Spectrum of echocardiographic findings in patients with severe and critical COVID-19: a single center experience

Introduction: Information on the cardiac manifestations of coronavirus disease 2019 (COVID-19) is scarce. In this study we assessed the echocardiogram of consecutive patients with COVID-19 infection to assess the frequency of cardiac abnormalities. Materials and Methods: This retrospective descriptive study examined the echocardiographic study of 43 patients with severe and critical COVID-19 infection admitted at the ICU of Chitwan Medical College from May 16, 2021 to June 05, 2021. The study focused on left ventricle (LV) and right ventricle (RV) function. The results were then compared between severe and critical infections to examine if any differences exist between them. Results: The mean age of the study population was 54 years and predominately males. One-third were classified as critical COVID-19 while the remaining were severe COVID-19. Majority(83.7%) had a normal echocardiogram. Among the patients with abnormal reports, the distribution of echocardiographic pattern were biventricular dilation with biventricular dysfunction in two patients (4.6%), LV dialtion with LV dysfunction in two patients (4.6%) and isolated LV dysfunction (diastolic and systolic) in three patients (6.9%). None of the echocardiographic parameters were significantly different between the severe and the critical infection. Conclusion: COVID-19 in primarily a respiratory disease and the cardiac complications is largely attributed to the critical nature of the illness than the specific infection. Considering the risk of infection spread, routine echocardiography for all patients with COVID-19 infection is not advisable.

Meningioma in a Kidney Transplant Recipient a Risk Factor for Primary Central Nervous System Lymphoma

Introduction: Calcineurin inhibitor (CNI) neurotoxicity is common;has a wide array of presentation. Compromised blood brain barrier (BBB) is a risk factor. We studied a case of PCNSL in a kidney transplant recipient (KTR) with meningioma in order to bring to awareness of association between meningioma and PCNSL. Case Description: A 56-year-old female is a deceased donor KTR from 11-years ago by thymoglobulin induction. She develops new left hemiparesis and confusion. She was maintained on Tacrolimus (FK), Mycophenolate (MMF) and Prednisone. FK levels were therapeutic and and serum creatinine was 0.9 mg/dL. Epstein Barr Virus (EBV) and SARS-CoV-2 antigen tests were negative. Computed tomography (CT) of the brain showed a 4.2 x 4.5 x 3.9 cm mass centered in the left lentiform nucleus;midline shift of 1.1cm and a calcified meningioma. CT of the abdomen and pelvis was normal. Brain biopsy was consistent with PCNSL lymphoma. EBV encoded RNA staining was positive. Despite cytoreductive surgery and chemotherapy, PCNSL progressed. Her family elected hospice care. Discussion(s): Meningioma is common primary brain tumor with latency period of up to 30 years. A meningioma makes BBB permeable due to neo-angiogenesis at its margins. PCNSL constitute only 1% of Non-Hodgkin Lymphoma (NHL). Yet, PCNSL is 65 times more common in solid organ transplant recipients (SOTR) than in general population and six times more common than Non-Hodgkin's lymphoma (NHL). Therefore, we posit that PCNSL is a form of neurotoxicity due to persistently high concentration CNI via a permeable BBB. EBV is present in 90% of cases which makes host cell genome vulnerable to neurostructural changes. In our case PCNSL occurred despite therapeutic levels of CNI and despite absence of EBV in the serum. Conclusion(s): Meningioma related BBB permeability, increases severity of neurotoxicity and therefore, risk of PCNSL in a SOTR. Due to long latency of meningioma, risk of PCNSL can be and should be assessed prior to transplantation.

FAIR DOMESTIC VACCINE PRIORITISATION

During the COVID-19 pandemic, many countries have prioritised individuals for vaccination primarily on the basis of (intrinsic) risk factors such as older age and presence of comorbidities. Such a prioritisation strategy ignores risk of exposure to the virus and harm from non-pharmaceutical interventions. In this paper, we develop an account of fair allocation of vaccines. First, we argue fairness requires maximal proportional satisfaction of claims. Second, we argue what grounds people's claim to vaccines is that they are at risk of harm, and fairness requires people are prioritised for vaccination in proportion to the risks they face. Third, we defend an expansive understanding of relevant harms;when allocating vaccines, governments should, in principle, include all pandemic- related risk of harm. Finally, we consider several ways in which different harms could be traded off against each other and defend giving priority to mitigating direct risk of harm from an infectious agent. Our account also provides a principled reason for compensating people who suffer disproportionally from indirect risks of harm (e.g., harms from nonpharmaceutical interventions).

Clinical Image: CT Findings in severe cases of COVID-19

Chest CT has a potential role in the diagnosis, detection of complications, and prognostication of corona virus disease 2019 (COVID-19). Implementation of appropriate precautionary safety measures, chest CT protocol optimization, and a standardized reporting system based on the pulmonary findings in this disease will enhance the clinical utility of chest CT However, chest CT examinations may lead to both false-negative and false-positive results. Furthermore, the added value of chest CT in diagnostic decision making is dependent on several dynamic variables, most notably available resources (real-time reverse transcription-polymerase chain reaction [RT-PCR] tests, personal protective equipment, CT scanners, hospital and radiology personnel availability, and isolation room capacity) and the prevalence of both COVID-19 and other diseases with overlapping manifestations at chest CT.

COVID-19 infections post-liver and kidney transplantation in a Southern CA program

Purpose: Southern CA is at the epicenter of the Covid-19 pandemic. We reviewed outcomes of our center's liver, kidney, and pancreas transplant patients stricken with Covid-19 infection. Methods: Retrospective review of 161 post-transplant patients with Covid-19 infection. Results: From March 2020 to January 2021, 43 liver, 107 kidney, 6 liver/kidney, and 4 kidney/pancreas patients came down with Covid-19 (TABLE). Transplants were performed from August 2000 to December 2020. Mean age was 54±1 yrs. Median time of infection was 27 months post-transplant (range 15 days to 21 years). Frequency of symptoms were: shortness of breath (55%), fever (52%), muscle aches (48%), diarrhea (36%), headaches (34%), loss of taste or smell (27%). Only 10 (6%) pts were asymptomatic. Overall mortality rate was 20% (33/161) and severe Covid-19 (hospitalization and death) occurred in 90/161 (56%) patients. Mortality risk factors included older age (62±2 vs 52±1 yrs, p<0.01), hospitalization (32/33, 97% vs 59/128, 46% p<0.01), mechanical ventilation (30/33, 91% vs 4/128, 3% p<0.01);there was no difference in gender (p=0.5), race (p=0.88), presence of diabetes (p=0.26), hypertension (p=0.06), or obesity (p=0.83). Liver/kidney recipients had the highest mortality rate (Table). Risk factors for severe Covid-19 included age (56±1 vs 51±2 yrs, P=0.01) and presence of diabetes (54/90, 60% vs 29/71, 41% p=0.02);there was no difference in gender (p=0.97), race (p=0.39), presence of hypertension (p=0.09), or obesity (p=0.82). Kidney patients had more severe Covid-19 than the other organ recipients. Kidney/pancreas patients were younger and tended to have mild infection and had no mortality. 156 (97%) patients were on tacrolimus (2 were on CyA, 2 on belatacept), 113 (70%) on MMF, and 127 (79%) on prednisone. 101 (63%) of patients were on triple immunosuppression. MMF was the most common agent to be adjusted (48/113, 42%) followed by tacrolimus (9/156, 6%). Of the 90 pts hospitalized, 70 (78%) received steroids, 30 (33%) received Remdesivir, and 53 (59%) were anticoagulated. 5 patients received convalescent plasma. Peak C-reactive protein levels when measured were significantly higher in patients who died (53.7±15.8 vs 19.8±5.3 mg/L, p=0.02). Conclusions: Covid-19 infection inflicts a high mortality rate in liver, kidney, and pancreas transplant recipients. (Table Presented).