Neurology and COVID-19: Acting now. Preparing for Future.

COVID-19 has a wide-ranging and multimodal neurological impact. First, several neurological symptoms and complications are commonly observed in patients with COVID-19. Second, medications and vaccinations used to counter the disease can have secondary neurological effects. Third, patients with pre-existing neurological disorders bear an increased health-risk due to COVID-19. And finally, the pandemic has disrupted the delivery of neurological and vaccination services, and associated educational and research programs. In this article we review the various channels through which the pandemic is known or projected to effect individual patients or the practice of neurology. We also provide recommendations to manage its immediate effects and prepare for the longer-term fall-out.

A case of Kytococcus schroeteri prosthetic valve endocarditis in a patient with COVID-19 infection.

64 years old male presented fever, gastrointestinal symptoms, COVID-19 infection with bioprosthetic mitral in situ, cardio embolic stroke 2 years ago. The 2 D ECHO showed a vegetation indicating infective endocarditis. Three paired blood cultures grew Kytococcus schroeteri. The organism was sensitive to Vancomycin, Teicoplanin, Gentamycin and Linezolid. Patient had multiorgan dysfunction which further deteriorated into failure, disseminated intravascular coagulation resulting into death of the patient.

The Emergence of Omicron: Challenging Times Are Here Again!

COVID-19 has been reported to have caused more than 286 million cases and 5.4 million deaths till date. COVID variants have appeared at regular intervals-alpha, beta, gamma, delta and now omicron. 'Omicron' is driving the current surge of cases in most countries including India and is poised to replace 'delta' the world over. This variant with more than 50 mutations is phylogenetically very different from other variants. The omicron variant spreads rapidly with an average doubling time of two days. The disease so far has been mild as compared with delta. Though previous infection and vaccination offer little or no protection against infection with omicron, they do seem to partially protect against hospitalization and severe disease. Booster vaccinations have not made any notable impact on the spread of omicron and have further worsened global vaccine equity. The indirect consequences of omicron from lockdowns, restrictions, travel bans, economic losses, health care worker infections and overwhelming of health care facilities are likely to be enormous. The direct effects of omicron on children are expected to be mild like with the previous variants. However, the indirect effects on child mental, physical, and social health may be considerable owing to school closures, missed vaccinations, neglect of other diseases, etc. It is, therefore, imperative that governments take rational decisions to navigate the world through this latest crisis.

Definition, diagnosis, and management of COVID-19-associated pulmonary mucormycosis: Delphi consensus statement from the Fungal Infection Study Forum and Academy of Pulmonary Sciences, India.

COVID-19-associated pulmonary mucormycosis (CAPM) remains an underdiagnosed entity. Using a modified Delphi method, we have formulated a consensus statement for the diagnosis and management of CAPM. We selected 26 experts from various disciplines who are involved in managing CAPM. Three rounds of the Delphi process were held to reach consensus (≥70% agreement or disagreement) or dissensus. A consensus was achieved for 84 of the 89 statements. Pulmonary mucormycosis occurring within 3 months of COVID-19 diagnosis was labelled CAPM and classified further as proven, probable, and possible. We recommend flexible bronchoscopy to enable early diagnosis. The experts proposed definitions to categorise dual infections with aspergillosis and mucormycosis in patients with COVID-19. We recommend liposomal amphotericin B (5 mg/kg per day) and early surgery as central to the management of mucormycosis in patients with COVID-19. We recommend response assessment at 4-6 weeks using clinical and imaging parameters. Posaconazole or isavuconazole was recommended as maintenance therapy following initial response, but no consensus was reached for the duration of treatment. In patients with stable or progressive disease, the experts recommended salvage therapy with posaconazole or isavuconazole. CAPM is a rare but under-reported complication of COVID-19. Although we have proposed recommendations for defining, diagnosing, and managing CAPM, more extensive research is required.

Multicenter Epidemiologic Study of Coronavirus Disease-Associated Mucormycosis, India.

During September-December 2020, we conducted a multicenter retrospective study across India to evaluate epidemiology and outcomes among cases of coronavirus disease (COVID-19)-associated mucormycosis (CAM). Among 287 mucormycosis patients, 187 (65.2%) had CAM; CAM prevalence was 0.27% among hospitalized COVID-19 patients. We noted a 2.1-fold rise in mucormycosis during the study period compared with September-December 2019. Uncontrolled diabetes mellitus was the most common underlying disease among CAM and non-CAM patients. COVID-19 was the only underlying disease in 32.6% of CAM patients. COVID-19-related hypoxemia and improper glucocorticoid use independently were associated with CAM. The mucormycosis case-fatality rate at 12 weeks was 45.7% but was similar for CAM and non-CAM patients. Age, rhino-orbital-cerebral involvement, and intensive care unit admission were associated with increased mortality rates; sequential antifungal drug treatment improved mucormycosis survival. The COVID-19 pandemic has led to increases in mucormycosis in India, partly from inappropriate glucocorticoid use.

The Chronic Effects of COVID-19 or "Long COVID"

The term "long COVID" is used to refer to patients who have persisting symptoms for 4 weeks or more after onset of COVID-19. The prevalence of these symptoms is reported to range from 10-80%. The commonest symptoms include fatigue, dyspnoea, chest pain, hair loss, loss of sense of taste and smell, cognitive difficulties, anxiety and depression. Serious complications in this period include thrombo embolic events (stroke, myocardial infarction, limb ischemia and venous thromboembolism), infections, pulmonary fibrosis and multi system inflammatory syndrome. Patients with post COVID-19 symptoms should be first evaluated in primary care and those with serious issues referred to appropriate specialties. The others should be provided with supportive and symptomatic care including respiratory care, nutrition, immunization, mental health support, management of comorbidities and if indicated anticoagulation and treatment of infections. The routine use of steroids, antifibrotics, anticoagulants, anti depressents and antibiotics in these patients should be avoided.

No correlation between Ct values and severity of disease or mortality in patients with COVID 19 disease.

There are several reports of Ct values of RT PCR assays for COVID 19 being associated with disease severity and infectivity. We studied the correlation between Ct values and disease severity and mortality at our hospital . All patients with RT PCR diagnosed COVID 19 illness admitted at the study site and for whom Ct values were available were included in the study. The patients with mild disease had significantly lower Ct values than patients with severe disease but had also been tested significantly earlier in the illness than those with severe disease. The patients who died had significantly lower Ct values than patients who survived but here again they had significantly shorter duration of symptoms before testing. We therefore recommend that the time of testing since onset of symptoms should be controlled for while correlating Ct values with disease severity.

An unusual cause of fever and jaundice.

A 52 year old previously healthy woman from Mumbai presented with fever and jaundice of 10 days duration. At admission, she was jaundiced with tachycardia, tachypnea, hypoxia, hypotension, conjunctival congestion and mild erythematous flush over the skin. She had very high WBC counts and CRP's with direct hyperbilirubinemia and azotemia. Investigations for infectious causes of fever were negative. RT-PCR for SARS-CoV-2 in the nasopharynx was negative. However her SARS-CoV-2 antibodies were reactive. She also had echocardiographic and biochemical evidence of cardiac dysfunction. The diagnosis of Multisystem inflammatory syndrome-Adult (MIS-A) was thus established. She rapidly improved with intravenous immunoglobulin (2 gm/kg) and high dose steroids.

Prevalence of COVID-19 antibodies in healthcare workers at the peak of the pandemic in Mumbai, India: A preliminary study.

Healthcare worker (HCW) infections due to COVID-19 are of serious consequence. Testing for antibodies against COVID-19 in HCWs has been previously recommended. We conducted a serosurvey in HCWs at a private hospital in Mumbai which is treating COVID patients. A total of 244 HCWs were tested. The prevalence of infection in asymptomatic HCWs was 4.3% and in previously symptomatic untested HCWs was 70%. We recommend that HCWs with a previous history of COVID symptoms who were not tested/tested negative by reverse transcription-polymerase chain reaction should be tested for antibodies at least 2 weeks after onset of symptoms.

Perinatal-Neonatal Management of COVID-19 Infection - Guidelines of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP)

JUSTIFICATION: During the current rapidly evolving pandemic of COVID-19 infection, pregnant women with suspected or confirmed COVID-19 and their newborn infants form a special vulnerable group that needs immediate attention. Unlike other elective medical and surgical problems for which care can be deferred during the pandemic, pregnancies and childbirths will continue. Perinatal period poses unique challenges and care of the mother-baby dyads requires special resources for prevention of transmission, diagnosis of infection and providing clinical care during labor, resuscitation and postnatal period. PROCESS: The GRADE approach recommended by the World Health Organization was used to develop the guideline. A Guideline Development Group (GDG) comprising of obstetricians, neonatologists and pediatricians was constituted. The GDG drafted a list of questions which are likely to be faced by clinicians involved in obstetric and neonatal care. An e-survey was carried out amongst a wider group of clinicians to invite more questions and prioritize. Literature search was carried out in PubMed and websites of relevant international and national professional organizations. Existing guidelines, systematic reviews, clinical trials, narrative reviews and other descriptive reports were reviewed. For the practice questions, the evidence was extracted into evidence profiles. The context, resources required, values and preferences were considered for developing the recommendations. OBJECTIVES: To provide recommendations for prevention of transmission, diagnosis of infection and providing clinical care during labor, resuscitation and postnatal period. RECOMMENDATIONS: A set of twenty recommendations are provided under the following broad headings: 1) pregnant women with travel history, clinical suspicion or confirmed COVID-19 infection;2) neonatal care;3) prevention and infection control;4) diagnosis;5) general questions.

A Review of Coronavirus Disease-2019 (COVID-19).

There is a new public health crises threatening the world with the emergence and spread of 2019 novel coronavirus (2019-nCoV) or the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus originated in bats and was transmitted to humans through yet unknown intermediary animals in Wuhan, Hubei province, China in December 2019. There have been around 96,000 reported cases of coronavirus disease 2019 (COVID-2019) and 3300 reported deaths to date (05/03/2020). The disease is transmitted by inhalation or contact with infected droplets and the incubation period ranges from 2 to 14 d. The symptoms are usually fever, cough, sore throat, breathlessness, fatigue, malaise among others. The disease is mild in most people; in some (usually the elderly and those with comorbidities), it may progress to pneumonia, acute respiratory distress syndrome (ARDS) and multi organ dysfunction. Many people are asymptomatic. The case fatality rate is estimated to range from 2 to 3%. Diagnosis is by demonstration of the virus in respiratory secretions by special molecular tests. Common laboratory findings include normal/ low white cell counts with elevated C-reactive protein (CRP). The computerized tomographic chest scan is usually abnormal even in those with no symptoms or mild disease. Treatment is essentially supportive; role of antiviral agents is yet to be established. Prevention entails home isolation of suspected cases and those with mild illnesses and strict infection control measures at hospitals that include contact and droplet precautions. The virus spreads faster than its two ancestors the SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), but has lower fatality. The global impact of this new epidemic is yet uncertain.