Severe Headache as an Early Manifestation of Brain Involvement in a Patient with Covid-19 Infection

Purpose of study COVID-19 primarily affects the respiratory system from flu-like syndrome to acute hypoxic respiratory failure. Neurological manifestations are uncommon and can result in serious complications. We report a unique case of sudden onset of rapidly progressive encephalopathy in the setting of COVID-19. Methods used Reviewed the manifestations, clinical course, and outcome for a patient presenting with altered mental status secondary to COVID-19. Summary of results A 48-year-old with no significant past medical history presented to the emergency department complaining of severe headache for four days. His vital signs on presentation showed a blood pressure of 154/90, pulse of 114 bpm, temperature of 99.6 degreeF, and oxygen saturation of 97% on room air. Physical exam was unremarkable. Lab work showed elevated D-dimer 8,500 ng/L, Elevated ESR:42, LDH:340 and Ferritin:692. White blood count: 7.59 uL, Platelets 50 x 103 uL. Computer tomography angiography (CTA) of the chest showed bilateral multifocal pneumonia. CT Head was performed and was negative for an acute hemorrhage, hydrocephalus or territorial infarcts. Patient spiked a fever shortly after admission 103degreeF. Patient was started on Ceftriaxone and Azithromycin. Blood and urine cultures were positive for Klebsiella pneumonia. Patient was re-evaluated in the morning and was found altered with associated neck stiffness. Antibiotics were switched to cover for suspected meningitis. Neurology was consulted and recommended lumbar puncture. Within a few hours, the patient's mental status deteriorated and was found to be hypertensive with a blood pressure of 220/110. Repeat CT Head was negative. The patient was tested and found to be positive for COVID-19. Patient further decompensated within a few hours and became unresponsive, pulseless. ACLS was performed and the patient was transferred to the intensive care unit. Conclusions This case report highlights the heterogenous presentation in patients with COVID-19 and the importance of recognizing a new onset, severe headache as the only initial presentation. Headaches in some cases may precede the respiratory symptoms or may be the only manifestations in COVID-19 patients and it is crucial to be aware of the neurological complications and the rapid decompensation these patients may undergo if not recognized early.

COVID-19 Reinfection and Disease Severity in the New York City Health + Hospitals System

Background. Though reinfection with SARS-CoV-2 is well documented, there remains uncertainty about the potential for more severe symptoms with reinfections compared to index infections. Methods. Patients who received SARS-CoV-2 PCR testing between March 1, 2020 and March 1, 2021 at New York City Health and Hospitals (NYC H+H) facilities and had two positive tests>=90 days apart were included in the analysis. Clinical and demographic data were extracted from the electronic medical record. Manual chart review was done to confirm symptomatology, assess COVID-19 related hospital admissions, and determine WHO disease severity. Patients were then classified as unlikely reinfection, possible reinfection, or probable reinfection based on symptomatology, PCR and antibody testing, and lack of alternative diagnoses. Patients were classified as 'unable to be assessed' if symptomatology could not be assessed for both episodes of PCR positivity. Results. During our study timeframe, 1,255,584 unique patients received at least one SARS-CoV-2 PCR test, 265 of whom had two positive tests>=90 days apart. We categorized 20 patients as unable to be assessed, 28 as unlikely reinfection (1 persistent PCR positivity, 27 unlikely true infection at index or second PCR-positive episode), and 217 as possible or probable reinfection. Of the 217, at their index episode 79 had an asymptomatic infection (36.4%) and 17 were severe or critical (7.8%). At their second episode, 162 patients had an asymptomatic infection (74.7%), and 5 were severe or critical (2.3%). Only 24 patients with possible/probable reinfection had a more severe COVID reinfection than index infection, and 20 of the 24 had asymptomatic index infections. Three patients were hospitalized at both episodes, and two deaths possibly attributable to COVID-19 reinfection were noted in this cohort. Figure 3: Change in WHO disease severity classification from index to second infection among probable/possible reinfection cases (n=217) Red indicates increase in disease severity from index to reinfection (n=24), blue indicates decrease in disease severity from index to reinfection (n=100), white indicates no change (n=74) and gray indicates unable to assess disease severity at index or second infection (n=19). Conclusion. COVID-19 reinfection was rare in a high incidence setting among patients tested at NYC H+H facilities. Disease severity was generally milder in reinfection, although severe and critical disease occurred in a small number of patients.These findings from earlier in the pandemic (presumably wild-type and alpha variant) provide data for comparison in understanding how reinfection is evolving with newer variants.

Tocilizumab Treatment Reduces Mortality in Hospitalized Patients With COVID-19: A Retrospective Cohort Study at a New York City Hospital

Aims This study aimed to investigate the potential of tocilizumab therapy in minimizing mortality and mechanical ventilation (MV) requirements among hospitalized COVID-19 patients. Methods A single-center, retrospective, observational cohort study of 375 patients with severe COVID-19 (from March 1 to April 22, 2020) included 150 patients treated with tocilizumab and 225 consecutive control patients adjusted for age and sex. Both groups received concomitant standard of care treatments in addition to tocilizumab. The statistical methods relied on survival analyses, conditional logistic regression models, and contingency analyses. The outcomes included in-hospital mortality and the MV requirement. Results Tocilizumab associated with improved in-hospital mortality (34.7% vs 46.7%, P = 0.0136) and lower requirement for MV on days 1, 3, and 5 after treatment (P = 0.005, P < 0.0001, and P = 0.0021, respectively). Lower mortality was observed if tocilizumab was administered within 48 hours after admission (P = 0.0226). Older age and low blood oxygen saturation on admission decreased the odds of survival (P < 0.005). Conclusions Our study demonstrates a significant reduction in mortality and decreased requirement of MV with tocilizumab treatment in addition to the standard of care. Early administration of tocilizumab within 48 hours reduces the risk of mortality.

Tocilizumab, corticosteroids, and anticoagulation in COVID-19 patients on mechanical ventilation

INTRODUCTION: Coronavirus Disease 2019 (COVID-19) can lead to rapid respiratory decompensation requiring mechanical ventilation. There is limited evidence regarding the efficacy of existing treatment for severe COVID-19 infection. The purpose of this study was to assess the efficacy and safety of tocilizumab (TCZ) alone or with the combination of corticosteroids and therapeutic anticoagulation in intensive care unit (ICU) patients on mechanical ventilation with COVID-19 infection. METHODS: A single-center observational cohort study was conducted at an urban community teaching hospital in the New York City area between March 9, 2020 and April 28, 2020. The primary outcome of this study was in-hospital mortality. Secondary outcomes included 30-day mortality, duration of mechanical ventilation, ICU length of stay, and hospital length of stay. RESULTS: A total of 152 COVID-19 positive ICU patients were included in this study, of which 40 (26.7%) patients received one dose of TCZ 400 mg IV and three patients received an additional 400 mg dose. There were no statistically significant differences noted between the treatment and control group in regards to in-hospital mortality [31 (77.5%) vs. 94 (83.9%), P = 0.35], 30-day mortality [28 (70%) vs. 90 (80.4%), P = 0.18], or duration of mechanical ventilation (13 days ± 15.4 vs. 9.7 days ± 10.6, P = 0.22). Patients receiving TCZ had a significantly longer ICU and hospital length of stay [(15.1 days ± 16.1 vs. 9.6 days ± 9.8, P = 0.05) and (25.5 ± 29.9 vs. 14.1 ± 16.9, P = 0.03), respectively]. There was no difference in the incidence of thromboembolic complications [7 (17.5%) vs. 9 (8%), P = 0.13] or atrial fibrillation [4 (10%) vs. 13 (11.6%), P = 1.0] between the two groups. No anaphylactic or injective site reactions were noted. Results of multivariate linear and logistic regression analyses demonstrated that corticosteroids and anticoagulants were not independent predictors of duration of mechanical ventilation or in hospital mortality. CONCLUSIONS: The use of TCZ alone or in combination with corticosteroids and therapeutic anticoagulation was not associated with a decreased risk of mortality or shorter duration of mechanical ventilation in critically ill patients with COVID-19 infection. Additional studies are needed to evaluate the efficacy of TCZ for COVID-19.

Apixaban fails to prevent right heart thrombi and pulmonary embolism in a COVID-19-infected patient

INTRODUCTION: Right heart thrombi (RVT) are uncommon, usually found concurrent with pulmonary embolism and associated with significantly increased mortality. We describe a rare etiology of RVT formation ?in situ? complicating acute pulmonary embolism of a patient with COVID-19 infection already on anticoagulation with direct oral anticoagulants (DOACs). METHODS: A 43 yo obese male was diagnosed with presumptive COVID-19 infection based on clinical, inflammatory markers, and radiographic evidence. PCR was negative, which is encountered in 38% of tests. D-dimer was elevated 12499 ng/L however, CT angiogram (CTA), lower extremity duplex, and transthoracic echocardiogram (TTE) were unremarkable for thrombus. He received therapeutic enoxaparin for 3 days and was discharged on apixaban 5 mg twice daily. 5 days later, he developed worsening shortness of breath and hypoxemic respiratory failure. Repeat CTA revealed bilateral pulmonary emboli and TTE showed a 1.4 x 1.2 cm mobile thrombus in the right ventricle. Hypercoagulable workup was negative. Catheterdirected thrombolysis and salvage extracorporeal membrane oxygenation (ECMO) were considered however, the patient was unstable for transfer and ultimately expired after a sudden cardiac arrest. RESULTS: The existing consensus favors enoxaparin as the preferred anticoagulation for COVID-19 patients. It promotes anti-inflammatory properties by reducing IL-6 and lung edema. Other benefits include reducing the exposure of personnel by the absence of activated partial thromboplastin monitoring. There is a lack of anti-inflammatory properties with the use of DOACs as well as an understanding of the appropriate dose requirements. Therefore, the decision to discharge patients on prophylactic anticoagulation with enoxaparin as compared to DOACs is essential given the increased propensity of thromboembolic disease. We highlight the unique challenges in the evaluation and treatment of patients with COVID-19 and an elevated D-dimer. The increased risk of microthrombi warrants the initiation of therapeutic anticoagulation. We recommend the use of enoxaparin upon discharge of patients with elevated D-dimer. Further studies are required to understand the best choice, role, dosage, and duration of anticoagulation therapy in patients with COVID-19 infection.