Clinical spectrum of COVID-19 and plasma angiotensin II levels

Angiotensin II levels in COVID-19 are controversial. We studied 12 hospitalized patients, including their baseline levels of peripheral lymphocyte subsets (via flow cytometry) and plasma angiotensin II (via radioimmunoassay). Controls comprised radioimmunoassay's 124 healthy subjects. Angiotensin II levels (pg/ml) were elevated among patients versus controls (Mean +or- standard deviation: 98.8 +or- 146.9 versus 23.7 +or- 15.6, p < 0.0001;Median, interquartile range: 27, 20 to 116 versus 22, 14 to 28). Half the patients had lymphocytopenia (< 1000 cells/mm3), and the CD3+/CD4+ counts were negatively associated with body mass index, viral load, hospital stay and non-home discharge. Angiotensin II imbalance appears to be a biomarker for COVID-19 morbidity and merits further investigation.

Ouch!My Chest. Pfizer-biontech COVID-19 Vaccination Induced Acute Myopericarditis: A Case Report

Introduction: During the pediatric trials for Coronavirus disease 2019 (COVID-19) vaccine the patient population was limited, likely leading to an inappreciable amount of adverse events. As more of the healthy adolescent male population began receiving the COVID-19 vaccination, cases of myocarditis shortly after became more frequently seen. Case Description: A previously well 15-year-old obese male presented to a pediatric ER with 3 days of left arm pain and 1 day of acute left-sided chest pain three days after receiving his second Pfizer-BioNTech COVID-19 vaccine in his left anterior deltoid area. The patient felt unwell afterwards with myalgias, headache, numbness, tingling, emesis, and 1-day history of fever of 38.8°C. He denied feelings of dizziness, syncope, palpitations, change in pain with position or deep breaths. Motrin and Tums did not seem to provide any relief. He had no history of recent viral illness and no known COVID-19 exposure. Initial evaluation included a normal chest Xray and normal sinus rhythm on EKG. Laboratory work revealed elevated troponin-I at 3.18 ng/mL, elevated Total CK at 399 units/L, CK-MB at 19 ng/mL, and BNP <10 pg/mL. Cardiology was consulted and following a normal echocardiogram, the patient was sent for a stat cardiac MRI. The imaging revealed acute myopericarditis with a small pericardial effusion. Mild patchy delayed subepicardial enhancement was also noted in the mid cavity and basal posterolateral wall (suggestive of postinflammatory scarring related to localized myocarditis.) During this time, CK-MB and Troponin-I continued to trend upwards. The patient was then started on standard treatment with Ibuprofen 800 mg Q6H and pantoprazole for gastric protection. His CK-MB peaked at 174 and Troponin-I at 26 which both subsequently trended downwards and normalized prior to discharge. Discussion: Patients who present with chest pain require a broad differential to encompass other possible etiologies including Coxsackie virus, Echovirus, Mycoplasma, EBV, and even Syphilis. Infectious diseases also followed along with the patient throughout his hospital course. All work-up for other potential causes remained negative. 1 week after presentation, his cardiac markers returned to baseline normal values. Conclusion: The study included close to 3,000 adolescents with only 754 ranging in the 16-17 age group further emphasizing the limited power of the study. Myocarditis and pericarditis are known, however rare, side effect of vaccinations and is seen more commonly in males. As the time period between receiving the COVID-19 vaccination and presenting with cardiac symptoms is short it is crucial to provide rapid care and adequate treatment.

An unlikely telemedicine diagnosis: A case report of rhizobiumradiobacter brain abscess

Introduction: Rhizobium radiobacter is a gram negative bacillus commonly found in soil. The frequency ofreported infections in the pediatric population is rare and typically affects immunocompromised patients. Thiscase highlights the incidence of a Rhizobium Radiobacter infection, prompted by a telemedicine consultation,in a healthy pediatric patient with no known risk factors. Case Description: A 12-year-old male with a history ofchronic sinusitis and renal agenesis presented to the emergency department after a new-onset generalizedseizure. The patient complained of having intermittent fevers for 5 days and left ear pain as well as left sidedperiorbital swelling. He was febrile with elevated leukocytosis and inflammatory markers, and found to haveextensive left-sided sinusitis with no focal neurological deficits. He was subsequently discharged withantibiotics and instructions to follow-up in one month with a pediatric neurologist. Three days after the initialpresentation, he returned to the emergency department with persistent fever and headache. He wasdetermined to have a sinus headache and instructed to complete the antibiotic course. The following day, he was evaluated by pediatric neurology via telemedicine. Secondary to the new onset seizures and changes inneurological status, he was referred for emergent inpatient admission. Just prior to arrival, the patient had a20-minute nonverbal episode, prompting rapid video EEG placement which was suggestive of seizure activity.The patient received a loading dose of levetiracetam and began maintenance dosing. Despite AEDs, thepatient continued to have multiple subclinical seizures in the frontal lobe. MRI brain was indicative ofmeningoencephalitis involving the left hemisphere, left frontal lobe cerebritis,and a multilocular extra-axialabscess. At this time intravenous antibiotics were begun at meningitic dosing. The patient was taken foremergent craniotomy for abscess evacuation, and cultures were found to be positive for RhizobiumRadiobacter. Discussion: In the setting of fever and new-onset seizure in an otherwise healthy patient,meningitis should be high on the differential. Infectious etiology cannot be excluded and necessitates furtherinvestigation including lumbar puncture with cerebrospinal fluid cultures. The delay in ascertaining a spinaltap, alongside the late-onset of IV antibiotic use, propagated the formation of a bacterial abscess. Conclusion:During the COVID-19 pandemic, the availability of telemedicine proved to be a lifesaving service. The clinicalacumen of the neurologist prompted admission to the hospital for further evaluation and the eventualdiagnosis of a bacterial brain abscess. A telehealth consultation with the patient in his home setting allowedfor the thorough history-taking required to develop the connection between the neurological changes andrecent sinusitis. This case exemplifies the functionality of pediatric telemedicine and serves to highlight aunique pathogen in this patient population.

7 year old male with 2 months of progressive left sidedweakness

Introduction: Gliomas are the most common primary CNS tumors making up 50-60% of brain tumors inchildren. Prognosis for gliomas depends on histologic grade and location of tumor. Impingement on normalbrain tissue or increase in intracranial pressure is caused by either obstruction of CSF flow or by direct masseffect. Symptoms can include lethargy, headache and vomiting. Signs of slow growing CNS tumors can includeirritability, poor school performance and loss of developing milestones. Most arise with no known underlyingrisk factor or disorder. Case Presentation: 7-year-old male with no significant past medical history presented with left sided weakness that began 8 weeks prior to admission. Initially mother noticed the patient to have anasymmetric smile. Patient was seen by PCP and was referred to ophthalmology and neurology at that time. 4weeks later, he was noted to have left arm weakness and difficulty writing with his left hand. A week later hebegan having weakness in his left leg and was noticed to have increased instability. Patient was reevaluated byPCP who instructed him to complete a 5-day course of steroids and follow-up with neurology. On the day of admission he was seen by an outpatient neurologist using telemedicine due to COVID outbreak. It was notedthe patient had left sided paralysis, a dilated left pupil, weakness of the left arm and leg with elevation. Afterseeing the physical exam findings through a webcam, the neurologist suggested for the patient to have urgentevaluation in the emergency department. CT brain with contrast revealed a heterogenous, complex mass inthe region of the right hypothalamus. MRI brain showed mass that involved the right and left cerebralhemisphere, with infiltration of the left optic tract. A brain biopsy was performed by neurosurgery andpathology was GFAP positive confirming astrocytoma in the brainstem. Discussion: About 25% ofastrocytomas are aggressive or high grade. Brainstem gliomas make up 10-20% of CNS tumors in children lessthan 15 years old. Diffuse midline gliomas are infiltrative tumors, usually with astrocytic morphology and arelocated in the pons, thalamus or spinal cord. Most cases have high grade features and are histologicallyconsistent with Grade 4. Treatment includes surgery, radiotherapy and chemotherapy. For high grade tumorssurgery can be performed as well as radiotherapy and chemotherapy. But without reasonable resectionchemotherapy is palliative. Brainstem gliomas cannot be removed, and therefore have a poor outcome.Conclusion: Despite lack of in person evaluation, this case highlights the importance of prompt recognitionand action when performing history and physical exams even in this new era of telemedicine. In the setting ofthe COVID-19 pandemic, the use of telemedicine proved to be prominent in the diagnosis of this patient.