Meningoencephalitis Associated with SARS-Coronavirus-2.

The aim of this work is to clarify the incidence of meningitis/encephalitis in SARS-CoV-2 patients. We conducted an initial search in PubMed using the Medical Subject Headings (MeSH) terms "meningitis," and "encephalitis,", and "COVID-19" to affirm the need for a review on the topic of the relationship between meningitis/encephalitis and SARS-CoV-2 infection. We included case series, case reports and review articles of COVID-19 patients with these neurological symptoms. Through PubMed database we identified 110 records. After removal of duplicates, we screened 70 record, and 43 were excluded because they focused on different SARS-CoV-2 neurological complications. For eligibility, we assessed 27 full-text articles which met inclusion criteria. Seven articles were excluded, and twenty studies were included in the narrative review, in which encephalitis and/or meningitis case reports/case series were reported. Neurological manifestations of COVID-19 are not rare, especially meningoencephalitis; the hypoxic/metabolic changes produced by the inflammatory response against the virus cytokine storm can lead to encephalopathy, and the presence of comorbidities and other neurological diseases, such as Alzheimer's disease, predispose to these metabolic changes. Further study are needed to investigate the biological mechanisms of neurological complications of COVID-19.

Acute heart damage and COVID-19: a case study

Background: COVID-19 disease is characterized by respiratory symptoms, but acute cardiovascular complications are reported in severe infections that adversely affect prognosis. Clinical Case: A patient is hospitalized for fever, chest pain, and dyspnoea. Clinical examination: pulmonary and peripheral congestion, low blood pressure values, oxygen saturation in ambient air 91%. Increased myocardiocytolysis and inflammatory indices. Nasopharyngeal swab: positive for COVID-19. Chest CT scan: interstitial pneumonia. ECG: sinus tachycardia, changes in ventricular repolarization. Echocardiogram: left ventricle dilated, hypertrophic and with severe global systolic dysfunction. Therapy: furosemide, high flow oxygen alternating CPAP, antiretrovirals, antibiotics, low molecular weight heparin, beta blocker. Cardiac MRI: focal edema of the anterior wall. Coronary angiography: moderate coronary artery disease. Control chest CT scan: resolution of pulmonary interstitial disease. Cardiac MRI after 2 months: improvement of the overall systolic function of the left ventricle. Conclusions: An entity defined as “acute myocardial damage” characterized by an increase in troponin with ECG and/or echocardiographic changes, is reported in COVID patients. These forms are not related to coronary artery disease but are the consequence of the septic state and the excessive activation of the infectious- inflammatory systems and can manifest themselves with myocarditis/stress myocardiopathy causing heart failure and left ventricular systolic dysfunction.

More than a third of SACA countries (South and Central America) do not have coverage of insulin, supplies and lab exams

Background: The IDF Diabetes Atlas 2019 points out that SACA is the region with the highest percentage of health expenditures on diabetes, 19.4%. The total number of individuals with diabetes in the region is 31.6 million, which means a prevalence of 9.4%. Countries with the largest percentage of expenditures are Cuba (24.3%), Brazil (24.2%), and Costa Rica (21.3%), while the lowest estimates are for Argentina (5.0%) and Uruguay (6.1%). Aim: Identify if insulin, oral medicines, supplies (syringes, test strips, needles, etc.) and lab exams are fully provided (free of charge) in those countries and if there is an association between percentage of expenditures on diabetes and care provision. Method: A digital online survey with 12 multiple choice questions was shared by e-mail and WhatsApp with all IDF members organizations in the SACA region. It was open for answers between April 4th and May 5th, during the COVID-19 pandemic. The question of interest for this was specifically about access to medicines and lab exams. Mean diabetes-related expenditure (USD) per person with diabetes (20–79 years) was based on IDF Diabetes Atlas 2019 data. Wilcoxon signed-rank test was used to compare expenditures of countries providing free supplies with those without free medical supplies. Results: The questionnaire was answered by 16 of the 18 IDF SACA region countries. Colombia and El Salvador were the only countries with no response. Most of the countries reported free access to oral medicines (69%), insulins (63%), supplies (syringes, needles, test strips, etc. - 56%) and lab exams (63%). Honduras was the only country where free access started because of the COVID-19 pandemic. Associations between expenditures and provision of free oral medicines, insulins, medical supplies or exams were not statistically significant, i.e. free provision of any of the four items was not associated with higher expenditures. Discussion: Our study revealed that expenditure does not determine whether medicines, supplies and exams are provided for free or not. We hypothesize that countries spending less in providing these essential items for free are still spending similar amounts due to the high costs of treating diabetes chronic complications caused by lack of access to insulin, oral medicines, supplies and lab exams. At the same time that most of the SACA countries already count on full coverage of essential diabetes medicines and supplies, such as insulin, metformin, test strips, and exams, there are still 6 countries (Bolivia, Cuba, Dominican Republic, Ecuador, Peru and Puerto Rico) lacking coverage of 3 out of four or of all essential items. It is especially worrisome that 100 years after the discovery of insulin more than a third of the countries in SACA regions still do not count on full provision of this essential life-saving medicine.

Hyperosmia after COVID-19: hedonic perception or hypersensitivity?

OBJECTIVE: COVID-19 has been associated with a wide range of quantitative and qualitative disorders of smell, including hyposmia/anosmia, parosmia, and phantosmia; however, no reports to date have reported hyperosmia as a sequela of SARS-CoV-2 infection. PATIENTS AND METHODS: We present two cases of subjective hyperosmia in a South Tyrolean Alps family, occurring within days after recovery from SARS-CoV-2 infection with transient anosmia. RESULTS: The subjects, a mother and son, exhibited subjective hyperosmia despite normal objective olfactory testing. During independent assessments, the severity of hyperosmia and specific odors affected were highly correlated, consistent with shared genetic and environmental factors. In contrast, two other family members with COVID-19 had no perceptual distortion and normal recovery of smell. CONCLUSIONS: Subjective hyperosmia after COVID-19 infection exhibited striking similarity in two affected family members, suggesting interaction of environment, genetics, and perception.

Proarrhythmic role of CoViD-19

Background: CoViD-19 infection can induce myocardial damage and heart failure, potentially complicated by arrhythmias, both as a direct consequence of CoViD-19 infection on cardiac activity, and as an effect of prescribed drug therapies. In fact, drugs such as azithromycin or hydroxychloroquine, used in CoViD-19 infection, can lengthen the QT interval with the possible risk of arrhythmias. Description of the case: A 40-year-old patient hospitalized for CoViD complains of heartbeat and atypical chest pain. Normal vital signs. ECG: rapid ventricular response atrial fibrillation. Echocardiogram: normal. Chest x-ray: bibasal interstitial pneumonia. Elevated troponin. Conclusions: Arrhythmias in patients with CoViD -19 infection are probably the consequence of direct myocardial damage or may occur as a result of metabolic disorder, hypoxia, neuro-hormonal alterations or inflammatory stress in the context of acute viremia. The onset of an arrhythmia in the presence of elevated cardiac markers may be an indication of underlying myocarditis. Since hypoxia and electrolyte abnormalities that can facilitate the onset of arrhythmias are common in the acute phase of the disease, especially in the most severe pictures, the exact arrhythmic risk of patients with less severe pictures and of patients in the post-acute phase is currently unknown. Stratification of the long-term arrhythmic risk of patients who have experienced episodes of arrhythmias in the acute phase of the disease is essential for their correct management.

Pathophysiology of thromboembolic risk in SARS-CoV-2 pneumonia

Background: SARS-CoV-2 disease may be associated with a state of hypercoagulability and an increased risk of both venous and arterial thromboembolism. Clinical and biological evidence has documented a high thromboembolic risk in the acute phase of the infection, but the incidence of the risk in the late phase of the disease requires further investigation. Description of the case: A hypertensive and diabetic patient comes to the emergency room for dyspnea and fever. It is hypotensive, tachycardic and hypoxemic. Elevated D-dimer and troponin. ECG: sinus tachycardia and right bundle branch block. Echocardiogram: hypertensive heart disease and right overload. Chest CT: bilateral interstitial pneumonia, with filling defects at the bifurcation of the right pulmonary artery. Nasopharyngeal swab for SARSCoV- 2: positive. Conclusions: SARS-CoV-2 is configured as a multidimensional disease whose characteristic physiopathological and clinical aspects are being defined: a) an increased immunological and inflammatory response with activation of a cytokine storm and consequent coagulopathy, which favours both venous thromboembolism events and thrombosis in situ in the pulmonary arterioles and alveolar capillaries;b) a high intrapulmonary shunt, which accounts for the severity of respiratory failure, attributed to a reduced hypoxic pulmonary vasoconstriction with pulmonary neoangiogenic phenomena. These patients may benefit from anticoagulant therapy initiated as early as the diagnosis of SARS-CoV-2 pneumonia.

Evaluation of Discomfort in Nasopharyngeal Swab Specimen Collection for SARS-CoV-2 Diagnosis.

BACKGROUND: The rapid spread of COVID-19 worldwide has impo-sed the need to identify a test that quickly recognizes affected subjects, both symptomatic and asymptomatic. The most reliable option has been proven to be the RT-PCR, which allows to detect virus RNA on a specimen from a high viral load site, such as nasopharynx. Nasopha-ryngeal sample collection is possible by means of a nasopharyngeal swab (NPS) and is a practical and relatively non-invasive technique, but rather bothersome for the recipient. AIM: The aim of the present study is to evaluate the discomfort evoked during NPS. MATERIALS AND METHODS: We surveyed 429 patients receiving NPS before hospitalization or other procedures non related to COVID-19. For each one we noted the discomfort level felt during the swab using a 11-point numeric rating scale (NRS) for pain and the total time needed for the procedure to be taken. Sex, age, smoking status and positive history of previous swab have been taken into account. RESULTS: We found that, among the variables, sex had a statistically significant impact on the perceived discomfort of nasal swab, with females experiencing slightly more discomfort. CONCLUSIONS: NPS is largely a none-to-minimum discomfort in-ducing procedure. The differences in perceived discomfort could be explained based on anatomical features, and should remark the need for a tailored and anatomy-oriented approach in each patient.

Diagnosis and treatment delay of head and neck cancers during COVID-19 era in a tertiary care academic hospital: what should we expect?

BACKGROUND: Since the spreading of SARS-CoV-2 from China, all deferrable medical activities have been suspended, to redirect resources for the management of COVID patients. The goal of this retrospective study was to investigate the impact of COVID-19 on head and neck cancers' diagnosis in our Academic Hospital. METHODS: A retrospective analysis of patients treated for head and neck cancers between March 12 and November 1, 2020 was carried out, and we compared these data with the diagnoses of the same periods of the 5 previous years. RESULTS: 47 patients were included in this study. We observed a significative reduction in comparison with the same period of the previous 5 years. CONCLUSIONS: Our findings suggest that the COVID-19 pandemic is associated with a decrease in the number of new H&N cancers diagnoses, and a substantial diagnostic delay can be attributable to COVID-19 control measures.

Meningoencephalitis Associated with SARS-Coronavirus-2.

The aim of this work is to clarify the incidence of meningitis/encephalitis in SARS-CoV-2 patients. We conducted an initial search in PubMed using the Medical Subject Headings (MeSH) terms "meningitis," and "encephalitis,", and "COVID-19" to affirm the need for a review on the topic of the relationship between meningitis/encephalitis and SARS-CoV-2 infection. We included case series, case reports and review articles of COVID-19 patients with these neurological symptoms. Through PubMed database we identified 110 records. After removal of duplicates, we screened 70 record, and 43 were excluded because they focused on different SARS-CoV-2 neurological complications. For eligibility, we assessed 27 full-text articles which met inclusion criteria. Seven articles were excluded, and twenty studies were included in the narrative review, in which encephalitis and/or meningitis case reports/case series were reported. Neurological manifestations of COVID-19 are not rare, especially meningoencephalitis; the hypoxic/metabolic changes produced by the inflammatory response against the virus cytokine storm can lead to encephalopathy, and the presence of comorbidities and other neurological diseases, such as Alzheimer's disease, predispose to these metabolic changes. Further study are needed to investigate the biological mechanisms of neurological complications of COVID-19.

Atypical clinical presentation of COVID-19: A case ofGuillain-Barrè Syndrome related to SARS-CoV-2 infection

Background: Emerging evidence indicates that SARS-CoV-2 infection may cause neurological complications.Case Report: 63-year-old male was admitted for acute progressive symmetric ascending weakness. He denied fever, cough, respiratory symptoms and his past medical history wasunremarkable. Physical examination showed normal blood pressure, oxygen saturation 98% on air, temperature 36,4°C, heartrate 96 bpm and severe weakness in all limbs. Chest X-ray,echocardiogram and abdominal ultrasonography were normal;ECG showed sinus rhythm (96 bpm). Cervical and brain magneticresonance revealed enhancement of the nerve roots. Abnormallaboratory tests were: PCR 447 mg/L, ferritin 1857 ng/mL, Ddimer 935 ng/mL, fibrinogen 1013 mg/dL, platelet count69000/μ L and lymphocytopenia (260/μ L). Viral serologies andautoimmune markers were negative. Cerebrospinal fluid analysisshowed normal cell count and lack of albumin-cytological dissociation. Guillain-Barrè Syndrome (GBS) was suspected and therapy by intravenous immunoglobulin and steroid was started. Anasopharyngeal swab was performed, which resulted positive toSARS-CoV-2 on RT-PCR assay. The patient was transferred to Infectious Diseases Unit to begin treatment by tocilizumab, hydroxychloroquine and plasmapheresis. Conclusions: GBS is immune-mediated disease often triggeredby various infections. Since SARS-Cov-2 may lead to a massiverelease of inflammatory cytokines, it could be hypothesized thatan aberrant immune response to SARS-CoV-2 infection inducesinflammatory damage in peripheral nerves with molecular mimicryreaction.

Impact of the COVID-19 Pandemic on Otolaryngology Residency: A Real-Life Experience

The coronavirus disease (COVID-19) pandemic as been rapidly spreading worldwide. In our country, the entire Italian Healthcare System has been forced to adapt to this unprecedented condition in this century. The Head and Neck Department clinical and surgical activity was substantially reduced. In this situation, the Ear, Nose and Throat (ENT) residents in University Hospitals find themselves in an uncertain position;we are physicians, facing a deadly disease about which much remains unknown, but we are also trainees, and there is a high risk for our residency training to be affected. With this Letter, we would like to give a testimony of our experience and give some advices to bridge the training gap.