COVID-19 mRNA Vaccine and Myocarditis.

Coronavirus disease 2019 (COVID-19) is believed to have originated in the Hua nan South China Seafood Market in Wuhan and can present with a spectrum of clinical manifestations. We report the case of 24-year-old male patient who developed chest pain after administration of the second dose of the Pfizer-BioNTech mRNA COVID-19 vaccine and who was diagnosed with myocarditis on work-up. LEARNING POINTS: Localized injection site reactions and systemic adverse effects can occur after administration of the various COVID-19 vaccines.Healthcare providers should maintain a high index of suspicion regarding myocarditis after mRNA COVID-19 vaccination in the appropriate clinical scenario.

Autoimmune Hepatitis-Primary Biliary Cholangitis Overlap Syndrome Triggered by COVID-19.

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 infection, has caused the ongoing global pandemic. Initially considered a respiratory disease, it can manifest with a wide range of complications (gastrointestinal, neurological, thromboembolic and cardiovascular) leading to multiple organ dysfunction. A range of immune complications have also been described. We report the case of a 57-year-old man with a medical history of hypertension, prediabetes and beta thalassemia minor, who was diagnosed with COVID-19 and subsequently developed fatigue and arthralgias, and whose blood work showed hyperferritinemia, elevated liver enzymes (AST/ALT/GGT), hypergammaglobulinemia, anti-smooth muscle antibody, anti-mitochondrial antibody, and anti-double-stranded DNA antibodies. The patient was diagnosed with autoimmune hepatitis-primary biliary cholangitis overlap syndrome triggered by COVID-19. To our knowledge, this is the first such case reported. LEARNING POINTS: COVID-19 can precipitate a wide range of immune complications; we report a case of autoimmune hepatitis-primary biliary cholangitis overlap syndrome triggered by COVID-19.Clinicians should be aware of this unusual manifestation of COVID-19 so that prompt and appropriate diagnostic and therapeutic interventions can be initiated if the syndrome is suspected or confirmed.Our case further suggests the necessity for continued and regular follow-up of patients who have recovered from COVID-19 in order to uncover the long-term effects of the novel virus.

COVID-19 and arterial thrombosis: Report of 2 cases.

The SARS-CoV-2 infection has been predominately associated with lung disease. However, emerging evidence has associated the COVID-19 infection with a hypercoagulable state. This hypercoagulable state can occur despite the use of anticoagulants and antiplatelets. In fact, it may even be the presenting symptom of COVID-19 in some patients. Thromboembolism associated with COVID-19 carries a worse prognosis and should be identified as early as possible. Therefore, we report 2 patients with arterial thrombosis in the form of limb ischemia in the setting of COVID-19.

COVID-19-Induced Hyperleucocytosis in Chronic Lymphocytic Leukaemia.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus responsible for the current global pandemic, coronavirus disease 2019 (COVID-19). COVID-19 usually presents with respiratory symptoms but can affect multiple organ systems. A wide spectrum of complications can occur depending upon the comorbidities of patients. There is limited literature available regarding the presentation and outcome of COVID-19 in chronic lymphocytic leukaemia (CLL) patients. We report 2 cases of COVID-19-induced hyperleucocytosis (WBC count >100,000/µl) in CLL patients. LEARNING POINTS: Lymphopenia has been associated with severe disease and is a poor prognostic factor in COVID-19 infected patients; however, our cases show COVID-19-induced hyperleucocytosis (WBC count >100,000/µl)/lymphocytosis in CLL patients.Prior reports suggest that ibrutinib may have a protective effect against COVID-19 by decreasing inflammation and preventing progression to ARDS.

COVID-19 Presenting as Acute Limb Ischaemia.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic that developed in late 2019 and early 2020 has caused thousands of deaths and has had an enormous impact on our health systems and economies. Coronavirus disease 2019 (COVID-19) complications include disseminated coagulation and thrombosis, but, to the best of our knowledge, the literature to date on these manifestations has been limited. Herein, we report an unusual presentation in a 43-year-old man with a medical history of diabetes and hypertension who presented with dyspnoea and acute pain in his right leg and was found to have acute limb ischaemia and diabetic ketoacidosis. Our case adds to the literature regarding arterial thrombosis in COVID-19. LEARNING POINTS: Arterial thrombosis in the form of acute limb ischaemia can occur in COVID-19.A high index of suspicion should be maintained for acute limb ischaemia, which is a vascular emergency.

A randomized open-label trial to evaluate the efficacy and safety of triple therapy with aspirin, atorvastatin, and nicorandil in hospitalised patients with SARS Cov-2 infection: A structured summary of a study protocol for a randomized controlled trial.

OBJECTIVES: The pathophysiology of SARS-Cov-2 is characterized by inflammation, immune dysregulation, coagulopathy, and endothelial dysfunction. No single therapeutic agent can target all these pathophysiologic substrates. Moreover, the current therapies are not fully effective in reducing mortality in moderate and severe disease. Hence, we aim to evaluate the combination of drugs (aspirin, atorvastatin, and nicorandil) with anti-inflammatory, antithrombotic, immunomodulatory, and vasodilator properties as adjuvant therapy in covid- 19. TRIAL DESIGN: Single-centre, prospective, two-arm parallel design, open-label randomized control superiority trial. PARTICIPANTS: The study will be conducted at the covid centre of Dr. Rajendra Prasad Government Medical College Tanda Kangra, Himachal Pradesh, India. All SARS-CoV-2 infected patients requiring admission to the study centre will be screened for the trial. All patients >18years who are RT-PCR/RAT positive for SARS-CoV-2 infection with pneumonia but without ARDS at presentation (presence of clinical features of dyspnoea hypoxia, fever, cough, spo2 <94% on room air and respiratory rate >24/minute) requiring hospital admission and consenting to participate in the trial will be included. Patients with documented significant liver disease/dysfunction (AST/ALT > 240), myopathy and rhabdomyolysis (CPK > 5x normal), allergy or intolerance to statins, allergy or intolerance to aspirin, patients taking medications with significant interaction with statins, prior statin use (within 30 days), prior aspirin use (within 30 days), history of active GI bleeding in past three months, coagulopathy, thrombocytopenia (platelet count < 100000/ dl), pregnancy, active breastfeeding, patient unable to take oral or nasogastric medications, patients in altered mental status, shock, acute renal failure, acute coronary syndrome, sepsis and ARDS at presentation will be excluded. INTERVENTION AND COMPARATOR: After randomization, participants in the intervention group will receive aspirin, atorvastatin, and nicorandil (Fig. 1). Atorvastatin will be prescribed as 40 mg starting dose followed by 40 mg oral tablets once daily for ten days or till hospital discharge whichever is later. Aspirin dose will be 325 starting dose followed by 75 mg once daily for ten days or till hospital discharge whichever is later. Nicorandil will be given as 10 mg starting dose followed by 5mg twice daily ten days or till hospital discharge whichever is later. All patients in the intervention and control group will receive a standard of care for covid management as per national guidelines. All patients will receive symptomatic treatment with antipyretics, adequate hydration, anticoagulation with low molecular weight heparin, intravenous remdesivir, corticosteroids (intravenous dexamethasone for 5 days or more duration if oxygen requirement increasing or inflammatory markers are raised), and oxygen support. Patients will receive treatment for comorbid conditions as per guidelines. Fig. 1 Schematic study design MAIN OUTCOMES: The patients will be followed up for outcomes during the hospital stay or for ten days whichever is longer. The primary outcome will be in-hospital mortality. Any progression to ARDS, shock, acute kidney injury, impaired consciousness, length of hospital stay, length of mechanical ventilation (invasive plus non-invasive) will be secondary outcomes. Changes in serum markers (CRP, D -dimer, S ferritin) will be other secondary outcomes. The safety endpoints will be hepatotoxicity (ALT/AST > 3x ULN; hyperbilirubinemia), myalgia-muscle ache, or weakness without creatine kinase (CK) elevation, myositis-muscle symptoms with increased CK levels (3-10) ULN, rhabdomyolysis-muscle symptoms with marked CK elevation (typically substantially greater than 10 times the upper limit of normal [ULN]) and with creatinine elevation (usually with brown urine and urinary myoglobin) observed during the hospital stay. RANDOMIZATION: Computer-generated block randomization will be used to randomize the participants in a 1:1 ratio to the active intervention group A (Aspirin, Atorvastatin, Nicorandil) plus conventional therapy and control group B conventional therapy only. BLINDING (MASKING): The study will be an open-label trial. NUMBERS TO BE RANDOMIZED (SAMPLE SIZE): A total of 396 patients will participate in this study, which is randomly divided with 198 participants in each group. TRIAL STATUS: The first version of the protocol was approved by the institutional ethical committee on 1st February 2021, IEC /006/2021. The recruitment started on 8/4/2021 and will continue until 08/07/2021. A total of 281 patients have been enrolled till 21/5/2021. TRIAL REGISTRATION: The trial has been prospectively registered in Clinical Trial Registry - India (ICMR- NIMS): CTRI/2021/04/032648 [Registered on: 8 April 2021]. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. The study protocol has been reported under the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines.

Does Baseline Diuretics Use Affect Prognosis in Patients With COVID-19?

The rapid emergence of coronavirus disease 2019 (COVID-19) has become the biggest healthcare crisis of the last century, resulting in thousands of deaths worldwide. There have been studies that evaluated the role of angiotensin-converting enzyme (ACE) inhibitors (ACEi) and angiotensin receptor blockers (ARBs) in treating patients with COVID-19. However, the prior use of diuretics and their effect on mortality in this setting remains unknown. The aim of the study was to evaluate the effect of diuretics in patients admitted with COVID-19. The current study was conducted between March 15, 2020, and April 30, 2020, during the COVID-19 pandemic in three different hospitals in Northern New Jersey, USA. The primary outcome was survival or in-hospital mortality from COVID-19 from the day of admission. The secondary outcome was severe or non-severe illness from COVID-19. This retrospective study included a total of 313 patients with a median age of 61.3 ± 14.6 years. There was a total of 68 patients taking diuretics at home and 245 patients who were not taking diuretics. There was a total of 39 (57.35%) deaths in patients taking diuretics as compared to 93 (37.96%) deaths in patients not taking diuretics (p-value 0.0042). Also, 54 (79.41%) patients who took diuretics had severe COVID-19 illness as compared to 116 (47.35%) who did not take diuretics (p-value <.0001). However, after adjusting for the confounding factors, there was no difference in mortality or severity of illness in COVID-19 patients taking diuretics at the time of admission. In conclusion, there was no effect of the baseline use of diuretics in the prognosis of COVID-19.

COVID-19 and Combined Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Coma: Report of 11 Cases.

We report 11 cases of combined diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNK) in coronavirus 2019 patients who presented to our institution in New Jersey, USA. The median age was 47 years (range 12-88 years). Out of the 11 patients, 7 were male and 4 were female. Out of 11 patients, 8 had type 2 diabetes mellitus (DM), 2 had undiagnosed DM, and 1 had type 1 DM. Presenting complaints included altered mental status, weakness, shortness of breath, cough, fever, vomiting, abdominal pain, chest pain, and foot pain. Out of 11 patients, pneumonia was diagnosed at presentation in 8 patients, while in 3 patients, chest X-ray was clear. Median value of initial glucose on presentation was 974 mg/dL (range 549-1556 mg/dL), and hemoglobin A1c on presentation was 13.8%. The median value of anion gap was 34 mEq/L. Out of the 11 patients, ketonemia was moderate in 6 patients, large in 3, and small in 2 patients. Acute kidney injury (AKI) occurred in 9 patients and 2 patients required renal replacement therapy. Out of the 11 patients, 6 required mechanical ventilation and 7 patients died. All the 6 patients requiring mechanical ventilation died. Our case series shows COVID-19 infection can precipitate acute metabolic complications in known DM patients or as first manifestation in undiagnosed DM patients. Patients can present with DKA/HHNK symptoms and/or respiratory symptoms. Mechanical ventilation is a poor prognostic factor. Further studies are needed to characterize prognostic factors associated with mortality in this vulnerable patient population.

Acute myocardial infraction and pulmonary embolism in a same patient with COVID -19: a rare association.

Coronavirus disease-2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 is associated with a hypercoagulable state leading to increased incidence of thromboembolism. However, it is exceedingly rare to see presence of both arterial and venous thromboembolism simultaneously. Herein, we report an unusual presentation of a 39-year-old male with recently diagnosed COVID -19 who initially had acute myocardial infarction secondary to thrombotic occlusion of right coronary artery followed by acute pulmonary embolism. Health care providers should be aware of this uncommon yet possible co-existence of two life-threatening manifestations in order to prevent fatal consequences.

COVID-19 vaccine induced Axillary and Pectoral Lymphadenopathy on PET scan.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the ongoing global pandemic. It can manifest a wide range of complications depending upon the severity of infection and comorbidities of the patient. Vaccines are very important measure to provide protection against COVID-19. We report a case of 72-year-old female with past medical history of hypertension and diabetes mellitus who underwent imaging with positron emission tomography (PET) scan imaging for staging of her small cell urinary bladder cancer and was found to have hypermetabolic uptake in the deltoid muscle of the left shoulder and hypermetabolic left axillary and pectoral lymph nodes due to mRNA BNT-162b2 (Pfizer-BioNTech COVID-19 vaccine) vaccine administrated 3 days ago prior to PET scan.

COVID-19 and Diabetic Ketoacidosis: Report of Eight Cases.

Aim To describe the clinical characteristics and outcome of hospitalized COVID-19 patients with diabetic ketoacidosis (DKA). Methods We report eight cases of diabetic ketoacidosis in COVID-19 who presented to our institution in New Jersey, USA. COVID-19 was diagnosed by nasopharyngeal swab reverse transcription polymerase chain reaction (RT-PCR). The patients' electronic medical records were reviewed. Data on patients' age, sex, ethnicity, laboratory values, glycosylated hemoglobin level, oral antihyperglycemic agents (OHAs), insulin, and clinical outcomes were collected. Results The median age of the patient was 42.5 years, and seven were males and one was female. Out of eight patients, five had type 2 diabetes mellitus (DM), two had undiagnosed DM, and one had type 1 DM. Median value of initial glucose on presentation was 454 mg/dL. Median value of HbA1c on presentation was 11.4% and of anion gap was 26.5 mEq/L. Four patients had large ketonemia, one patient had moderate ketonemia, and three patients had small ketonemia. All the patients were started on standard treatment protocol for DKA with intravenous fluids and IV insulin infusion. Acute kidney injury (AKI) was seen in four patients, and one patient required renal replacement therapy. Out of eight patients, three required mechanical ventilation, and the same three patients died. Conclusion Our case series shows that COVID-19 infection can precipitate DKA in patients with known diabetes mellitus patients or as a first manifestation in undiagnosed DM patients; COVID-19 with DKA is associated with substantial mortality. Further studies are needed to characterize poor risk factors associated with mortality in these patients.

The use of direct acting oral anticoagulants in patients with COVID-19 infection.

The use of direct-acting oral anticoagulants (DOACs) has increased rapidly in the last decade; becoming the mainstay for both the prophylaxis and the treatment of venous thromboembolism in various situations including non-valvular atrial fibrillation, joint replacement surgeries and acute DVT/PE, etc. In the present times, DOACs are possibly one of the most widely prescribed medications in the developed world. The worldwide epidemic caused by COVID-19 caused significant changes in the practice of medicine worldwide. Patients who developed severe respiratory illness caused by COVID-19 were noted to develop a wide range of complications, including both arterial and venous thromboembolic complications including deep vein thrombosis and pulmonary embolism, etc. This review is an attempt to identify the role of DOACs in the treatment and prevention of these complications as well as the safety of continuing therapy with DOACs in the patients who were receiving them before contracting the infection.

COVID-19 Induced Bilateral Lower Limb Ischemia and Visceral Infarcts.

Emerging cases of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) have been associated with a variety of disorders including respiratory failure, immune reactive syndrome, multiorgan failure, and hypercoagulable states. COVID-19 induces a severe global inflammatory response which can result in endothelial damage leading to hypercoagulability. Most COVID-19 cases of hypercoagulable states reported venous thrombosis. We report here a case of a 65-year-old Hispanic male diagnosed with bilateral acute lower limb ischemia and renal infarcts secondary to a severe COVID-19 infection.

COVID-19 and Diabetic Ketoacidosis: A Single Center Experience.

BACKGROUND AND OBJECTIVES:  To describe the clinical characteristics and outcomes of hospitalized coronavirus disease 2019 (COVID-19) patients with diabetic ketoacidosis (DKA) -- a single center tertiary hospital experience. MATERIALS AND METHODS:  A retrospective study was conducted among patients admitted to our hospital in the United States between March 1st and June 15th, 2020 with DKA and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection known as COVID-19. We compared the baseline characteristics, laboratory data, and clinical course between survivors and nonsurvivors to identify the risk factors associated with mortality in the patients with DKA. RESULTS:  A total number of 43 patients were included in this study. The median age was 52 years. Thirty-three (76.7%) patients were male. Median value of initial glucose on presentation was 553 mg/dL (300.0-1927.0 mg/dL). On admission, 33 (76.7%) patients had glycated hemoglobin (HbA1c) ≥ 8% (64 mmol/mol) and HbA1c was not obtained in 10 (23.3%) patients. Acute kidney injury (AKI) was seen in 37 (86.0%) patients, 6 (14%) patients required renal replacement therapy and 22 (51.2%) required mechanical ventilation. Among the 43 patients, 25 (58.1%) died. Out of 25 patients who died 15 (60.0%) were Hispanics, 6 (24.0%) were White, 3 (12.0%) were African American, 1 (4%) was Arabic, and 1 (4%) was Asian. The patients who died were older in age than who survived (mean age 58 ± 6.13 vs 46 ± 9.39; p = 0.023). Some 95% of the patients requiring mechanical ventilation died (odds ratio [OR]: 89.25; 95% confidence interval [CI]: 9.10-874.96); p = 0.001). Compared to survivors, nonsurvivors had significantly higher d-dimer (13.00 ± 3.20 mcg/mL vs 6.15 ± 3.66 mcg/mL; p< 0.006) and peak ferritin values (2763.66 ± 1105.32 ng/mL vs 835.16 ± 257.07 ng/mL; p= 0.016).  Conclusion: Our retrospective study shows COVID-19 infection may present as DKA in patients with diabetes mellitus (DM). Older age, mechanical ventilation, elevated d-dimer, and ferritin are associated with poor prognosis in these patients. Our study shows that COVID-19 is associated with substantial mortality in DKA patients and adds to the limited literature available regarding poor risk factors associated with mortality in these patients.

Rhabdomyolysis in COVID-19: Report of Four Cases.

Coronavirus disease 2019 (COVID-19) is a global public health emergency. COVID-19 is most well known for affecting the respiratory system, although it can also result in several extrapulmonary manifestations. Limited literature is available regarding rhabdomyolysis in COVID-19. We report four cases of rhabdomyolysis in COVID-19 patients. High index of suspicion is required for the appropriate clinical scenario to recognize this life-threatening situation so that complications can be avoided.