A Case Report of Fascicular Ventricular Tachycardia in a COVID-19 Patient.

A 29-year-old man with moderate coronavirus disease 2019 (COVID-19) pneumonia presented with a one-day history of palpitations. On examination, he was febrile and tachycardic (pulse rate of 182 beats per minute), with a blood pressure of 120/80 mmHg and oxygen saturation of 96%. Electrocardiography revealed sustained monomorphic wide-complex tachycardia. Carotid sinus massage and adenosine administration were ineffective. Although amiodarone administration slowed the heart rate and relieved his symptoms, sinus rhythm was not restored. We administered intravenous verapamil which terminated his arrhythmia. We diagnosed the patient with fascicular ventricular tachycardia (VT) with a right bundle branch block. He recovered from COVID-19 weeks later. The workup excluded all possible risk factors associated with VT except for COVID-19 infection.

Thyroid storm in pregnancy: A case study

Introduction: Inadequately treated maternal hyperthyroidism increases the risk of severe preeclampsia, heart failure, and thyroid storm. Thyroid storm is a life-threatening endocrine emergency characterized by multiple organ failure due to severe thyrotoxicosis. A storm can be triggered by precipitating events such as trauma, surgery, infection, delivery;even pregnancy itself. Case Description: A 35-year-old lady presented to the emergency department with complete miscarriage. She had underlying hyperthyroidism for six years but defaulted her follow-ups and medications since the beginning of the Covid-19 pandemic. She complained of palpitations despite minimal vaginal blood loss. ECG showed sinus tachycardia with a heart rate of 190 beats per minute. Her hemoglobin level was stable, but thyroid function test showed hyperthyroidism with raised free T4 (60 pmol/L) and low TSH (< 0.01 mIU/L). Her Burch-Wartofsky score was 35, implying an impending thyroid storm. IV Verapamil was given immediately and her heart rate improved to 140-150 bpm. She was transferred to a high dependency ward for close monitoring and started on oral Propylthiouracil and Propranolol. Regrettably, when she began to improve, she requested for discharge against medical advice. Discussion: The diagnosis of thyroid storm is clinical, with laboratory tests consistent with overt hyperthyroidism. Clinical scoring systems such as the Burch-Wartofsky Score helps to confirm diagnosis and triage disease severity. Treatment is multimodal using medications (thioamides, iodide, beta-blockers, corticosteroids, antipyretics), oxygen, volume resuscitation, and correction of electrolyte imbalance. A high index of suspicion, rapid recognition, prompt treatment and intensive monitoring are key elements of management.

THE BIG IMPACT OF SMALL CHANGES IN NARROW THERAPEUTIC INDEX DRUGS

CASE: An 84-year-old woman with atrial fibrillation on Digoxin presented with acute onset of confusion associated with a week history of abdominal pain, vomiting, and poor fluid intake. A few days prior, Amiodarone was added to her drug regimen which included Lasix. Additionally, she received the COVID-19 booster vaccine which led to a viral-like syndrome resulting in dehydration. The patient was afebrile, normotensive, but bradycardic. EKG showed a prolonged PR interval and scooped ST segments. Labs showed hyperkalemia, pre-renal acute kidney injury (AKI), and a Digoxin level of 4.3 ng/mL (therapeutic range: 0.8-2.0 ng/mL). Digoxin and Lasix were held and Digoxin antidote, Digibind, was administered with normalizing heart rate, potassium, and clinical improvement. IMPACT/DISCUSSION: Digoxin is used to slow conduction in atrial fibrillation and increase cardiac contractility in heart failure. It inhibits the membrane sodium-potassium-adenosine triphosphatase pump (Na/K ATPase), resulting in increased cytosolic calcium and subsequent cardiac contractility and automaticity. In turn, this can also cause premature ventricular contractions and tachycardia. In the carotid sinus, increased baroreceptor firing and subsequent increased vagal tone occurs which can cause bradycardia, atrioventricular blocks, hypotension, and GI symptoms. In skeletal muscle, hyperkalemia can result due to the abundance of Na/K ATPase pumps. Digoxin has a narrow therapeutic index with serum levels easily affected by many commonly prescribed drugs by way of decreasing renal clearance, inhibiting P-glycoprotein, and inducing secondary electrolyte disturbances. That said, drug dosing should be individualized with close monitoring to avoid potentially life-threatening effects that may result with even mildly increased digoxin levels. Acute toxicity manifests as non-specific GI, and neurologic symptoms (confusion, lethargy, visual changes), hyperkalemia, and brady or tachy-arrhythmias. Treatment is with digoxin specific fragment antigen binding (Fab) antibody, Digibind, which binds digoxin, inactivating it within 6-8 hours. Postadministration, digoxin serum testing cannot distinguish free verse bound drug;therefore, drug levels remain elevated for days to weeks until the FabDigoxin complex is excreted. In the case above, the viral-like-syndrome after the booster vaccine with subsequent AKI secondary to dehydration likely precipitated Digoxin toxicity. Accompanying drug interactions of diuretics causing dehydration and hypokalemia, P-glycoprotein inhibitors (Amiodarone, Verapamil, Diltiazem, Quinidine), and ACE inhibitors can further worsen renal clearance and culminate in Digoxin toxicity. CONCLUSION: Given Digoxin's narrow therapeutic index, small clinical changes such as post COVID-19 vaccine flu-like symptoms, dehydration, and medication changes can manifest drug toxicity. Therefore, attentive monitoring of accompanying comorbidities and drug interactions is imperative at preventing catastrophic toxic effects.

TELEMEDICAL EVALUATION OF ACUTE HEADACHE IN SETTING OF ONGOING COVID PANDEMIC

CASE: 50 yo generally healthy female with two sudden “throbbing” frontal headaches (HA) over the 7 days. First episode (rated 9 out of 10) was preceded by abd pain and emesis. The HA worsened in the laying down, which decreased after 5 hrs of “pacing around the house." Second HA preceded by neck pain and nausea. HA persist (2 out of 10) after the episodes with 'persistent brain fog.' Positive for recent life stressors. Has Mirena. During the video visit, she appears alert, not in distress, speech and mentation at baseline. Face symmetrical. However, no traditional intake such as vital signs were not available and the physical exam was limited. Due to the red flags symptoms, imaging was indicated. CT is the first pass work up for intracranial hemorrhage. Differential diagnoses include migraines, benign HA, hemorrhage, thrombosis, dissection, and neoplasms. There were logistical limitations as this occurred over the holiday with reduced clinic hours, no urgent care and the ED on diversion. An urgent head CT ordered with the plan for follow up in person visit after the holiday for further assessment, and likely consultation with neuro. Findings concerning for acute SAH. Radiology sends patient to ED. Repeat CT angio, again, shows “multifocal beaded and narrowing in circulation. Suggestive of cerebral vasoconstriction syndrome (RCVS).” After admission, pt is evaluated by neuro and undergoes angio, which finds mild diffused artery luminal stenosis consistent with RVCS. Intra-arterial verapamil administered into 3 cerebral arteries had marked improvement. Discharged on 90 days of oral verapamil with close PCP follow up. IMPACT/DISCUSSION: RVCS is evolving neurological condition. Given the low incidence of 3 in 1million patients, the understanding of RVCS continues to grow. RVCS commonly presents as severe thunderclap HA. Triggered by use of vasoconstricting medication, illicit drug, postpartum and grief. However, acute HA have a relatively large differential. Primarily diagnosed through imaging. As in this case, RVCS requires urgent interventions. To differentiate from benign etiologies of HA particularly as health services are limited or overwhelmed by COVID health epidemic, telehealth can play a pivotal role in increasing accessibility to reduce pt harm and potentially negative outcomes. Impact on practice: Red flag symptoms associated with thunderclap HA, even after improvement necessitate urgent evaluation of address the risk of RCVS. Thorough limited neuro examinations through video can assist in diagnostic differential development. As the COVID continues and impacts burden of healthcare, post pandemic incorporation of telehealth can play in acute settings with limited resources that can significantly reduce poor pt outcomes. CONCLUSION: Thorough investigations of presenting illness and medical history supply critical details in distinguishing atypical HA In the setting of limited resources and time constraints, virtual assessments provide sufficient information to support expedited workup.

Ion channel inhibition with amiodarone or verapamil in symptomatic hospitalized nonintensive-care COVID-19 patients: The ReCOVery-SIRIO randomized trial.

BACKGROUND: Ion channel inhibition may offer protection against coronavirus disease 2019 (COVID-19). Inflammation and reduced platelet count occur during COVID-19 but precise quantification of risk thresholds is unclear. The Recov ery-SIRIO study aimed to assess clinical effects of amiodarone and verapamil and to relate patient phenotypes to outcomes. METHODS: RECOVERY-SIRIO is a multicenter open-label 1:1:1 investigator-initiated randomized trial with blinded event adjudication. A sample of 804 symptomatic hospitalized nonintensive-care COVID-19 patients, follow-up for 28 days was initially planned. RESULTS: The trial was stopped when a total of 215 patients had been randomized to amiodarone (n = 71), verapamil (n = 72) or standard care alone (n = 72). At 15 days, the hazard ratio (hazard ratio [HR], 95% confidence interval [CI]) for clinical improvement was 0.77 (0.52-1.14) with amiodarone and 0.97 (0.81-1.17) with verapamil as compared to usual care. Clinically relevant associations were found between mortality or lack of clinical improvement and higher peak C-reactive protein (CRP) levels or nadir platelet count at 7, 10 and 15 days. Mortality rate increased by 73% every 5 mg/dL increment in peak CRP (HR 1.73, 95% CI 1.27-2.37) and was two-fold higher for every decrement of 100 units in nadir platelet count (HR 2.19, 95% CI 1.37-3.51). By cluster analysis, thresholds of 5 mg/dL for peak CRP and 187 × 103/mcL for nadir platelet count identified the phenogroup at greatest risk of dying. CONCLUSIONS: In this randomized trial, neither amiodarone nor verapamil were found to significantly accelerate short-term clinical improvement. Peak CRP and nadir platelet counts were associated with increased mortality both in isolation and by cluster analysis.

A new challenge: post-COVID syndrome in adolescents

Post-COVID syndrome (or long COVID) is a set of multiple symptoms oc-curring after a documented SARS-CoV-2 infection and persisting for more than 2 months. The pediatric population is also affected, especially pre-adolescents and adolescents, even if data about this age group are still scarce. Persistent symptoms can have a strong impact on quality of life and schooling, school absenteeism and social withdrawal being of major concern. For this reason, the Division of General Pediatrics at the Univer-sity Hospital of Geneva has set up in May 2021 a specific consultation for adolescents with post-COVID syndrome, offering global and multidiscipli-nary care. To date 50 patients have been addressed to our consultation by their gen-eral practitioner. The mean age is 14 years, two thirds are girls. The symp-toms are multiple and non-specific, and are similar to those described in adults. The most frequent ones are fatigue, dizziness, headaches, dysp-nea, loss of smell, brain fog, sleep disorders, mood disorders. The Peds-QL questionnaire (assessing 4 aspects of teenagers' daily life), shows an impact of these symptoms on the quality of life, schooling and daily activities being the most affected. Reassuringly, peer relationships seem preserved. Impact on schooling is important, with two thirds of pa-tients reporting an impact on school performance, and one fourth having extended school absenteeism. The Adolescent Depression Rating Scale shows that 44% of our patients are at risk for depression. One third needs a psychological support. If necessary, patients can be referred to specialized consultations in our multidisciplinary group (ENT, pulmonology, neurology, cardiology, etc.) or to complementary examinations (Tilt-Test, stress test). Patients having symptoms due to physical activity (fatigability, shortness of breath, dysau-tonomia with standing position intolerance) can benefit from a progres-sive and individualized reconditioning program with an adapted sport coach. We offer a global follow-up to patients and families. School attendance is supported by making individual arrangements if required, through close collaboration with the education system. Repetition of the questionnaires 3-6 months after the beginning of the follow-up shows a trend towards clear improvement, however a longer follow-up period would be necessary to confirm these observations. (To allow fully up-to-date informations, numbers are susceptible to change until June).

Brensocatib: Dipeptidyl peptidase 1 (DPP1) inhibitor Treatment of non-cystic fibrosis bronchiectasis

Neutrophils, which are among the first immune cells to respond to both infection and injury, when activated can release pre-stored serine proteases such as neutrophil elastase, cathepsin G and proteinase 3. An abundant release of these proteolytic enzymes in the alveolar compartment as well as the airways can trigger collateral pulmonary tissue damage. Indeed, much of the tissue destruction that characterizes non-cystic fibrosis bronchiectasis appears to be caused by serine proteases. The transitory pharmacological inhibition of bone marrow dipeptidyl peptidase 1 (DPP1), which converts neutrophil proteolytic enzymes into their mature active form, is a therapeutic possibility to decrease the constitutively produced serine protease pool of neutrophils. Brensocatib (also called INS-1007 or AZD-7986) is a potent reversible DPP1 inhibitor that has been successfully evaluated in a phase II trial as a treatment for non-cystic fibrosis bronchiectasis and, consequently, has been granted breakthrough therapy designation by the U.S. Food and Drug Administration and Priority Medicines (PRIME) designation by the European Medicines Agency.

Management of hypertension in COVID-19.

The ACE2 receptor plays a central role in severe acute respiratory syndrome coronavirus 2 host cell entry and propagation. It has therefore been postulated that angiotensin converting enzyme inhibitors and angiotensin receptor blockers may upregulate ACE2 expression and thus increase susceptibility to infection. We suggest that alternative anti-hypertensive agents should be preferred among individuals who may be exposed to this increasingly common and potentially lethal virus.