Delirium during COVID‑19: A report of eight cases and a review of the literature

Delirium is an acute confusional state, often associated with long‑term hospitalization, oxygen supplementation, the male sex and an older age. Since the start of the corona‑ virus disease 2019 (COVID‑19) pandemic, there was an abrupt increase in intensive care unit (ICU) admissions and hospitalization in general, as well as in the need for oxygen therapy and enforced isolation due to the contagion risk. This caused a sudden increase in the episodes of delirium. The diagnosis of delirium, however, remains a difficult task, as it can often be misdiagnosed or confused with underlying dementia, particularly among the elderly. The present study describes present eight cases of patients admitted to hospital due to severe acute respiratory syndrome coronavirus 2 infection, who manifested delirium. Notably, only one of the patients had psychiatric comorbidities prior to hospitalization. The most prevalent sex was the male (7:1) one, the mean age of the patients was 81.7±4 years, and the mean duration of hospitalization was 23.6±6 days. In total, 3 patients had a virological recovery and were discharged, 3 had a clinical recovery and were transferred to a lower intensity COVID‑19 facility and 2 patients did not survive. In the eight cases described herein, the mortality rate was 25%. Delirium was found to be commonly associated with a higher mortality rate and a longer hospitalization period. Therefore, it is imperative to develop protocols and tools with which to rapidly assess delirium and treat it accordingly. In addition, it is fundamental to improve the quality of life of hospitalized patients, supporting behavioral therapy and the environmental factors that can affect patients, to prevent delirium as well. © 2023 Spandidos Publications. All Rights Reserved.

A misunderstood severe aortic stenosis in a COVID-19 patient

Background: It is crucial to differentiate patients affected by COVID-19 from others who only tested positive to SARS-CoV-2 to optimize the treatments. We need to identify respiratory symptoms unrelated to SARS-CoV-2 infection. We report a case of severe cardiogenic dyspnea in a patient admitted for COVID-19. Case Report: A 79-year-old woman with nasal swab positive for SARS-CoV-2 was admitted for dyspnea and asthenia for 2 weeks. At the admission she presented with orthopnea, ankles swelling and oliguria. EKG showed atrial fibrillation and echocardiogram showed diffuse left ventricle hypokinesia, severe reduced ejection fraction, right ventricle normal dimensions and kinesia, not very modular inferior venae cavae, negative femoro popliteal CUS, absence of pericardial effusion, diffuse and homogeneous thoracic pattern B. She started furosemide and dobutamine with strict clinical and ultrasound monitoring. Because of the reduction of dyspnea and an incremented diuresis, dobutamine was stopped in the second day. On day 3 there was a worsening, echocardiogram showing a severe aortic stenosis, very small inferior venae cavea. Liquid infusion was started with caution to increase preload. Once obtained hemodynamic stabilization, the patient underwent coronary angiography. No coronary lesions were found and TAVI was performed successfully. Conclusions: The patient experimented respiratory symptoms due to acute heart failure. Dobutamine infusion made manifest a preexisting severe aortic stenosis that was successfully treated.

A case of toxic epidermal necrolysis in a COVID-19 patient

Background: We report a severe hypersensitivity reaction due to warfarin in a COVID19 patient with sepsis. Case Report: An 86-year-old man was admitted for COVID19 pneumonia. He was vaccinated with 2 ComirNaty doses. He was affected by hypertension and CKD in emodialysis. At the admission he presented fever and tachypnea, the laboratory tests showed a septic state. We started administration of empiric therapy with piperacillina/tazobactam, it was replaced with meropenem and linezolid on the 29th day. After 10 days linezolid was stopped for thrombocitopenia. On the 14th day we prescribed warfarin for tromboembolic risk prevention when paroxysmal atrial fibrillation occurred . At the fifth week there was a clinic and laboratory worsening so we started target antibiotic therapy with cefiderocol and colistin due to positive blood cultures for A. Baumanii XDR. On the 24th day an inguinal erytema with blister-like lesion occurred and involved progressively face, neck, limbs, trunk and abdomen with extensive skin sloughing and crusted lesions appeared in the perioral and perinasal mucosa. Nikolsky sign was negative. Skin biopsy showed signs of inflammatory reaction. Warfarin was stopped and 1mg/kg methylprednisone was started with slow and progressive benefit. Conclusions: The patient has developed a warfarin linked hypersensitivity reaction with clinical features similar to toxic epidermal necrolysis. We assume that it was a borderline condition of hypersensitivity to warfarin in a patient with hyperactivation of immune system due to COVID19 and sepsis.

COVID-19 and pregnancy: clinical outcomes and scientific evidence about vaccination.

Pregnant women and their infants are at high risk to develop a severe COVID-19, with increased rates of hospitalisation to intensive care units, need for mechanical ventilation and mortality. Preterm birth, fetal vascular malperfusion, and premature rupture of membrane have been the most reported adverse pregnancy outcomes and these effects have been especially associated with the onset of the disease at early gestational age. The early expression of ACE2 and TMPRSS2 in human embryos has been proven, determining an increased susceptibility to SARS-CoV-2. Preterm infants born to women infected by SARS-CoV-2 have a higher risk of need for specialist neonatal care with prolonged hospitalization. Moreover, inflammation of developing embryos could cause long-term defects, regardless of vertical transmission of SARS-CoV-2. Due to Maternal Immune Activation (MIA), in utero inflammation is associated with neurodevelopmental, cognitive and psychiatric disorders in affected offspring. Despite risks that COVID-19 could induce in pregnancy, there are not many published data describing the safety and/or efficacy of COVID-19 vaccines in pregnant women, commonly not included in vaccine research. The evidence from the few pregnant women unintentionally enrolled in clinical trials and vaccinated suggests that COVID-19 vaccines, both based on mRNA and viral vectors, do not pose significant risks to the fetus or breastfeeding infants. Moreover, human studies using mRNA-based vaccines against Zika virus, influenza, and rabies have reported good safety and immunogenicity during pregnancy. In this review, we evaluate the role of COVID-19 in adverse pregnancy and neonatal outcomes and the need to vaccinate pregnant women.

Trace elements and the carotid plaque: the GOOD (Mg, Zn, Se), the UGLY (Fe, Cu), and the BAD (P, Ca)?

Multiple epidemiological studies have suggested that industrialization and progressive urbanization should be considered one of the main factors responsible for the rising of atherosclerosis in the developing world. In this scenario, the role of trace metals in the insurgence and progression of atherosclerosis has not been clarified yet. In this paper, the specific role of selected trace elements (magnesium, zinc, selenium, iron, copper, phosphorus, and calcium) is described by focusing on the atherosclerotic prevention and pathogenesis plaque. For each element, the following data are reported: daily intake, serum levels, intra/extracellular distribution, major roles in physiology, main effects of high and low levels, specific roles in atherosclerosis, possible interactions with other trace elements, and possible influences on plaque development. For each trace element, the correlations between its levels and clinical severity and outcome of COVID-19 are discussed. Moreover, the role of matrix metalloproteinases, a family of zinc-dependent endopeptidases, as a new medical therapeutical approach to atherosclerosis is discussed. Data suggest that trace element status may influence both atherosclerosis insurgence and plaque evolution toward a stable or an unstable status. However, significant variability in the action of these traces is evident: some - including magnesium, zinc, and selenium - may have a protective role, whereas others, including iron and copper, probably have a multi-faceted and more complex role in the pathogenesis of the atherosclerotic plaque. Finally, calcium and phosphorus are implicated in the calcification of atherosclerotic plaques and in the progression of the plaque toward rupture and severe clinical complications. In particular, the role of calcium is debated. Focusing on the COVID-19 pandemia, optimized magnesium and zinc levels are indicated as important protective tools against a severe clinical course of the disease, often related to the ability of SARS-CoV-2 to cause a systemic inflammatory response, able to transform a stable plaque into an unstable one, with severe clinical complications.

Liver infection and COVID-19: the electron microscopy proof and revision of the literature.

OBJECTIVE: COVID-19, the newly emerging infectious disease, has been associated with acute liver injury, often related to progression to severe pneumonia. The association between moderate-severe liver injury and more severe clinical course of COVID-19 has suggested that liver injury is prevalent in severe than in mild cases of COVID-19, while no difference in liver involvement has been reported between survivors and non-survivors. The spectrum of liver involvement during COVID-19 ranges from an asymptomatic elevation of liver enzymes to severe hepatitis. Only rarely, cases with acute hepatitis have been reported in the absence of respiratory symptoms. Both epithelial and biliary cells possess the angiotensin-converting enzyme-2 receptors that SARS-CoV-2 uses to be internalized. However, to our knowledge, no ultrastructural identification of the virus in liver cells has been reported to date. Here we provide evidence of SARS-CoV-2 in the liver of two patients, a 34-year-old woman and a 60-year-old man with COVID-19. PATIENTS AND METHODS: We investigated two patients with COVID-19 showing several virions within cytoplasmic vacuoles of cholangiocytes and in endothelial cells of hepatic sinusoids. In both patients, we performed histological and ultrastructural examinations by liver biopsy. After two months, both patients were free of symptoms, and the SARS-CoV-2 infection had resolved. RESULTS: Liver biopsy histological and ultrastructural examination showed liver injury and several virions within cytoplasmic vacuoles of cholangiocytes and in endothelial cells of hepatic sinusoids. CONCLUSIONS: Although most studies in COVID-19 have been focused on the lungs, recently, cholestatic liver pathology has been introduced in the spectrum of pathological changes related to COVID-19. To the best of our knowledge, those presented in this paper are the first images of hepatic SARS-CoV-2 infected liver cells. Our findings suggest a role for cholangiocytes and biliary structures in the COVID-19.

Transmission mode associated with coronavirus disease 2019: a review.

OBJECTIVE: In late December 2019 in Wuhan (China), Health Commission reported a cluster of pneumonia cases of unknown etiology, subsequently isolated and named Severe Acute Respiratory Syndrome (SARS) Coronavirus 2 (CoV-2). In this review, the main transmission routes and causes of mortality associated with COVID-19 were investigated. MATERIAL AND METHODS: A review was carried out to recognize relevant research available until 10 April 2020. RESULTS: The main transmission routes of COVID-19 have been the following: animal to human and human-to-human pathways, namely: respiratory transmission; oro-fecal transmission; air, surface-human transmission. Transmission from asymptomatic persons, healthcare transmission, and interfamily transmission have been well documented. CONCLUSIONS: SARS-CoV-2 possesses powerful pathogenicity and transmissibility. It is presumed to spread primarily via respiratory droplets and close contact. The most probable transmission pathway is definitely the inter-human one. Asymptomatic patients seem to play a crucial role in spreading the infection. Because of COVID-19 infection pandemic potential, careful surveillance is essential to monitor its future host adaptation, viral evolution, infectivity, transmissibility, and pathogenicity in order to gain an effective vaccine and flock immunity and reduce mortality as soon and as much as it is possible.