with multiple flare-ups and extensive heterotopic ossification in a 45-year-old female patient

Social and Clinical Impact of COVID-19 on Patients with Fibrodysplasia Ossificans Progressiva

Bilateral heterotopic ossification of the hip in a patient COVID19: A case report

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