Delirium during COVID‑19: A report of eight cases and a review of the literature

Delirium is an acute confusional state, often associated with long‑term hospitalization, oxygen supplementation, the male sex and an older age. Since the start of the corona‑ virus disease 2019 (COVID‑19) pandemic, there was an abrupt increase in intensive care unit (ICU) admissions and hospitalization in general, as well as in the need for oxygen therapy and enforced isolation due to the contagion risk. This caused a sudden increase in the episodes of delirium. The diagnosis of delirium, however, remains a difficult task, as it can often be misdiagnosed or confused with underlying dementia, particularly among the elderly. The present study describes present eight cases of patients admitted to hospital due to severe acute respiratory syndrome coronavirus 2 infection, who manifested delirium. Notably, only one of the patients had psychiatric comorbidities prior to hospitalization. The most prevalent sex was the male (7:1) one, the mean age of the patients was 81.7±4 years, and the mean duration of hospitalization was 23.6±6 days. In total, 3 patients had a virological recovery and were discharged, 3 had a clinical recovery and were transferred to a lower intensity COVID‑19 facility and 2 patients did not survive. In the eight cases described herein, the mortality rate was 25%. Delirium was found to be commonly associated with a higher mortality rate and a longer hospitalization period. Therefore, it is imperative to develop protocols and tools with which to rapidly assess delirium and treat it accordingly. In addition, it is fundamental to improve the quality of life of hospitalized patients, supporting behavioral therapy and the environmental factors that can affect patients, to prevent delirium as well. © 2023 Spandidos Publications. All Rights Reserved.

Impact of the COVID-19 pandemic on HPV vaccination coverage in the general population and in PLWHs.

OBJECTIVE: On March 11, 2020, the World Health Organization (WHO) has declared the novel coronavirus (COVID-19) outbreak as a global pandemic. COVID-19 pandemic has impacted health services, including immunization programs, with a consequent reduction in vaccination coverage in those categories for which the prevention of vaccine-preventable diseases is strongly recommended. SUBJECTS AND METHODS: We conducted a retrospective cross-sectional study on the general population and on PLWHs, comparing anti-human papillomavirus (HPV) vaccination coverage data in 2019, before COVID-19 pandemic, and the 2020 data, after the announcement of the pandemic state and the lockdown and the implementation of restrictive measures to contain the contagion. RESULTS: Compared to 2019, 2020 data show a 42% reduction in HPV vaccine coverage in the general population and 36% in PLWHs. The greatest reduction in anti-HPV vaccination coverage occurred during periods of greatest restriction and mainly concerned the general population. CONCLUSIONS: The prevention of vaccine-preventable diseases remains essential. Above all, it is essential to increase and recover the anti-HPV vaccine coverage, in consideration of the data that show its preventive oncological efficacy.

A misunderstood severe aortic stenosis in a COVID-19 patient

Background: It is crucial to differentiate patients affected by COVID-19 from others who only tested positive to SARS-CoV-2 to optimize the treatments. We need to identify respiratory symptoms unrelated to SARS-CoV-2 infection. We report a case of severe cardiogenic dyspnea in a patient admitted for COVID-19. Case Report: A 79-year-old woman with nasal swab positive for SARS-CoV-2 was admitted for dyspnea and asthenia for 2 weeks. At the admission she presented with orthopnea, ankles swelling and oliguria. EKG showed atrial fibrillation and echocardiogram showed diffuse left ventricle hypokinesia, severe reduced ejection fraction, right ventricle normal dimensions and kinesia, not very modular inferior venae cavae, negative femoro popliteal CUS, absence of pericardial effusion, diffuse and homogeneous thoracic pattern B. She started furosemide and dobutamine with strict clinical and ultrasound monitoring. Because of the reduction of dyspnea and an incremented diuresis, dobutamine was stopped in the second day. On day 3 there was a worsening, echocardiogram showing a severe aortic stenosis, very small inferior venae cavea. Liquid infusion was started with caution to increase preload. Once obtained hemodynamic stabilization, the patient underwent coronary angiography. No coronary lesions were found and TAVI was performed successfully. Conclusions: The patient experimented respiratory symptoms due to acute heart failure. Dobutamine infusion made manifest a preexisting severe aortic stenosis that was successfully treated.

A case of toxic epidermal necrolysis in a COVID-19 patient

Background: We report a severe hypersensitivity reaction due to warfarin in a COVID19 patient with sepsis. Case Report: An 86-year-old man was admitted for COVID19 pneumonia. He was vaccinated with 2 ComirNaty doses. He was affected by hypertension and CKD in emodialysis. At the admission he presented fever and tachypnea, the laboratory tests showed a septic state. We started administration of empiric therapy with piperacillina/tazobactam, it was replaced with meropenem and linezolid on the 29th day. After 10 days linezolid was stopped for thrombocitopenia. On the 14th day we prescribed warfarin for tromboembolic risk prevention when paroxysmal atrial fibrillation occurred . At the fifth week there was a clinic and laboratory worsening so we started target antibiotic therapy with cefiderocol and colistin due to positive blood cultures for A. Baumanii XDR. On the 24th day an inguinal erytema with blister-like lesion occurred and involved progressively face, neck, limbs, trunk and abdomen with extensive skin sloughing and crusted lesions appeared in the perioral and perinasal mucosa. Nikolsky sign was negative. Skin biopsy showed signs of inflammatory reaction. Warfarin was stopped and 1mg/kg methylprednisone was started with slow and progressive benefit. Conclusions: The patient has developed a warfarin linked hypersensitivity reaction with clinical features similar to toxic epidermal necrolysis. We assume that it was a borderline condition of hypersensitivity to warfarin in a patient with hyperactivation of immune system due to COVID19 and sepsis.

Severe Neutropenia after Sarilumab Administration in Two COVID-19 Patients: Case Reports and Literature Review

BACKGROUND: Two years have passed since the WHO declared a pandemic state for SARS-CoV2 infection. COVID-19 pathogenesis consists of a first viral phase responsible for early symptoms followed by an inflammatory phase, which is cytokine-mediated, responsible for late-onset signs up to acute respiratory distress syndrome. Considering that interleukin (IL)6 plays a key role in the development and maintenance of inflammation, drugs targeting both IL6 and IL6 receptors have been evaluated. CASE REPORTS: The present study reports the cases of two hospitalized patients with severe respiratory COVID-19 treated with a single dose of intravenous sarilumab, a monoclonal anti-IL6 antibody, along with standard of care medications and high-flow oxygen therapy. Although a few days following sarilumab administration, clinical and biochemical conditions started ameliorating, these patients developed severe and self-limiting neutropenia. CONCLUSION: Sarilumab may represent a promising weapon to treat the fearsome hyperinflammatory phase;however, more trials are needed to decide whether to use it in combination with other drugs or alone, and to better understand pharmacokinetics and side effects.

Pain crisis management in a patient with sickle cell disease during SARS-CoV-2 infection: A case report and literature review

Patients with sickle cell disease (SCD) are more susceptible to severe coronavirus disease 2019 (COVID-19) infection, in comparison with the general population, due to the possibility that the inflammatory state, along with hypoxia and hypercoagulability may increase the risk of developing acute SCD-related complications. The present study reports the case of a 33-year-old female affected by SCD, who although vaccinated against COVID-19, tested positive for SARS-CoV-2 and developed febrile pneumonia. During hospitalization, the patient complained about generalized intense pain, along with fever recurrence and increased inflammatory marker, procalcitonin and haemoglobin S levels. The patient was treated with an intravenous analgesic therapeutics cocktail in combination with red blood cell manual exchange procedure and broad-spectrum antibiotic therapy, achieving the rapid resolution of pain and an improvement in the laboratory test results. From the case presented herein, it is thus suggested that patients with SCD and COVID-19 infection need to be critically evaluated by clinicians, as such patients may develop severe outcomes, attributed to the overlap of two difficult to treat conditions. © 2022 by the authors.

COVID-19 and pregnancy: clinical outcomes and scientific evidence about vaccination.

Pregnant women and their infants are at high risk to develop a severe COVID-19, with increased rates of hospitalisation to intensive care units, need for mechanical ventilation and mortality. Preterm birth, fetal vascular malperfusion, and premature rupture of membrane have been the most reported adverse pregnancy outcomes and these effects have been especially associated with the onset of the disease at early gestational age. The early expression of ACE2 and TMPRSS2 in human embryos has been proven, determining an increased susceptibility to SARS-CoV-2. Preterm infants born to women infected by SARS-CoV-2 have a higher risk of need for specialist neonatal care with prolonged hospitalization. Moreover, inflammation of developing embryos could cause long-term defects, regardless of vertical transmission of SARS-CoV-2. Due to Maternal Immune Activation (MIA), in utero inflammation is associated with neurodevelopmental, cognitive and psychiatric disorders in affected offspring. Despite risks that COVID-19 could induce in pregnancy, there are not many published data describing the safety and/or efficacy of COVID-19 vaccines in pregnant women, commonly not included in vaccine research. The evidence from the few pregnant women unintentionally enrolled in clinical trials and vaccinated suggests that COVID-19 vaccines, both based on mRNA and viral vectors, do not pose significant risks to the fetus or breastfeeding infants. Moreover, human studies using mRNA-based vaccines against Zika virus, influenza, and rabies have reported good safety and immunogenicity during pregnancy. In this review, we evaluate the role of COVID-19 in adverse pregnancy and neonatal outcomes and the need to vaccinate pregnant women.

Reasons why COVID-19 survivors should follow dietary World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) recommendations: from hyper-inflammation to cardiac dysfunctions.

The World Cancer Research Fund and American Institute for Cancer Research (WCRF/AICR) advise cancer survivors to follow their lifestyle recommendations for cancer prevention.  Recent research indicates that a proper diet could exerts beneficial metabolic and immune effects in humans through the involvement of several, not yet properly known, metabolic pathways. Here, we argue that following WCRF/AICR recommendations could be a strategy to prevent cardiovascular outcomes [fulminant myocarditis, heart failure, venous thromboembolism (VTE)] and acute respiratory distress syndrome (ARDS) in patients during follow-up post COVID-19 infection. We discuss the metabolic effects of a WCRF/AICR based diet, highlighting on the involved cardio-metabolic pathways related on NLRP3 inflammasome-cytokines axis aimed to improve prognosis of COVID-19, especially in patients with cancer.

High-flow nasal cannula oxygenation and tocilizumab administration in patients critically ill with COVID-19: A report of three cases and a literature review

Since late 2019, SARS-CoV2 has spread worldwide, leading the WHO to declare a pandemic state. Italy was deeply affected by the virus, particularly North Italy. Several molecules have been tested for the treatment of coronavirus disease (COVID-19), comparing the treatment efficacy and collateral effects. To date, no antiviral drugs have been approved for the treatment of the COVID-19 viral phase or for the inflammatory phase. Undoubtedly, oxygen support plays a key role in the management of patients affected by this virus. The present study reports the cases of 3 patients critically ill with COVID-19. Despite antiviral therapy, their clinical conditions deteriorated a few days following admis- sion, particularly as regards respiratory performance, together with chest X-ray findings and arterial blood gas parameters. The levels of inflammatory markers were also elevated. The patients were treated with high-flow nasal cannula (HFNC) oxygenation along with a double dose of tocilizumab. A few days following HFNC and tocilizumab administration, the respiratory rates and arterial blood gas data were ameliorated alongwithchestX-rayresults.TheuseofHFNCwasthenslowly reduced until it was terminated, with the patients achieving a successful discharge. On the whole, as presented herein, it is indisputable more data and guidelines for COVID-19 therapies are warranted in order to guide clinicians as to the appropriate clinical treatment which will guarantee an optimal therapeutic response. © 2020 World Academy of Sciences Journal. All rights reserved.

Clinical application of lung ultrasound score on COVID-19 setting: a regional experience in Southern Italy.

OBJECTIVE: We aimed to assess the correlation between LUS Soldati proposed score and clinical presentation, course of disease and the possible need of ventilation support/intensive care. PATIENTS AND METHODS: All consecutive patients with laboratory confirmed SARS-CoV-2 infection and hospitalized in two COVID Centers were enrolled. All patients performed blood gas analysis and lung ultrasound (LUS) at admission. The LUS acquisition was based on standard sequence of 14 peculiar anatomic landmarks with a score between 0-3 based on impairment of LUS picture. Total score was computed with their sum with a total score ranging 0 to 42, according to Soldati LUS score. We evaluated the course of hospitalization until either discharge or death, the ventilatory support and the transition in intensive care if needed. RESULTS: One hundred and fifty-six patients were included in the final analysis. Most of patients presented moderate-to-severe respiratory failure (FiO2 <20%, PaO2 <60 mmHg) and consequent recommendation to invasive mechanic ventilation (CPAP/NIV/OTI). The median ultrasound thoracic score was 28 (IQR 18-36) and most of patients could be ascertained either in a score 2 (40%) or score 3 pictures (24.4%). The bivariate correlation analysis displayed statistically significant and high positive correlations between the LUS score and the following parameters: ventilation (rho=0.481, p<0.001), lactates (rho=0.464, p<0.001), dyspnea (rho=0.398, p=0.001) mortality (rho=0.410, p=0.001). Conversely, P/F (rho= -0.663, p<0.001), pH (rho = -0.363, p=0.003) and pO2 (rho = -0.400 p=0.001) displayed significant negative correlations. CONCLUSIONS: LUS score improve the workflow and provide an optimal management both in early diagnosis and prognosis of COVID-19 related lung pathology.

Computational modeling ofimmunologic response to immune checkpoint inhibitors inCOVID-19 patients with and without cancer

Cancer patients have an increased risk of severe COVID-19 infection due to the suppression of the immune systemand the development of cytokine release syndrome (CRS) that favor respiratory syndromes and interstitialpneumonia. However, substantial differences exist between patients treated with chemotherapy and patients treated with immune checkpoint inhibitors (ICIs), for which the risk of COVID-19 infection and the immunologic and cytokineprofile in case of infection have not yet been well characterized. The administration of ICIs for the treatment ofsevere COVID-19 infection has been recently suggested. However, no conclusive data have been generated on thismatter. To recognize the therapeutic potential of ICIs administration in COVID-19 patients with or without cancer, theUniversal Immune System Simulator (UISS) prediction model was used to simulate the immunologic response ofCOVID-19 patients after ICIs administration. Briefly, UISS represents an appropriate computational modelinginfrastructure able to simulate the dynamics of every single entity of the immune system after a stimulus or atherapeutic intervention by using an agent-based methodology. Therefore, the UISS platform, already used for theprediction of the efficacy of specific SARS-CoV-2 candidate vaccines, was here adopted to characterize theimmunologic behavior in both COVID-19 and cancer patients and to predict the effects of ICIs in these patients. Thecomputational results allowed us to identify key inflammatory and immune-related factors responsible for severerespiratory syndromes in COVID-19 infected patients with and without cancer. UISS results suggest that theadministration of ICIs modulates the immune system and the inflammatory status in both groups of patients withCOVID-19 infection, reducing the risk of severe symptoms. Although the results of the present study are still undervalidation in peripheral blood samples obtained from COVID-19 patients and from cancer patients after two cycles oftreatment with ICIs, we can speculate that ICIs may be a good therapeutic approach for the treatment of COVID-19severe respiratory syndrome even with a concomitant cancer diagnosis. If this is the case, the lower expressionlevels of inflammatory biomarkers can result in the drop-down of the viral load, assessed by droplet digital PCR inCOVID-19 patients.

Transmission mode associated with coronavirus disease 2019: a review.

OBJECTIVE: In late December 2019 in Wuhan (China), Health Commission reported a cluster of pneumonia cases of unknown etiology, subsequently isolated and named Severe Acute Respiratory Syndrome (SARS) Coronavirus 2 (CoV-2). In this review, the main transmission routes and causes of mortality associated with COVID-19 were investigated. MATERIAL AND METHODS: A review was carried out to recognize relevant research available until 10 April 2020. RESULTS: The main transmission routes of COVID-19 have been the following: animal to human and human-to-human pathways, namely: respiratory transmission; oro-fecal transmission; air, surface-human transmission. Transmission from asymptomatic persons, healthcare transmission, and interfamily transmission have been well documented. CONCLUSIONS: SARS-CoV-2 possesses powerful pathogenicity and transmissibility. It is presumed to spread primarily via respiratory droplets and close contact. The most probable transmission pathway is definitely the inter-human one. Asymptomatic patients seem to play a crucial role in spreading the infection. Because of COVID-19 infection pandemic potential, careful surveillance is essential to monitor its future host adaptation, viral evolution, infectivity, transmissibility, and pathogenicity in order to gain an effective vaccine and flock immunity and reduce mortality as soon and as much as it is possible.

Outbreak of COVID-19 infection in children: fear and serenity.

OBJECTIVE: The recent outbreak of SARS-CoV-2 greatly involves the resources of the global healthcare system, as it affects newborns, adults, and elders. This infection runs in three major stages: a mild cold-like illness, a moderate respiratory syndrome and a severe acute interstitial pneumonia. SARS-CoV-2 infection seems to have a more benign evolution in children. As a matter of fact, low susceptibility and minor aggressivity have been highlighted in most cases. There are currently no effective antiviral drugs treatment for the affected children. No sufficient results have been reached by the use of interferon (IFN), lopinavir/ritonavir, orbidol, and oseltamivir in the treatment of the coronaviruses infection. The aim of this short review is to highlight the differences existing between COVID-19 cases in adults and children.