Recurrence of disease in a patient with Covid-19: Re-activation or re-infection?

Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) was expected to induce a monophasic disease with subsequent immunity. However, case reports have since emerged which have found patients with either re-infection or re-activation of the virus. We describe a 44-year-old man with severe Covid-19-induced pneumonia who had recurrence of the disease after testing Covid-19-negative on three consecutive reverse transcriptase-polymerase chain reaction (RT-PCR) tests. Our patient underlines that caution should be exercised while planning for discharge of a patient irrespective of his previous negative test, especially in vulnerable patients and those who had moderate-to-severe disease requiring the use of immunosuppressive therapy. The fact that such patients could experience a re-activation or re-infection, requires monitoring and vigilance in the management of the pandemic at individual and collective levels.

Impact of COVID-19 on Thrombus Burden and Outcome in Acute Myocardial Infarction.

Background Cardiovascular manifestations are one of the most common complications in coronavirus disease 2019 (COVID-19) infection and are associated with increased mortality. However, the impact of COVID-19 infection on thrombus burden and the outcome of acute myocardial infarction (AMI) has not been studied. Methods This was a retrospective, observational study that included all adult patients (>18 years) diagnosed with AMI with or without COVID-19 infection. Epidemiological, laboratory, clinical, interventional, and outcome data were extracted and the impact of COVID-19 on thrombus burden and the primary clinical composite endpoint of all-cause death during hospital admission or 30 days after discharge was studied. Results The study population included 336 patients, including 56 patients with COVID and AMI and 280 patients with AMI without COVID-19 infection. Chest pain was the most common symptom (84.8%) while one or more co-morbidity was present in 117 (34.8%) patients. Forty-eight patients in the AMI with COVID group had ST-segment elevation myocardial infarction (STEMI) while 256 patients in the AMI without COVID group had STEMI, eight patients in the AMI with COVID group had non-ST-segment elevation myocardial infarction (NSTEMI), and 24 in the AMI without COVID group had NSTEMI. Patients with COVID-19 co-infection had a higher thrombus burden as compared to the patients without COVID-19 AMI group (p-value 0.008). The primary outcome in the form of all-cause mortality was seen in 13 (3.9%) patients, which was also more in the AMI with COVID group. Conclusion COVID-19 in AMI is a state of high thrombus burden associated with higher mortality, especially in patients with chronic co-morbidities.

Epidemiological, demographic, laboratory, clinical management, and outcome data of symptomatic bradyarrhythmia in COVID-19 patients

Background: Cardiovascular manifestations are an important cause of mortality and morbidity in COVID-19 infections. Conduction system abnormality in the form of symptomatic bradyarrhythmia is underreported in the literature. Aim: To evaluate epidemiological, demographic, laboratory, clinical management, and outcome data of symptomatic bradyarrhythmia in COVID-19 patients. Methods: This was a retrospective, observational study including all the adult patients (>18 years) who were diagnosed with COVID-19 infection and had complete heart block (CHB) or symptomatic high-grade Atrio-Ventricular (AV) block requiring a temporary pacemaker insertion (TPI). Epidemiological, demographic, laboratory, clinical management, and outcome data were extracted from all the enrolled patients and studied for the primary clinical composite endpoint of all-cause death. Results: The study population included 15 patients, including 14 patients with CHB and 1 patient with 2:1 AV block. Syncope was the most common presentation. The clinical endpoint in the form of death was seen in 5 patients (33.3%), 3 patients reverted to sinus rhythm, and 7 patients required permanent pacemaker implantation. The markers of inflammation were raised in all patients;however trend towards more inflammation was seen in patients reaching the primary clinical endpoint. 3 out of 7 patients with narrow QRS rhythm reverted to normal sinus rhythm, while all 8 patients with broad complex QRS either died or required a permanent pacemaker insertion. Conclusion: Symptomatic bradyarrhythmia is associated with a high inflammatory state, and high mortality in COVID-19 infection and a transient conduction block in patients with narrow QRS rhythm may suggest local subclinical myocardial inflammation. Resumen Antecedentes: Las manifestaciones cardiovasculares son una causa importante de mortalidad y morbilidad en las infecciones por COVID-19. La anomalía del sistema de conducción en forma de bradiarritmia sintomática no se informa en la literatura. Objetivo: evaluar datos epidemiológicos, demográficos, de laboratorio, de manejo clínico y de resultado de la bradiarritmia sintomática en pacientes con COVID-19. Métodos: este fue un estudio observacional retrospectivo que incluyó a todos los pacientes adultos (> 18 años) que fueron diagnosticados con infección por COVID-19 y tenían bloqueo cardíaco completo (HBC) o bloqueo auriculoventricular (AV) de alto grado sintomático que requería una inserción de marcapasos (TPI). Los datos epidemiológicos, demográficos, de laboratorio, de manejo clínico y de resultado se extrajeron de todos los pacientes inscritos y se estudiaron para el criterio de valoración clínico primario compuesto de muerte por cualquier causa. Resultados: la población del estudio incluyó a 15 pacientes, incluidos 14 pacientes con HBC y 1 paciente con bloqueo AV 2: 1. El síncope fue la presentación más común. El criterio de valoración clínico en forma de muerte se observó en 5 pacientes (33,3%), 3 pacientes revirtieron al ritmo sinusal y 7 pacientes requirieron implantación de marcapasos permanente. Los marcadores de inflamación se elevaron en todos los pacientes;sin embargo, se observó una tendencia hacia una mayor inflamación en los pacientes que alcanzaron el criterio de valoración clínico primario. 3 de cada 7 pacientes con QRS estrecho revirtieron al ritmo sinusal normal, mientras que los 8 pacientes con QRS de complejo ancho murieron o requirieron la inserción de un marcapasos permanente. Conclusión: la bradiarritmia sintomática se asocia con un estado inflamatorio alto y una alta mortalidad en la infección por COVID-19 y un bloqueo transitorio de la conducción en pacientes con ritmo QRS estrecho puede sugerir una inflamación miocárdica subclínica local.

Clinical and Epidemiological Features of SARS-CoV-2 Patients in SARI Ward of a Tertiary Care Centre in New Delhi.

IMPORTANCE: Rapid spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Wuhan, China, prompted heightened surveillance in India. Since the first laboratory confirmed case of SARS-CoV-2 was reported from Kerala on January 30, 2020 novel coronavirus infected pneumonia (NCIP) has been presenting to the hospital emergencies as severe acute respiratory illness (SARI). We aim to find out the rate of SARS-CoV-2 positivity in SARI cases and further clarify the epidemiological and clinical characteristics of NCIP in New Delhi, India. AIMS AND OBJECTIVES: To find out the rate of SARS-CoV-2 positivity in SARI cases presenting to the hospital emergency and describe the epidemiological and clinical characteristics of NCIP. DESIGN, SETTING AND PARTICIPANTS: Retrospective, single-center case series of the 82 consecutive hospitalized patients with SARI and subsequent confirmed NCIP cases at Dr Ram Manohar Lohia Hospital, New Delhi between 10th April 2020 and 30th April 2020. MAIN OUTCOMES AND MEASURES: Epidemiological, demographic, clinical, laboratory, radiological, and treatment data were collected and analyzed. The primary composite end-point was admission to an intensive care unit (ICU), the use of mechanical ventilation or death. Patients were categorized as severe pneumonia and non-severe pneumonia at time of admission and outcome data was compared. RESULTS: Of the 82 SARI cases, 32(39%) patients were confirmed to be SARS-CoV-2 positive. The median age of NCIP cases was 54.5 years (IQR, 46.25 - 60) and 19(59.3%) of them were males. 24(75%) cases were categorized as severe pneumonia on admission. 22(68.8%) patients had 1 or more co-morbidities. Diabetes mellitus 16(50%), hypertension 11(34.4%) and chronic obstructive airway disease 5(15.6%) were the most common co-existing illnesses. Compared with the patients who did not meet the primary outcome, patients who met the primary outcome were more likely to be having at least 1 underlying comorbidity (p-0.03), diabetes (p-0.003) and hypertension (p-0.03). Common symptoms included dyspnea 29(90.6%) followed by cough 27(84.4%), fever 22(68%), bodyache and myalgias 14(43.75%). Median time from symptom onset to hospital admission was 3 days. The most common pattern on chest X-ray was bilateral patchy nodular or interstitial infiltration seen in 30(93.8%) patients. Leucopenia was present in 10(31.2%) of the patients, with majority of patients presenting with lymphocytopenia, 24(75%) [lymphocyte count (1106 cells/ dL), interquartile range {IQR}, (970-1487)]. Thrombocytopenia was seen in 14(43.8%) patients, pancytopenia in 10(31.2%) patients and anemia was seen in 14(43.8%) patients. Hypoalbuminemia was present in 22(68.8%) cases. Raised CK-MB was seen in 7(21.9%) patients. The primary composite end-point occurred in 12(37.5%) patients, including 9(28.13%) patients who required mechanical ventilation and subsequently expired. 3(9.3%) of these patients who recovered, were subsequently shifted to COVID-19 ward from the ICU. The patients who met the primary outcome were older in age (56.5 years vs 50 years), had significantly higher SOFA scores (6 vs 3.5), were in shock (41.7% vs 5%), in higher respiratory distress (66.7% vs 10%), had lower mean arterial oxygen saturation (85% vs 89.5%), had higher CK-MB values (66 vs 26)U/L [6(54.5%) vs 2(9.5%)], had hypoalbuminemia (100% vs 50%) and acute kidney injury 8(72.7%) vs 5(23.8%) on admission. Of the 50 non-COVID-19 SARI patients in our study cohort, 13 (26%) patients met the primary composite outcome. Of them 9 (18%) patients expired and remaining 4 patients have subsequently recovered. As on 17th May 2020, 23 patients were still hospitalized, recovering in COVID-19 ward. CONCLUSION AND RELEVANCE: In this single-center case series from New Delhi, out of 82 patients of SARI, 32 patients were confirmed NCIP, with a COVID-19 positivity of 39%. 75% of NCIP presented in severe pneumonia and 37.5% required ICU care. The case fatality rate was 28%.