COVID-19 and cutaneous manifestations: Two cases and a review of the literature

COVID-19 can affect multiple organs, including skin. A wide range of skin manifestations have been reported in literature. Six main phenotypes have been identified: i) urticarial rash, ii) confluent erythematous/maculopapular/morbilliform rash, iii) papulovesicular exanthem, iv) a chilblain-like acral pattern, v) a livedo reticularis/racemosa-like pattern, and vi) a purpuric vasculitic pattern. The pathogenetic mechanism is still not completely clear, but a role of hyperactive immune response, complement activation and microvascular injury have been postulated. The only correlation between the cutaneous phenotype and the severity of COVID-19 has been observed in the case of chilblain-like acral lesions, that is generally associated with the benign/subclinical course of COVID-19. Herein, we report two cases of SARS-CoV-2 infection in patients who developed cutaneous manifestations that completely solved with systemic steroids and antihistamines. The first case is a female patient not vaccinated for SARS-CoV-2 with COVID-19 associated pneumonia, while the second case is a vaccinated female patient with only skin manifestations.

The pain in the Emergency Department: Choosing and treating wisely before and during the COVID-19 era

Pain is a frequent reason for referral to the Emergency Department (ED). Adequate management of pain is a moral and ethical imperative. If not correctly treated, acute pain can cause physical and psychological complications, and become chronic with severe consequences such as anxiety, depression, and social isolation. As consequence, emergency clinicians should treat pain as soon as possible, avoiding delays even in case of acute abdominal pain. Pain management is particularly complex in the elderly and emergency clinicians should always consider AGS Beers criteria (R) to avoid inappropriate medications, severe side-effects, and drug-drug interactions. Pain is also a common cause of delirium in older patients. The SARS CoV-2 infection not only can cause acute pain, but also exacerbate chronic pain, particularly in the elderly, who are at high risk to be infected. Looking at all this evidence, emergency clinicians should treat pain with different strategies according to their experience and cultural background, making the right choice for each patient. This work is a critical review of the pain management in the ED, with a particular attention on the effects of COVID-19 in the EDs. We conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline from 2000 to 2020, using the keywords of "pain", "emergency", "COVID19", "elderly", "palliative care", "ketamine", "dexmedetomidine", and "post-traumatic stress disorder". The aim of this review is to help emergency clinicians to correctly manage pain in the ED with a new point of view regarding the pain management in COVID-19 patients.

A case of hematuria and vomiting in the emergency room: Never forget the emphysematous pyelonephritis

We describe the case of a 68-year-old man with a known history of hypertension and diabetes mellitus presented to our Emergency Department, complaining of hematuria and vomiting in the last 12 hours, stypsis and urinary incontinence in the last week, and worsening hyporexia in the last 6 months. Bedside ultrasound documented a slight right pleural effusion with B lines in the middle and basal right field, gastrectasis, dilated fluid-filled bowel loops, potential signs of gas in the upper right quadrant, grade 3 bilateral hydronephrosis, and bladder globe. Abdominal CT scan confirmed the bilateral hydroureteronephrosis and showed the right kidney with Emphysematous Pyelonephritis (EPN) with extension into the perinephric and muscular planes for 24 cm, and initial EPN in the left kidney. A RT-PCR nasopharyngeal swab for SARS CoV-2 was negative. A diagnosis of ileum paretic, acute renal failure and urosepsis due to EPN was made.

COVID-19 or not COVID-19, that is the question. The role of screening criteria and point-of-care lung ultrasound in the triage decision-making process in an Emergency Department during the phase 2 of the COVID-19 Italian epidemic

In the COVID-19 era the real challenge for the Emergency Departments (ED) is to avoid the spread of the viral infection within the so called "clean area" of the emergency room and the hospital. Different protocols have been proposed and adopted in the EDs to quickly identify suspected COVID-19 patients and to correctly manage these patients, all based on clinical and epidemiological criteria. To the best of our knowledge, our pre-triage decisional making-process first integrates the pre-triage interview with point-of-care Lung Ultrasound (LUS) performed in the triage area. The aim of our study is to assess the sensitivity and specificity of our screening clinical and/or epidemiological criteria, and to investigate the role of LUS in the triage decision-making process during the "phase 2" of the COVID-19 Italian epidemic. Our study confirms the pivotal role of the triage in the decision-making process and the management of the entire ED, and it demonstrates that further studies are necessary to validate the role of LUS as tool to promptly identify COVID-19 patients, if combined with a correct pre-triage interview.