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Background: Myasthenia Gravis (MG) is an autoimmune disease of the neuromuscular junction characterized by fluctuating, fatigable weakness of specific muscles. Most new MG cases have no identifiable triggers, though infections have been suggested as provoking factor. In the literature have been recently described few newly diagnosed and exacerbation MG cases associated both with SARS-CoV2 infection and COVID-19 vaccine. Case presentation: A 67-year-old smoker woman presented to the Emergency Department with worsening dyspnoea and fluctuating diplopia some days apart the second dose of BNT162b2 COVID-19 vaccine. Neurological examination revealed hypophonia, diplopia, inferior limbs' weakness and fatigability, therefore MG was suspected. Computed tomography of the thorax excluded thymoma. Magnetic resonance imaging of the brain was unremarkable. The clinical suspicion of MG was confirmed by serological demonstration of MuSK antibodies and neurophysiological studies. Despite early administration of anticholinesterase inhibitors, the patient experienced a myasthenic crisis with respiratory failure requiring invasive ventilatory support. She was subsequently treated with intravenous immunoglobulin, plasma exchange and steroids resulting in clinical improvement. She was finally discharged with anticholinesterase inhibitors and long-term immunosuppression therapy. Conclusions: New onset MG following COVID-19 vaccine has rarely been described in the literature, but clinicians should be aware of this possible association to achieve earlier diagnosis and more favourable outcomes.
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Background: Autoimmune limbic encephalitis (ALE) is an inflammatory disease involving the medial temporal lobes. It is characterized by subacute onset of short-term memory deficits, seizures and psychiatric disorders. Few new cases of ALE associated both with SARS-CoV2 infection and COVID-19 vaccine have recently been described. Case presentation: A 56-year-old woman was admitted to emergency department for persistent fever and acute onset of confusion few days apart the first dose of BNT162b2 COVID-19 vaccine. Neurological examination revealed confusion and short-term memory loss. Blood test showed only leukopenia and mild increase of the PCR. The patient underwent brain CT-scan which excluded organic lesion for the cognitive deficit. During the hospitalization the patient presented tonic clonic seizures and postictal state therefore an EEG was performed and revealed epileptiform abnormalities in the temporal lobes. Since the hypothesis of encephalitis brain MRI and lombar puncture for cerebral spinal fluid (CSF) analysis were performed with evidence of T2 hyperintensity in temporal lobes and normal values of CSF. Despite steroid and antiepileptic therapy with Carbamazepine, Valproate and Perampanel, several epileptic relapses occurred and there was no improvement of neurological manifestation. The patient was finally discharged with need of home care Conclusions: New onset ALE following COVID-19 vaccine or infection has rarely been described. Clinicians should monitor neurological symptoms to ensure appropriate therapy to maximize the likelihood of good outcome.
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Background: Eosinophilic granulomatosis with polyangiitis (EGPA) is a medium and small vessel vasculitis. Discussion: A 58-years man was admitted to the Emergency Department in January 2022 for myalgia and weakness of lower limbs in recent COVID-19 infection. He had a clinical history of allergic asthma and eosinophilic pneumonia (ANCA negative) diagnosed as secondary to sensitization work-related in 2001. Blood test showed a severe hypereosinophilia (absolute eosinophil count: 9875/microL) and elevated creatine kinase (CK: 7555 U/L). He was hospitalized in HUB COVID. During hospitalization reported paraesthesia of upper and lower limbs and fever;blood test showed elevation of inflammation markers. Autoimmune screening showed a antineutrophil cytoplasmic antibodies positivity (ANCA anti-MPO 178UI/mL). A sinus CT showed nasal polyposis. A neurological evaluation and electromyography were performed with the evidence of polyneuropathy. Muscle biopsy showed eosinophil-associated vascular occlusion and eosinophilassociated tissue damage. The investigation excluded renal, cardiac, pulmonary and gastro-intestinal involvement. A steroid therapy (Prednisone 1 mg/kg/die) was started with clinical improvement. Conclusions: EGPA is a multisystemic disorder, typically suspected based on a combination of clinical findings, such as asthma, nasal and sinus symptoms, peripheral neuropathy, and eosinophilia ≥1500/microL. ANCA antibodies are positive in around 40% of patients and diagnosis can often be challenging and delayed.
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Background: Coronavirus disease 2019 (COVID-19) pandemic imposed enormous burdens of morbidity and mortality while severely disrupting people, especially frontline healthcare working in hospitals.The vaccine discovery gives hope to the world population, but it was received with skepticism and fear stressed by the great media coverage. Materials and Methods: We conducted an anonymous survey of the quality of life during pandemic era and the likelihood of COVID- 19 vaccine acceptance on a sample of healthcare at the Italian Hospital more involved by COVID-19 pandemic. Results: 3134 survey respondents represented a random sample in which was represented different health workers.Of these survey participants, 644 contracted SARS-CoV-2.Healthcare workers could be psychologically stressed by covid-19 pandemic.A considerable proportion of participants reported symptoms of depression and sadness (52%), anxiety (40.9%), insomnia (33.02%) and distress (55.4%).Most healthcare workers have documented vaccination through scientific articles 1423 (45.4%) by social media news 348 (11.1%) while 152 (4.8%) haven't documented at all.They would take a vaccine if it were proven safe and effective. Conclusions: Health workers who have to be on the front line during an epidemic are more exposed to psychological distress as, in addition to guaranteeing the necessary care and assistance, they are constantly in the condition of being affected by the epidemic itself.Specific projects aimed at the prevention of burn-out and distress of health workers will be carried out to improve the entire care process.
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Background and Aim of the study: Evidence suggests that most patients who recovered from COVID-19 carry residual respiratory symptoms. Aim of the study was to evaluate blood gas changes in post-COVID-19 patients. Materials and Methods: Hospitalized COVID-19 patients attending the outpatient clinic for post-COVID-19 patients in Magenta (Italy) were included in this retrospective study. They underwent blood draw (for inflammatory biomarkers and arterial blood gas analysis [ABG]) and chest high-resolution computed tomography (HRCT) scan. The primary endpoint was the assessment of blood gas exchanges after 3 months. Other endpoints included assessment of symptoms and chest HRCT scan abnormalities and changes in inflammatory biomarkers after 3 months from hospital discharge. Results: Eighty-eight patients (n=65 men) were included. Admission ABG showed hypoxia and hypocapnia and a PaO2/FiO2 of 271.4 (IQR 238-304.7) mmHg, that greatly improved after 3 months (426.19 [IQR 395.2-461.9] mmHg, p<0.001). Forty percent of patients were hypocapnic after 3 months, while inflammatory biomarkers improved. Fever, resting dyspnea, and cough were common at hospital admission and improved after 3 months, when dyspnea on exertion and arthralgias arose. On chest HRCT scan, more than half of individuals still presented interstitial involvement after 3 months. Conclusions: While inflammatory biomarkers normalized after 3 months, signs of lung damage persisted for a longer period, suggesting the need for an adequate follow-up of post-COVID- 19 patients.
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Background and Aim: Monoclonal antibodies (mAb) are a promising treatment for patients with COVID-19. The primary objective of this analysis was to evaluate the effectiveness and safety of mAb, using real-world data relating to patients belonging to the HUB COVID of the Varese Hospital. Materials and Methods: A retrospective analysis was carried out on patients treated with mAb from April 2021 to January 31, 2022. Information was collected on: disease status, immediate and late adverse drug reactions (ADRs), and outcome at 10 and 30 days after mAb administration. Results: Three hundred twenty-eight patients (M/F 191/137;median age 59.3 yrs) were treated: 176 with bamlanivimab/etesevimab, 117 with casirivimab/imdevimab, 35 with sotrovimab. One hundred eight (32.9%) patients were not fully vaccinated and 10 (3%) vaccinated with only 2 doses more than 120 days. Eighty (24.4%) were affected by cardiovascular disease, 73 (22.2%) immunodeficiency, 69 (21%) BMI>=30, 52 (15.8%) diabetes, 35 (10.7%) chronic lung disease and 7 (2.1%) end-stage renal failure. Severe ADRs did not occur. The median time between treatment and symptom resolution was 4 days. Among the 190 outpatients, only 9 (4.7%) needed hospitalization for COVID pneumonia, with a favorable outcome. In addition, 89.8% of hospitalized patients (60 with pneumonia and negative serology, 78 hospitalized not for COVID pneumonia) had symptom resolution without disease progression. Conclusions: Our study confirms the effectiveness and safety of the early treatment with mAb for COVID-19 to reduce the risk of disease progression.
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Description of the case: A 79-year-old smoking patient with COPD, diabetes, previous bladder cancer, and family members positive for SARS-CoV2 was admitted to the hospital for pneumonia and severe respiratory insufficiency. During hospitalization, the nasopharynx sample was persistent negative for SARS-CoV-2, but the serology positive. CT showed signs of interstitial pneumonia. Antibiotic therapy, high-dose dexamethasone, and oxygen therapy were introduced. After an initial worsening of clinical conditions, inflammation indices normalization and marked clinical improvement until the suspension of oxygen therapy were observed. In the discharge phase, fever and increase in CRP and IL6 returned without respiratory failure. Black lesions with a necrotic ulcerated base located on the palate and posterior tongue were observed. Blood cultures were positive for Actinomyces oris, and Aspergillus galactomannan- antigen was detected. CT showed consolidations, cavitations, ground-glass opacity. Fibrobronchoscopy found tracheobronchial full-layer involvement with pharyngeal/laryngeal and bronchial obstruction by necrotic pseudomembranes. BAL was positive for SARS-CoV-2 and Aspergillus niger, and Aspergillus fumigatus. Voriconazole and beta-lactam antibiotics were started. The patient improved with the need for repeated FB to eliminate the pseudomembranes, but he died in the ICU due to heart failure. Conclusions: Hematogenous spread of Actinomyces is rare as well as pseudomembranous necrotizing oral-tracheobronchial aspergillosis, but to be considered in CoViD-19 patients receiving high doses of steroids.
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Description of the case: A 38-year-old patient of Moroccan ethnicity, who had vaginally delivered a healthy baby girl in the obstetric ward the previous night, was transferred to the CoViD Hub of Varese Hospital due to the onset of nausea and emesis and severe hypertransaminasemia. The patient was known to be positive for SARS-CoV-2 infection but was not taking any medications at home. Physical examination was normal, except for scleral icterus. Laboratory tests were significant for bilirubin 2.52 mg/dl, AST 2729 U/L, ALT 513 U/L, LDH>1800 U/L;we also found mild thrombocytopenia (104,000/L), INR 1.24, d-dimer>9000 ng/ml, prolonged prothrombin time, and reduced fibrinogen levels. Serological tests were negative for hepatitis A, B, C, and E, EBV, CMV, HSV type 1 and 2, and HIV. Autoimmune or toxic hepatitis was excluded. No teardrop-shaped erythrocytes were visualized. No vaginal bleeding was found. HRCT showed diffuse multiple bilateral consolidations, and abdomen CT excluded portal thrombosis. Infusive fluid and prophylactic therapy with sodium enoxaparin were started. During hospitalization, the detection of SARS-CoV-2 RNA in the nasopharynx sample was persistently positive. On the tenth day post-hospitalization, the patient was discharged with normalization of liver values and clinical well-being. Conclusions: Severe acute hepatitis has been reported in patients with severe CoViD-19, but it is rare in pregnant women with asymptomatic SARS-CoV-2 infection without other pregnancy-related disorders, as in the present case.
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Available data suggest that the issue of CoViD-19 is particularly critical in patients with diabetes. In Italy, Internal Medicine (IM) wards have played a pivotal role in contrasting the spread of SARS-Cov2. During this pandemic, FADOI submitted a brief questionnaire to a group of its members acting as Head of IM units. Considering 38 units, 58% of beds dedicated to CoViD patients in CoViD Hospitals were in charge of IM, and globally cared for 6650 patients during a six-week period. Of these patients, 1264 (19%) had diabetes. Mortality rate in CoViD patients with or without diabetes were 20.5% and 14%, respectively (p < 0.001). Our survey seems to confirm that diabetes is a major comorbidity of CoViD-19, but it does not support an increased incidence of CoViD-19 infection in people with diabetes, if compared with the figures of patients with diabetes and hospitalized before the outbreak. On the other side, patients with diabetes appeared at a significantly increased risk of worse outcome. This finding underlines the importance of paying special attention to this patient population and its management.