Anosmia and Dysgeusia in the Absence of Other Respiratory Diseases: Should COVID-19 Infection Be Considered?

We describe two elderly patients evaluated at emergency departments for anosmia/dysgeusia in the absence of any other respiratory symptoms prior to or upon admission. In the current epidemiological context, clinical and biological work-up led to a diagnosis of COVID-19 infection. Unfortunately, one of the patients died during hospitalization, but the other recovered and was discharged. LEARNING POINTS: In the current epidemiological situation, anosmia and dysgeusia in the absence of other respiratory conditions should be carefully evaluated.Special attention should be given to patients with non-classic COVID-19 symptoms in order to reduce transmission and protect health providers.

Thrombocytopenia in the Course of COVID-19 Infection.

We report three cases of severe thrombocytopenia during COVID-19 infection associated with either cutaneous purpura or mucosal bleeding. The initial investigations ruled out other causes of thrombocytopenia. Two of the patients were treated with intravenous immunoglobulins and eltrombopag, while the third recovered spontaneously. A good clinical and biological response was achieved in all patients leading to hospital discharge. LEARNING POINTS: Immune thrombocytopenia should be considered in COVID-19-infected patients presenting with thrombocytopenia.Coronavirus-related thrombocytopenia can be severe and life-threatening.Despite the severity of coronavirus-related immune thrombocytopenia, recovery may be spontaneous or achieved following immunoglobulin or platelet growth factor administration.

Cutaneous Complications Secondary to Haemostasis Abnormalities in COVID-19 Infection.

We describe the case of a patient hospitalized for acute decompensated heart failure in a standard medical ward. During hospitalization, he was diagnosed with COVID-19 and transferred to a special unit. The clinical course was marked by worsening of the respiratory disease, the development of right parotiditis and thrombosis of the left internal jugular vein. Therapeutic anticoagulation was initiated and 2 days later, the minimal dermatoporosis lesions previously present in the upper extremities evolved to haemorrhagic bullae with intra-bullae blood clots and dissecting haematomas. Surgical management of the dissecting haematomas was difficult in the context of haemostasis abnormalities. The patient died 29 days after hospital admission. LEARNING POINTS: Single room accommodation should be preferred to double room accommodation in standard wards during the COVID-19 pandemic.Anticoagulation therapy and the presence of lupus anticoagulant may induce cutaneous complications during COVID-19 infection.The discontinuation of anticoagulation therapy did not help improve the management of cutaneous lesions.

The Effects of a Therapeutic Strategy Guided by Lung Ultrasound on 6-Month Outcomes in Patients with Heart Failure: Results from the EPICC Randomized Controlled Trial.

BACKGROUND: Pulmonary congestion (PC) is associated with an increased risk of hospitalization and death in patients with heart failure (HF). Lung ultrasound is highly sensitive for detecting PC. The aim of this study is to evaluate whether lung ultrasound-guided therapy improves 6-month outcomes in patients with HF. METHODS: A randomized, multicenter, single-blind clinical trial in patients discharged after hospitalization for decompensated HF. Participants were assigned 1:1 to receive treatment guided according to the presence of lung ultrasound signs of congestion (semi-quantitative evaluation of B lines and the presence of pleural effusion) versus standard of care (SOC). The primary endpoint was the combination of cardiovascular death, readmission, or emergency department or day hospital visit due to worsening HF at 6 months. In September 2020, after an interim analysis, patient recruitment was stopped. RESULTS: A total of 79 patients were randomized (mean age 81.2 +/- 9 years) and 41 patients (51.8%) showed a left ventricular ejection fraction >50%. The primary endpoint occurred in 11 patients (29.7%) in the SOC group and in 11 patients (26.1%) in the LUS group (log-rank = 0.83). Regarding nonserious adverse events, no significant differences were found. CONCLUSIONS: LUS-guided diuretic therapy after hospital discharge due to ADHF did not show any benefit in survival or a need for intravenous diuretics compared with SOC.

Prognostic Significance of Lung and Cava Vein Ultrasound in Elderly Patients Admitted for Acute Heart Failure: PROFUND-IC Registry Analysis.

INTRODUCTION: Heart failure is an extremely prevalent disease in the elderly population of the world. Most patients present signs and symptoms of decompensation of the disease due to worsening congestion. This congestion has been clinically assessed through clinical signs and symptoms and complementary imaging tests, such as chest radiography. Recently, pulmonary and inferior vena cava ultrasound has been shown to be useful in assessing congestion but its prognostic significance in elderly patients has been less well evaluated. OBJECTIVES: This study aims to compare the clinical and radiological characteristics and predictive values for mortality in patients admitted for heart failure through the determination of B lines by lung ultrasound and the degree of collapsibility of the inferior vena cava (IVC). Secondarily, the study aims to assess the prediction of 30-day mortality based on the diameter of the IVC by means of the ROC curve. METHODS: This is an observational cohort study based on data collected in the PROFUND-IC study, a nationwide multicentric registry of patients admitted with decompensated heart failure. Data were collected from these patients between October 2020 and April 2022. RESULTS: A total of 482 patients were entered into the PROFUND-IC registry between October 2020 and April 2022. Bedside clinical ultrasound was performed during admission in 301 patients (64.3%). The number of patients with more than 6 B-lines on lung ultrasound amounted to 194 (66%). Statistically significant differences in 30-day mortality (22.1% vs. 9.2%; p = 0.01) were found in these patients. The sum of patients with IVC collapsibility of less than 50% amounted to 195 (67%). Regarding prognostic value, collapsibility data were significant for the number of admissions in the last year (12.5% vs. 5.5%; p = 0.04), in-hospital mortality (10.1% vs. 3.3%, p = 0.04) and 30-day mortality (22.6% vs. 8.1%; p < 0.01), but not for readmissions. Regarding the prognostic value of IVC diameter for 30-day mortality, the area under the ROC curve (AUC) was 0.73, with a p < 0.01. The curve cut-off point with the highest sensitivity (70%) and specificity (70.3%) was for an IVC value of 22.5 mm. In the logistic regression analysis, we observed that the variable most associated with patient survival at 30 days was the presence of a collapsible inferior vena cava, with more than 50% OR 0.359 (CI 0.139-0.926; p = 0.034). CONCLUSIONS: The subgroups of patients analyzed with more than six B lines per field and IVC collapsibility less than or equal to 50%, as measured by clinical ultrasound, had higher 30-day mortality rates than patients who did not fall into these subgroups. IVC diameter may be a good independent predictor of 30-day mortality in patients with decompensated heart failure. Comparing both ultrasound variables, it seems that in our population, the assessment of the inferior vena cava may be more associated with short-term prognosis than the pulmonary congestion variables assessed by B lines.

Hearing Loss and Sixth Cranial Nerve Paresis after COVID-19.

An 80-year-old patient was admitted to the internal medicine department for binocular diplopia and hearing loss with sudden onset. The patient had presented with SARS-CoV-2 infection 3 weeks previously and had been admitted to hospital. Complete work-up including autoimmunity, serum and LCR viral serology and MRI did not allow a diagnosis to be established. The hypothesis of a microvascular origin or the previous SARS-CoV-2 infection was considered. The latter was retained in light of the temporal relationship, the absence of other pathologies after exhaustive work-up, and the clinical evolution. LEARNING POINTS: A temporal relationship between SARS-CoV-2 infection and symptoms in the absence of other pathologies is important for diagnosis.Mid or long-term follow-up is necessary in patients with unexplained symptoms after SARS-CoV-2 infection.

SARS-CoV-2 infection and psychiatric manifestations in a previous healthy patient.

BACKGROUND: The clinical presentation of SARS-CoV-2 infection was initially dominated by respiratory symptoms. However, the clinical spectrum is wide and neuropsychiatric syndromes are also a source of medical concern. Our aims are to present an atypical clinical presentation of SARS-CoV-2 infection characterized by auditory hallucinations and unusual behavior and to emphasize the diversity of clinical manifestations of SARS-CoV-2 infection. CASE PRESENTATION: A 33-year-old woman was admitted to the emergency department (ED) with a one-day history of auditory hallucinations, unusual behavior, changes in her sleeping habits and incoherent speech. No other symptoms were reported. Blood examinations confirmed high elevated white cell count and C-reactive protein. The head CT scan was normal but the chest scan showed right ground-glass opacities in the lower zones. The oropharyngeal swab was positive for SARS-CoV-2. Based on these results, the diagnosis of SARS-CoV-2 infection was retained. The patient received no specific treatment for SARS-CoV-2 infection and only needed oxygen therapy support for 7 days. The additional dose of Olanzapine 10 mg daily was initially prescribed but the patient was back to her usual self on day 14 of hospital admission leading to its discontinuation. This clinical course was consistent with a first episode of psychosis triggered by SARS-CoV-2 infection. CONCLUSION: Neuroinflammation owing to SARS-CoV-2 infection could be responsible for a wide and unknown spectrum of neuropsychiatric manifestations. During this pandemic, special attention should be given to patients with no previous history of psychiatric disorders presenting to ED with neuropsychiatric syndromes of unknown etiology.

The SADDEN DEATH Study: Results from a Pilot Study in Non-ICU COVID-19 Spanish Patients.

Introduction: The worldwide pandemic, coronavirus disease 2019 (COVID-19) is a novel infection with serious clinical manifestations, including death. Our aim is to describe the first non-ICU Spanish deceased series with COVID-19, comparing specifically between unexpected and expected deaths. Methods: In this single-centre study, all deceased inpatients with laboratory-confirmed COVID-19 who had died from March 4 to April 16, 2020 were consecutively included. Demographic, clinical, treatment, and laboratory data, were analyzed and compared between groups. Factors associated with unexpected death were identified by multivariable logistic regression methods. Results: In total, 324 deceased patients were included. Median age was 82 years (IQR 76-87); 55.9% males. The most common cardiovascular risk factors were hypertension (78.4%), hyperlipidemia (57.7%), and diabetes (34.3%). Other common comorbidities were chronic kidney disease (40.1%), chronic pulmonary disease (30.3%), active cancer (13%), and immunosuppression (13%). The Confusion, BUN, Respiratory Rate, Systolic BP and age ≥65 (CURB-65) score at admission was >2 in 40.7% of patients. During hospitalization, 77.8% of patients received antivirals, 43.3% systemic corticosteroids, and 22.2% full anticoagulation. The rate of bacterial co-infection was 5.5%, and 105 (32.4%) patients had an increased level of troponin I. The median time from initiation of therapy to death was 5 days (IQR 3.0-8.0). In 45 patients (13.9%), the death was exclusively attributed to COVID-19, and in 254 patients (78.4%), both COVID-19 and the clinical status before admission contributed to death. Progressive respiratory failure was the most frequent cause of death (92.0%). Twenty-five patients (7.7%) had an unexpected death. Factors independently associated with unexpected death were male sex, chronic kidney disease, insulin-treated diabetes, and functional independence. Conclusions: This case series provides in-depth characterization of hospitalized non-ICU COVID-19 patients who died in Madrid. Male sex, insulin-treated diabetes, chronic kidney disease, and independency for activities of daily living are predictors of unexpected death.

Ninety days post-hospitalization evaluation of residual COVID-19 symptoms through a phone call check list.

An observational and descriptive study including patients discharged for COVID-19 was carried out by the COVID-19 Working Group of the Hospital Clínico San Carlos (HCSC). We aimed to identify the main symptoms after 90 days of hospital discharged. A structured interview was conducted, through a "checklist" that included symptoms within the 90 days post-discharge. A total of 134 patients were enrolled. The most frequently referred symptoms were asthenia, dyspnea and weight loss. Anxiety was the most frequent psychological symptom found through the GAD-7 scale.