Rare Case of Immune-Mediated Necrotizing Myopathy With Isolated Dysphagia as Presenting Symptom

Introduction: Immune mediated necrotizing myopathy (IMNM) is a rare, but progressive disease that accounts for about 19% of all inflammatory myopathies. Dysphagia occurs in 20-30% of IMNM patients. It often follows proximal muscle weakness and ensues in the later stages of the disease. We report a rare case of IMNM, presenting with dysphagia as the initial symptom, followed by proximal muscle weakness. Case Description/Methods: A 74-year-old male with a past medical history of coronary artery disease, hypertension, and hyperlipidemia presented to the ED with 2-3 weeks of intractable nausea, vomiting, and dysphagia for solids and liquids. Vital signs were stable, and initial labs displayed an AST of 188 U/L and ALT of 64 U/L with a normal bilirubin. Computed tomogram of the chest, abdomen, and pelvis were negative. An esophagram showed moderate to severe tertiary contraction, no mass or stricture, and a 13 mm barium tablet passed without difficulty. Esophagogastroduodenoscopy exhibited a spastic lower esophageal sphincter. Botox injections provided no significant relief. He then developed symmetrical proximal motor weakness and repeat labs demonstrated an elevated creatine kinase (CK) level of 6,357 U/L and aldolase of 43.4 U/L. Serology revealed positive PL-7 autoxantibodies, but negative JO-1, PL-12, KU, MI-2, EJ, SRP, anti-smooth muscle, and anti-mitochondrial antibodies. Muscle biopsy did not unveil endomysial inflammation or MHC-1 sarcolemmal upregulation. The diagnosis of IMNM was suspected. A percutaneous endoscopic gastrostomy feeding tube was placed as a mean of an alternative route of nutrition. He was started on steroids and recommended to follow up with outpatient rheumatology. He expired a month later after complications from an unrelated COVID-19 infection. Discussion(s): The typical presentation of IMNM includes painful proximal muscle weakness, elevated CK, presence of myositis-associated autoantibodies, and necrotic muscle fibers without mononuclear cell infiltrates on histology. Dysphagia occurs due to immune-mediated inflammation occurring in the skeletal muscle of the esophagus, resulting in incoordination of swallowing. Immunotherapy and intravenous immunoglobulin are often the mainstay of treatment. Our patient was unique in presentation with dysphagia as an initial presenting symptom of IMNM, as well as elevated enzymes from muscle breakdown. It is critical as clinicians to have a high degree of suspicion for IMNM due to the aggressive nature of the disease and refractoriness to treatment.

Transverse myelitis 48 hours after the administration of an mRNA COVID 19 vaccine

Background Vaccinations against SARS-CoV-2 have been a topic of political, social, and medical intrigue since the declaration of the COVID-19 pandemic in early 2020. The vaccine side effects have been relatively mild to date, with few observed systemic effects. Case presentation A 69-year-old previously healthy female presented with symptoms of asymmetric bilateral lower and upper extremity weakness 2 days after vaccination with the Pfizer-BioNTech mRNA vaccine. MRI of the cervical spine revealed a non-compressive myelitis extending from C3-4 to T2-3. Common known causes of transverse myelitis were ruled out by diagnostic techniques. Conclusions Transverse myelitis is a rare autoimmune disorder that has been shown to have a temporal association with vaccination in the past. With a progressively partisan societal view on vaccinations, it is important for clinicians to remain vigilant on documenting potential associations without encouraging fear of causation.Copyright © 2021 The Author(s)

A case report of multiple sclerosis after COVID-19 infection: causality or coincidence?

Introduction: Since the declaration of COVID-19 pandemic, several cases of demyelination of both peripheral and central nervous systems have been reported. The association of viral infection and the development of CNS demyelination has long been studied, and this link has recently been reported following SARS-CoV-2 infection as well. Case report: We report a case of a 36-year-old male who developed CNS demyelinating disease, that fulfilled the diagnostic criteria of multiple sclerosis (MS), 2 months after laboratory-confirmed infection with SARS-CoV-2. Conclusion(s): To our knowledge, this is the second published case report of MS in association with COVID-19 infection, and the first case from Middle East and North Africa (MENA) region, adding to the growing literature of a probable causal relationship between SARS-CoV-2 infection and the development of MS.Copyright © 2021 The Author(s)

Emotional distress and quality of life among adults with developmental coordination disorder during COVID-19

Introduction: Individuals with developmental coordination disorder frequently report emotional and functional difficulties. A stressful era as COVID-19 pandemic may enhance emotional load. The present study aimed to (1) examine the emotional distress and quality of life among adults with developmental coordination disorder during COVID-19 as compared to typical controls, and (2) examine the relationships between these factors in adults with developmental coordination disorder. Method: Participants were 317 adults, aged 18–66, recruited during the first year of COVID-19: 227 were included in the developmental coordination disorder group, and 90 in the control group (normal motor performance) based on the Adult Developmental Co-ordination Disorders/Dyspraxia Checklist cutoff score. Participants completed a sociodemographic health status/daily life under COVID-19 questionnaire and self-reports about their emotional status (depression, anxiety, stress) and a quality of life. Results: The developmental coordination disorder group had significantly greater depression, anxiety, stress, and lower quality of life. Participants with developmental coordination disorder who were infected by COVID-19 or reported reduction of working hours due to COVID-19 had the lowest social and environmental quality of life. Depression significantly predicted reduced quality of life and mediated between developmental coordination disorder severity and quality of life. Conclusions: Prevention and intervention programs for adults with developmental coordination disorder should be elaborated, with reference to emotional load and to implications on daily life, especially in times of crisis, like COVID-19.

Evaluation of the reproducibility of the sentinel lymph node study in breast cancer, melanoma and cervical cancer

Aim/Introduction: Sentinel lymph node (SLN) biopsy is widely accepted for lymph node staging in breast cancer, intermediaterisk melanoma and low-grade cervical cancer. The reproducibility of lymphatic drainage is a fundamental premise behind this procedure, but it has not been sufficiently studied yet. The aim is to evaluate the reproducibility of the lymphoscintigraphy for SLN detection in breast cancer, melanoma and cervical cancer using SPECT/CT images. Material(s) and Method(s): Retrospective study from February/2009 to October/2021 that included 64 consecutive patients (36-81 y.o., 62+/-11 years, 60 female) who underwent SLN study on two consecutive occasions due to suspension of the surgical procedure for different reasons (insufficient fasting, respiratory infection, hypertension, coordination problems, COVID-19). Fifty-six had breast cancer, 6 had melanoma and 2 cervical cancer. The interval between the two studies was 1-112 days. Patients with previous breast surgery or excisional biopsy were excluded. The radiopharmaceutical used was 99mTc-nanocolloid by subdermal periareolar injection in breast cancer, in 4 points surrounding the surgical scar in melanoma and in 4 points in the cervix in cervical cancer. Planar images followed by SPECT/CT of the region were acquired. Result(s): In the 56 patients with breast cancer, 115 SLNs were detected in the first procedure (85 level I, 20 level II and level III and 2 in the internal mammary chain) and 120 SLNs in the second procedure (87 level I, 24 level II, 8 level III and 1 internal mammary chain). One patient did not show SLN uptake in the first study and 2 level I SLNs were observed in the second. Ninety-eight percent concordance was observed in the topography of the SLNs of the level I. In the 6 patients with melanoma (2 of the upper limbs, 2 of the lower limbs, one from the back and one from the head) 21 SLNs were detected. The topography of the SLN was concordant in all cases. In the 2 patients with cervical cancer, 6 nodes were detected (4 bilateral external iliac and 2 obturator nodes). One patient had bilateral SLNs in the first study and unilateral in the second. Conclusion(s): The technique showed high reproducibility in breast cancer and melanoma. Concordance was maintained even in patients who showed several SLNs, suggesting that the main determining factor is the individual variability of the lymphatic drainage, beyond possible differences in the technical conditions of the procedure. More data are needed for cervical cancer.

The Role of Vitamin D in the Prevention of Cephalgic Complications of Coronavirus Infection

The article is devoted to the study of vitamin D levels in patients who have had a coronavirus infection. As a result of the study, it was revealed that there is an inverse correlation between the severity of neurological complications after COVID-19 and the vitamin D content in the blood of patients who have undergone COVID-19, i.e. the lower the vitamin D content in the blood, the higher the probability of a severe course of postcovid neurological complications in the form of cephalgic syndrome. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Assessing technology needs and satisfaction of virtual appointments during the pandemic

Introduction: COVID-19 imposed constraints on in-person medical care, challenging pediatric diabetes care. Patients and healthcare providers (HCP) can benefit from telehealth virtual visits at this time. Objective(s): Assess the access to and utilization of technology as it relates to videoconferencing and telehealth services. Assess patient and HCP satisfaction with the current virtual care services offered. Method(s): A survey was sent to patients, primary caregivers, and HCP at the clinic. Questions related to technology access, usage, and satisfaction with virtual care. Interviews were then conducted with HCP. The baseline characteristics were summarized descriptive results relating to technology access and usage were included, along with mean and median satisfaction scores. Answers to the open-ended questions and interviews were transcribed and analyzed using theme analysis. Result(s): Response rate was highest among patients with HbA1C of 7- 7.9% and lowest with HbA1C > 10%. Access to appropriate technology was high, patient and HCP satisfaction with virtual care was high. Patients preferred virtual education focused visits and in-person clinical visits. Benefits to virtual care include convenience, efficiency, money saving and challenges include lack of physical exam, excess coordination, lack of personal connection, technology issues, increased administrative burden on the HCP and a decrease in interprofessional collaboration. HCP prefer to continue with virtual care with 30%-80% of their practice. Conclusion(s): Virtual care appointments were satisfactory with few technology concerns. Participants in study were high income, high education, and spoke English. Suggestions to improve virtual care from the HCP and patient perspective were provided to include a technology support team, appointment reminders, notification for delayed appointments & better organization of blood requisitions. Further evaluation required assessing clinical outcomes of virtual care, needs of patients with language barriers, low-income & higher HbA1C.

LIPOID PNEUMONIA DUE TO PHARYNGOESOPHAGEAL DYSPHAGIA CAUSING PARAFFIN BRONCHOASPIRATION

TYPE: Case Report TOPIC: Occupational and Environmental Lung Diseases INTRODUCTION: We present a case of exogenous lipoid pneumonia caused by paraffin broncoaspiration due to pharyngoesophageal motor dysphagia. CASE PRESENTATION: A 57 year old female consulted for diarrhea. She had a previous history of ischemic stroke related to hypercoagulability syndrome, causing oropharyngeal dysphagia due to pharyngo-esophageal motor incoordination. Owing to possible neurogenic dysfunction she also presented megadolichocolon with chronic diarrhea-constipation syndrome. Due to the epidemiological situation caused by SARS-COV2, a chest X-ray was performed showing increased density of the right middle lobe. The control X-ray exhibited a persistence of this alteration, therefore a thoracic tomographic study was performed (findings included in image), as well as a bronchoalveolar lavage. The bronchoalveolar lavage fluid was initially turbid white which, posterior to resting, revealed a superficial layer of fat, supporting the diagnosis of lipoid pneumonia. The patient was subsequently interrogated. She associated the consumption of oily materials from herbalists and paraffin in order to palliate her constipation symptoms, which in relation to her esophageal motor-pharyngeal incoordination produced bronchoaspiration of the referred oily material. DISCUSSION: Oily substance ingestion was suspended. Subsequently she underwent a corticosteroid treatment and is currently under clinical control. CONCLUSIONS: The ground glass pattern is a finding that causes a wide differential diagnosis in the radiological study, therefore it is of great importance to take an adequate clinical history and to take into account the motor dysfunctions related to swallowing, due to the high consumption of herbalist products that contain oily materials that can cause exogenous lipoid pneumonia. DISCLOSURE: Nothing to declare. KEYWORD: Exogenous_Lipoid_Pneumonia

Challenges and proposed solutions in making clinical research on COVID-19 ethical. a status quo analysis across german research ethics committees

Background: In the course of the COVID-19 pandemic, the biomedical research community's attempt to focus the attention on fighting COVID-19, led to several challenges within the field of research ethics. However, we know little about the practical relevance of these challenges for Research Ethics Committees. Methods: We conducted a qualitative survey across all 52 German Research Ethics Committees on the challenges and potential solutions with reviewing proposals for COVID-19 studies. We de-identified the answers and applied thematic text analysis for the extraction and synthesis of challenges and potential solutions that we grouped under established principles for clinical research ethics. Results: We received an overall response rate of 42%. The 22 responding Research Ethics Committees reported that they had assessed a total of 441 study proposals on COVID-19 until 21 April 2020. For the review of these proposals, the Research Ethics Committees indicated a broad spectrum of challenges regarding (1) social value (e.g. lack of coordination), (2) scientific validity (e.g. provisional study planning), (3) favorable risk-benefit ratio (e.g. difficult benefit assessment), (4) informed consent (e.g. strict isolation measures), (5) independent review (e.g. lack of time), (6) fair selection of trial participants (e.g. inclusion of vulnerable groups), and (7) respect for study participants (e.g. data security). Mentioned solutions ranged from improved local/national coordination, over guidance on modified consent procedures, to priority setting across clinical studies. Conclusion: Research Ethics Committees are facing a broad spectrum of pressing challenges in reviewing COVID-19 studies. Some challenges for consent procedures are well-known from research in intensive care settings but are further aggravated by infection measures. Other challenges such as reviewing several clinical studies at the same time that potentially compete for the recruitment of in-house COVID-19 patients are unique to the current situation. For some of the challenges, the proposed solutions in our survey could relatively easy be translated into practice. Others need further conceptual and empirical research. Our findings together with the increasing body of literature on COVID-19 research ethics, and further stakeholder engagement should inform the development of handson guidance for researchers, funders, Research Ethics Committees, and further oversight bodies.