A comprehensive review of therapeutic options for COVID-19

Introduction: COVID-19 is a disease that is induced by severe acute respiratory syndrome coronavirus (SARS). Its viral infection is spread swiftly around the world and causes many restrictions, health problems, and expensive treatment costs worldwide. Due to its high prevalence and mortality rate, there is a global challenge to find an effective therapeutic protocol for the prevention and treatment of COVID-19. No one could disclaim the immediate need for a standardized protocol for COVID-19 treatment. Methods: Aiming to prepare a comprehensive review of introducing appropriate remedial options for COVID-19, a wide range of investigation on relevant articles established in the English language published through different publications such as PubMed, Medline, Embase, Science Direct, Scopus, and COVID-Evidence . all researchers and clinicians should try to make more precise knowledge about the viral behavior and treatment of COVID-19 to find an effective vaccine to prevent and treatment of this virus. The main objective of the present study is to review and investigate the available evidence for achieving a more precise preventive and treatment protocol to deal with COVID-19. Findings: many available drugs have been reviewed that include Azithromycin, Lopinavir/ritonavir (LPV/r), Remdesivir, Corticosteroids, Chloroquine, Hydroxychloroquine, Hydroxychloroquine sulfate, Immunoglobulin, Ivermectin, Ribavirin, Favipiravir, Interferon. On the other hand, it is recommended to conduct precise clinical trials on current antimicrobial and antiviral agents that are administered for a long time to find an expeditious and effective response to the COVID-19 pandemic. Although disappointing, it should be noted that there is no effective drug regimen or vaccine against the novel coronavirus. In this regard, using other available antiviral drugs for the treatment of COVID-19 may be effective to some extent. In this study, by investigating some available antimicrobial medicines that may diminish COVID-19 infection, we are trying to introduce a general protocol for controlling this disease.

Intracranial Hypertension and Papilledema: An Unusual Complication After the Adenoviral DNA Vector-Based Coronavirus Disease 2019 Vaccination in an Air Medical Transportation Pilot.

A 32-year-old male, Mil Mi-17 (air medical transport) helicopter pilot presented to the emergency department with a headache and visual blurring 12 days after the first dose of the Sputnik V vaccine. He had no past medical history; he successfully passed his last annual medical examination, and his vital signs were in the normal range. The significant findings were decreased visual acuity, papilledema, severe visual field narrowing, and increased nerve fiber layer thickness in both eyes. The aviation medical examiner suspended him from flight duties and referred him for a complete neuro-ophthalmic investigation. The patient underwent a lumbar puncture; his cerebrospinal fluid pressure was 39 cm H2O, and his cerebrospinal fluid biochemical analysis and blood tests were normal. He refused ventriculoperitoneal shunt surgery and received methylprednisolone with acetazolamide. After 10 days, the patient reported a significant improvement. One month later, his visual acuity and visual field were better, papilledema resolved, and disc pallor appeared. Three months later, he needed no medical treatment; he had normal visual acuity and near-normal visual fields. Based on the aviation medical regulations and the importance of flight safety in air medical transportation operations, he cannot return to flight duties until full neuro-ophthalmic recovery is confirmed.

Association of thyroid dysfunction and COVID-19: A systematic review and meta-analysis.

This systematic review and meta-analysis was conducted to evaluate the effect of COVID-19 on thyroid function and the role of thyroid hormones alterations in predicting the severity of COVID-19. Online databases, including Scopus, Medline/PubMed, EMBASE, Google Scholar, and Cochrane were searched up to August 2, 2022. After screening titles, abstracts, and full manuscripts, respectively, 30 reports were enrolled. The risk of bias (ROB) was evaluated using the QUADAS-2 tool. In addition, odds ratio (OR) and hazard ratio (HR) analysis for assessing the OR of abnormal thyroid function tests (TFT) in predicting the COVID-19 severity and poor outcomes. Among 30 enrolled studies, ROB of the current study is estimated low to moderate. The average number of patients in each study was 325 (range: 40-3,703), with an overall mean age of 57.6, and the female proportion of 40.4%. Overall, the pooled analysis showed that the prevalence of thyroid dysfunction among 9,707 COVID-19 cases was 15%. Among mild to moderate COVID-19 patients, 6.2% had abnormal TFT, and among patients who experienced severe to critical COVID-19, 20.8% had abnormal TFT. The pooled OR for abnormal TFT and the severity of COVID-19 obtained from 3,865 COVID-19 patients was 3.77 (2.03, 6.99). The pooled HR of TSH level of COVID-19 mortality was 1.57 (0.91, 2.72). Our results demonstrate a high prevalence of thyroid dysfunction in COVID-19, and that among patients severe cases had a 3.77-fold higher risk of abnormal TFT compared to mild to moderate COVID-19. Further studies are required to evaluate the longer-term prognostic role of thyroid dysfunction in severe COVID-19, and investigate potential therapeutic strategies.

Acute vestibular neuritis: A rare complication after the adenoviral vector-based COVID-19 vaccine.

Vestibular neuritis was first reported in 1952 by Dix and Hallpike, and 30% of patients reporting a flu-like symptom before acquiring the disorder. The most common causes are viral infections, often resulting from systemic viral infections or bacterial labyrinthitis. Here we presented a rare case of acute vestibular neuritis after the adenoviral vector-based COVID-19 vaccination. A 51-year-old male pilot awoke early in the morning with severe vertigo, nausea, and vomiting after receiving the first dose of the ChAdOx1 nCoV-19 vaccine 11 days ago. Nasopharyngeal SARS-CoV-2 RT-PCR test and chest CT scan were inconclusive for COVID-19 pneumonia. Significant findings were a severe spontaneous and constant true-whirling vertigo which worsened with head movement, horizontal-torsional spontaneous nystagmus, abnormal caloric test, positive bedside head impulse tests, and inability to tolerate head-thrust test. PTA, MRI of the brain and internal auditory canal, and cerebral CT arteriography were normal. According to the clinical, imaging, and laboratory findings, he was admitted to the neurology ward and received treatment for vestibular neuritis. His vertigo increased gradually over 6-8 h, peaking on the first day, and gradually subsided over 7 days. Ten days later, the symptoms became tolerable; the patient was discharged with advice for home-based vestibular rehabilitation exercises. Despite the proper treatment and rehabilitation, signs of dynamic vestibular imbalances persisted after 1 year. Based on the Federal Aviation Administration (FAA) regulations, the Air Medical Council (AMC) suspended him from flight duties until receiving full recovery. Several cases of vestibular neuritis have been reported in the COVID-19 patients and after the COVID-19 vaccination. This is the first case report of acute vestibular neuritis after the ChAdOx1 nCoV-19 vaccination in a healthy pilot without past medical history. However, the authors believe that this is a primary clinical suspicion that must be considered and confirmed after complete investigations.

Thalamic hemi-chorea: a rare complication after receiving the adenoviral vector-based COVID-19 vaccine: a case report.

Lacunar strokes occur when a branch of a large cerebral artery is blocked. The thalamus is often affected, causing uncontrollable motions. A 72-year-old previously healthy man presented with involuntary motions in the right limbs, which were present at rest, and exacerbated during voluntary actions. He had received the first dose of the adenoviral vector-based coronavirus disease 2019 vaccine (ChAdOx1 nCoV-19) 9 days ago. Severe thrombocytopenia and elevated levels of lactate dehydrogenase, ferritin, C-reactive protein, and D-dimer were found, without any evidence of connective tissue disease. Electromyography demonstrated typical choreiform movements, and the brain magnetic resonance imaging indicated a small high signal lesion on the left side of the thalamus. Detection of the immunoglobulin G antibodies against platelet factor 4 in the blood, negative heparin-induced platelet activation (HIPA) test, and positive modified HIPA test confirmed the thalamic stroke due to the vaccine-induced prothrombotic immune thrombocytopenia (VIPIT). He was admitted to the intensive care unit and received nadroparin, sodium ozagrel, edaravone, methylprednisolone, and haloperidol. His hemi-chorea improved gradually over 2 weeks, and he was discharged after 21 days with rehabilitation advice. VIPIT due to the ChAdOx1 nCoV-19 is a novel immune-mediated response that needs clinicians' awareness and further investigations.

Recurrent unilateral pupillary dilation and transient visual blurring: A clinical challenge during hypoxia exposure in a male fighter pilot

Hypoxia is an operational concern in military aviation, and fighter pilots should undertake altitude hypoxia training. Anisocoria is a significant clinical dilemma and may remain a diagnostic challenge for specialists. We present a case of atraumatic unilateral mydriasis during hypobaric chamber training. Our diagnostic dilemma is novel and unique because the authors reported no similar presentation yet, it occurred in a fighter pilot whose occupational future depends on having normal vision, and second, the presence of hypoxia seems to trigger symptoms.

New-Onset Transient Global Amnesia: A Clinical Challenge in an Air Medical Transportation Pilot With a History of Coronavirus Disease 2019.

A 43-year-old male Bell 214C helicopter pilot presented to the emergency ward with flu-like syndrome. His nasopharyngeal severe acute respiratory syndrome coronavirus 2 real-time polymerase chain reaction test was positive, and a chest computed tomographic scan confirmed coronavirus disease 2019 pneumonia. He was admitted, received treatment, was discharged, and returned to flying. During the mission debrief, copilots who had flown with him reported that he experienced episodes of in-flight dizziness and blacked out. They occurred briefly during the cruise and hovering flight, perhaps for a few seconds of disorientation and unconsciousness. Rapid identification of the copilot and control of the helicopter prevented any incident or accident. Afterward, he explained the sudden onset and unexpected brief periods of loss of consciousness after a headache. The flight safety office referred him to the aviation medical center for further investigations. The cardiovascular, neurologic, laboratory, and toxicologic assessments were inconclusive with the approach to sudden-onset transient loss of consciousness. The only abnormal finding was hippocampus lesions on brain magnetic resonance imaging (MRI). Because of the possible diagnosis of transient global amnesia, the aviation medical examiner suspended him from flight duties until complete recovery and the absence of any probable complications.

Clinical, Laboratory and Imaging Characteristics of Hospitalized COVID-19 Patients with Neurologic Involvement; a Cross-Sectional Study.

Introduction: Although neurologic involvement and neuroimaging abnormalities have been frequently identified in COVID-19 patients, the underlying factors remain unclear. In this study, we assessed the association of the neurological manifestations and neuroimaging features of hospitalized COVID-19 patients with their clinical, laboratory, and imaging characteristics. Methods: This multicenter cross-sectional study was conducted between September 2020 and March 2021 at two large academic hospitals in Tehran, Iran. We used census sampling from medical records to enroll hospitalized patients with a positive COVID-19 Polymerase chain reaction (PCR) test who underwent brain imaging due to presenting any acute neurologic symptom during hospital stay. Results: Of the 4372 hospitalized patients with COVID-19, only 211 met the inclusion criteria (35.5% with severe infection). Central nervous system and psychiatric manifestations were significantly more common in severe cases (p ≤ 0.044). Approximately, 30% had a new abnormality on their neuroimaging, with ischemic (38/63) and hemorrhagic (16/63) insults being the most common. The most frequent reasons that provoked cranial imaging were headache (27%), altered consciousness (25.6%), focal neurologic signs (19.9%), and delirium (18%). Analysis revealed a positive correlation for age, neutrophilia, lymphopenia, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) with the emergence of neuroimaging abnormalities (p ≤ 0.018). In addition, patients with new neuroimaging abnormalities had a significantly higher lung CT score than those without any pathologic findings (11.1 ± 4.8 vs. 5.9 ± 4.8, p < 0.001). Conclusion: Approximately 30% of the study population had various acute neuroimaging findings. The lung CT score, neutrophil count, and age were strong predictors of acute neuroimaging abnormalities in hospitalized COVID-19 patients.

Overt hematochezia : A rare gastrointestinal presentation in patients with corona virus disease 2019.

World health care systems are affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and its associated disease, coronavirus disease 2019 (COVID-19). This new human pathogen mostly affects the respiratory system, but various extrapulmonary pathologies have been reported in the literature. It seems that the gastrointestinal system is one of the target organs for SARS-CoV- 2. Diarrhea as a long-term bowel symptom is not rare, although its occurrence is not as high as that of fever and cough.

Guillain-Barré Syndrome Associated with SARS-CoV-2 Infection: A Case Report.

A 56-year-old man was referred to the emergency department for the subacute onset of and weakness in the lower extremities, paraesthesia and pain. He was diagnosed with SARS-CoV-2 pneumonia and then, he received the necessary treatment according to national protocol. Radiographic, laboratory, and electroneurographic findings indicated an acute polyradiculoneuritis with prominent demyelination and suggesting the diagnosis of Guillain-Barr syndrome associated with COVID-19 infection.

Acute transverse myelitis after SARS-CoV-2 infection: a rare complicated case of rapid onset paraplegia.

A 63-year-old Caucasian male, known case of controlled type 2 diabetes, chronic renal failure, and ischemic heart disease, was presented with weakness and loss of movement in lower limbs, an absent sensation from the chest below, constipation, and urinary retention. About 4 days before these symptoms, he experienced a flu-like syndrome. Suspicious for COVID-19, his nasopharyngeal specimen's reverse transcription-polymerase chain reaction (RT-PCR) resulted positive. Chest X-ray and HRCT demonstrated severe pulmonary involvement. Immediately, he was admitted to the emergency ward, and the treatment was started according to the national COVID-19 treatment protocol. Subsequently, diagnostic measures were taken to investigate the patient's non-heterogeneous peripheral (spinal) neuromuscular manifestations. Brain CT scan and MRI were normal, but spinal MRI with gadolinium contrast showed extensive increased T2 signal involving central gray matter and dorsal columns, extended from C7 to T12 with linear enhancement in the sagittal plane, posteriorly within the mid and lower thoracic cord. The CSF specimen demonstrated pleocytosis, positive RT-PCR for SARS-CoV-2, and elevated IgG index. Clinical presentation, MRI, CSF, and laboratory findings prioritized the acute transverse myelitis (ATM) as a probable complication of COVID-19 infection over other differential diagnoses. Intravenous methylprednisolone and, subsequently, IV human immunoglobulin were added to the treatment regimen. In the end, the complete resolution of dysesthesia, urinary retention, and constipation were achieved. After continuous and extended respiratory and motor rehabilitation programs, he was discharged asymptomatic.

Acute Cardiac Tamponade: A Case of Life-Threatening Coronavirus Disease 2019 Complication During Air Medical Transportation.

A 42-year-old man with coronavirus disease 2019 pneumonia was admitted to a small town hospital that did not have intensive care unit (ICU)-level resources available. Twelve hours later, the patient suddenly became agitated, and an extensive anterolateral ST-elevation myocardial infarction was detected by 12-lead electrocardiography and supported by a rise in serum cardiac enzymes. Low blood oxygen saturation (59%) and cardiac ejection fraction (ejection fraction = 20%) reflected criticality that could potentially require a catheterization laboratory, coronary artery bypass graft surgery, and ICU-level resources. After the coordination of physicians with the nearest equipped hospital and air medical crew, a Mil Mi-17 medical helicopter unit was dispatched. About 20 minutes before reaching the destination hospital, his clinical condition declined; his heart was 50 beats/min, his blood pressure was 75/40 mm Hg, and he had jugular vein distention. Muffled heart sounds, decreased electrocardiographic voltage, and the accumulation of pericardial effusion on a bedside ultrasound indicated cardiac tamponade. The air medical crew resuscitated the patient through the interventions of intubation, mechanical ventilation, administration of intravenous fluids, and initiation of an epinephrine infusion. Ultrasound-guided pericardiocentesis was performed in the helicopter, which kept him alive until pericardotomy could be performed at the destination hospital. Unfortunately, after pericardiotomy and coronary artery bypass graft surgery, the patient died 7 days later in the ICU due to severe cardiopulmonary failure.

Coronavirus Disease 2019 Suspicion: A Case Report Regarding a Male Emergency Medical Service Pilot With Newly Diagnosed Sarcoidosis.

A 38-year-old emergency medical service Bell 214 male pilot with a dry cough, fever, anorexia, fatigue, and sweating for the past 3 days; an oral temperature of 38°C; blood pressure of 105/65 mm Hg; heart rate of 94 beats/min; respiratory rate of 21 breaths/min; and pulse oximetry of 93% on room air was suspicious for coronavirus disease 2019. Surprisingly, reverse transcription polymerase chain reaction was negative, but bilateral hilar adenopathy was reported in his chest radiography as a new challenge. The pathologic report of the adenopathy biopsy was noncaseating sarcoid-type granulomas. Serologic tests showed a serum angiotensin-converting enzyme level of 58 nmol/mL/min. The bronchoalveolar lavage fluid CD4/CD8 ratio was 3.68. The bronchoalveolar lavage findings provided an accurate sarcoidosis diagnosis, and a high-resolution computed tomographic scan revealed stage 1 pulmonary involvement. Because of the pulmonary involvement, clinical manifestations, use of inhaled fluticasone, and need for longer and accurate follow-up and to protect against coronavirus disease 2019, he has been temporarily suspended until the final assignment.