Initial COVID-19 Severity and Long-COVID Manifestations: An Observational Analysis

OBJECTIVE: New-onset or persistent symptoms beyond after 4 weeks from COVID-19 are termed "long-COVID." Whether the initial severity of COVID-19 has a bearing on the clinicoradiological manifestations of long COVID is an area of interest. MATERIAL AND METHODS: We did an observational analysis of the long-COVID patients after categorizing them based on their course of COVID-19 illness into mild, moderate, and severe groups. The clinical and radiological profile was compared across these groups. RESULT(S): Out of 150 long-COVID patients recruited in the study, about 79% (118), 14% (22), and 7% (10) had a history of mild, moderate, and severe COVID-19, respectively. Fatigue (P = .001), breathlessness (P = .001), tachycardia (P = .002), tachypnea (P < .001), raised blood pressure (P < .001), crepitations (P = .04), hypoxia at rest (P < .001), significant desaturation in 6-minute walk test (P = .27), type 1 respiratory failure (P = .001), and type 2 respiratory failure (P = .001) were found to be significantly higher in the long-COVID patients with a history of severe COVID-19. These patients also had the highest prevalence of abnormal chest X-ray (60%) and honeycombing in computed tomography scan thorax (25%, P = .027). CONCLUSION(S): The course of long COVID bears a relationship with initial COVID-19 severity. Patients with severe COVID-19 are prone to develop more serious long-COVID manifestations.Copyright © Author(s).

Severe COVID-19 as a Possible Mediator of Autoimmunity and Sjögren's Syndrome.

We treated a 65-year-old man for COVID-19 who was hospitalized urgently due to life-threatening respiratory decompensation and later developed cardiac arrest, both of which were successfully treated. Three days prior to the patient's urgent hospitalization, he had a high fever of over 38.0°C. Viral infection was diagnosed by polymerase chain reaction (PCR) on the day of admission, which was negative on the 11th day. Blood analysis on the second day was strongly positive for COVID-19 IgG antibodies, which continued for one year. Because of the acute increase in viral IgG antibodies, we performed other immunological analyses; Sjögren's syndrome antigen A (SS-A) and Sjögren's syndrome antigen B (SS-B) antibodies were positive, although he had no history of autoimmune diseases. Subsequent salivary-gland biopsy and pathological analysis confirmed the diagnosis of Sjögren's syndrome. The severe clinical manifestations and early antibody seroconversion in this case suggest COVID-19 as a mediator of autoimmunity and Sjögren's syndrome.

Bronchopulmonary Fistula Development in an Elderly Male With COVID-19 Infection.

COVID-19 pneumonia can cause a wide range of complications including pneumothorax and empyema. However, in severe cases, it can lead to bronchopulmonary fistula (BPF) formation and a persistent air leak due to a connection between the pleural space and the bronchial tree. We report the case of a 77-year-old man with a history of hypertension, who presented to the emergency department for evaluation of dyspnea. Admission labs were significant for a positive rapid antigen SARS-Cov-2 test and elevated troponin I. A chest x-ray demonstrated patchy interstitial opacification and ground glass appearance bilaterally. Within the first 24 hours of presentation, the patient developed a right-sided spontaneous pneumothorax and had a 14 French pigtail catheter placed. The patient subsequently developed a persistent air leak after chest tube placement and required video-assisted thoracoscopic surgery (VATS) with talc pleurodesis and a 32 French chest tube placement. In this unique case, we describe an elderly patient's experience of bronchopulmonary fistula formation as a complication of COVID-19 pneumonia and the successful management of this complication with VATS.

Randomized Open Investigation Determining Steroid Dose in Severe COVID-19: The ROIDS-Dose Clinical Trial.

Introduction Treatment with dexamethasone reduces mortality in patients with coronavirus disease 2019 (COVID-19) pneumonia requiring supplemental oxygen, but the optimal dose has not been determined. Objective To determine whether weight-based dexamethasone of 0.2 mg/kg is superior to 6 mg daily in reducing 28-day mortality in patients with COVID-19 and hypoxemia. Materials and methods A multicenter, open-label, randomized clinical trial was conducted between March 2021 and December 2021 at seven hospitals within Northwell Health. A total of 142 patients with confirmed COVID-19 and hypoxemia were included. Participants were randomized in a 1:1 ratio to dexamethasone 0.2 mg/kg intravenously daily (n = 70) or 6 mg daily (n = 72) for up to 10 days. Results There was no statistically significant difference in the primary outcome of 28-day all-cause mortality with deaths in 12 of 70 patients (17.14%) in the intervention group and 15 of 72 patients (20.83%) in the control group (p = 0.58). There were no statistically significant differences among the secondary outcomes. Conclusion In patients with COVID-19 and hypoxemia, the use of weight-based dexamethasone dosing was not superior to dexamethasone 6 mg in reducing all-cause mortality at 28 days. Clinical trial registration This study was registered under ClinicalTrials.gov (identifier: NCT04834375).

The Impact of Elexacaftor/Ivacaftor/Tezacaftor on Cystic Fibrosis Patients Who Acquire COVID-19 Infection.

The combination of medication containing elexacaftor, ivacaftor, and tezacaftor (EIT) has dramatically impacted the treatment and prognosis for patients with cystic fibrosis (CF). Lung function, weight, and self-reported quality of life have improved for many of these patients, but little is known about whether this treatment will have a beneficial effect in preventing morbidity and/or mortality from respiratory infections such as COVID-19. EIT received Food and Drug Administration (FDA) approval shortly before the first cases of COVID-19 appeared in the United States. We performed an analysis using the TriNetX (Cambridge, MA, USA) research database to determine if patients being treated with EIT who became infected with COVID-19 experienced significantly different outcomes compared to patients who were not receiving it.

A Puzzling Diagnosis of Cerebral Vein Thrombosis in a COVID-19-Vaccinated Patient.

Cerebral vein thrombosis (CVT) is a rare condition equivalent to deep vein thrombosis of the intracranial veins. Delayed diagnosis will result in severe and disabling complications. We report a case of a 59-year-old man with CVT with no significant past medical or surgical history. On admission, he reported right-sided numbness and weakness concerns, preceded by the sudden onset of bilateral vision loss and dysarthria. Magnetic resonance imaging and computed tomography scans confirmed the diagnosis of CVT. The most interesting relative risk factor was flying overseas twice a month for the last 10 years; each flight was longer than eight hours. Another possible contributing factor to our patient's condition was polycythemia, with a hemoglobin level of 19, but the most questionable and puzzling is the recent coronavirus disease 2019 (COVID-19) vaccination two months, eight months, and one year prior to admission. Our case highlights a rare COVID-19 vaccine-related CVT diagnosis and that close monitoring for new symptoms and signs is vital to prevent life-threatening complications, herniation, and hemorrhagic transformation.

Effect of Intubation Timing on the Outcome of Patients With Severe Respiratory Distress Secondary to COVID-19 Pneumonia.

Background The optimal timing of intubation for critically ill patients with severe respiratory illness remains controversial among healthcare providers. The coronavirus disease 2019 (COVID-19) pandemic has raised even more questions about when to implement this life-saving therapy. While one group of providers prefers early intubation for patients with respiratory distress because these patients may deteriorate rapidly without it, other providers believe that intubation should be delayed or avoided because of its associated risks including worse outcomes. Research question Our objective was to assess whether the timing of intubation in patients with severe COVID-19 pneumonia was associated with differences in mortality or other outcomes. Study design and methods This was a single-center retrospective observational cohort study. We analyzed outcomes of patients who were intubated secondary to COVID-19 pneumonia between March 13, 2020, and December 12, 2020, at Henry Ford Hospital in Detroit, Michigan. Patients were categorized into two groups: early intubated (intubated within 24 hours of the onset of severe respiratory distress) and late intubated (intubated after 24 hours of the onset of severe respiratory distress). Demographics, comorbidities, respiratory rate oxygenation (ROX) index, sequential organ failure assessment (SOFA) score, and treatment received were compared between groups. The primary outcome was mortality. Secondary outcomes were ventilation time, intensive care unit stay, hospital length of stay, and discharge disposition. Post hoc and Kaplan-Meier survival analyses were performed. Results A total of 110 patients were included: 55 early intubated and 55 late intubated. We did not observe a significant difference in overall mortality between the early intubated (43%) and the late intubated groups (53%) (p = 0.34). There was no statistically significant difference in patients' baseline characteristics including SOFA scores (the early intubation group had a mean score of 7.5 compared to 6.7 in the late intubation group). Based on the ROX index, the early intubation group had significantly more patients with a reduced risk of intubation (45%) than the late group (27%) (p = 0.029). The early intubation group was treated with a high-flow nasal cannula at a significantly lower rate (47%) than the late intubation group (83%) (p < 0.001). Significant differences in patient baseline characteristics, treatment received, and other outcomes were not observed. Post hoc analysis adjusting for SOFA score between 0 and 9 revealed significantly higher mortality in the late intubation group (49%) than in the early intubation group (26%) (p = 0.03). Patients in the 0 to 9 SOFA group who were intubated later had 2.7 times the odds of dying during hospital admission compared to patients who were intubated early (CI, 1.09-6.67). Interpretation The timing of intubation for patients with severe COVID-19 pneumonia was not significantly associated with overall mortality or other patient outcomes. However, within the subgroup of patients with SOFA scores of 9 or lower at the time of intubation, patients intubated after 24 hours of the onset of respiratory distress had a higher risk of death than those who were intubated within 24 hours of respiratory distress. Thus, patients with COVID-19 pneumonia who are not at a high level of organ dysfunction may benefit from early mechanical ventilation.

A Case of Severe Acute Pancreatitis Secondary to COVID-19 Infection in a 30-Year-Old Male Patient.

A 30-year-old male with no significant medical history presented to the emergency department with complaints of fever, two days of intermittent abdominal pain, dry cough, nausea, vomiting, four days of diarrhea, and worsening dyspnea. Initial evaluation revealed a fever of (102.5 F) and tachycardia (114/min) with hypoxia (SaO2: 84% on room air) and bilateral wheezing on lung auscultation. X-ray of the chest revealed bilateral and peripheral ground-glass and consolidative pulmonary opacities. CT scan of the abdomen was notable for interstitial edema, mild inflammatory changes, and homogenous enhancement of the pancreatic parenchyma. His COVID-19 test came positive, and he was admitted to the intensive-care unit. He was managed symptomatically, and improvement in his clinical condition was observed after three days of admission. This case highlights a possible association between Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), abdominal pain secondary to acute pancreatitis, and the need for meticulous clinical evaluation in patients presenting with gastrointestinal complaints.

Use of Dexmedetomidine in Early Prone Positioning Combined With High-Flow Nasal Cannula and Non-Invasive Positive Pressure Ventilation in a COVID-19 Positive Patient.

As the COVID-19 pandemic continues to manifest in our society, we still lack evidence-based treatment guidelines. Current treatment for COVID-19 pneumonia has been modeled from currently established guidelines such as that of acute respiratory distress syndrome (ARDS). COVID-19 pneumonia, also known as SARS-CoV-2, is characterized by severe hypoxia and near-normal respiratory system compliance with a time-related presentation. Dexmedetomidine is a centrally acting alpha-2 receptor agonist that promotes sedative and anxiolytic effects without the risk of respiratory depression and can provide cooperative or semi-rousable sedation. Patients who are developing ARDS secondary to COVID-19 pneumonia have been treated with self-proning intervals in combination with supplementation of oxygenation via high-flow nasal cannula (HFNC) or non-invasive positive pressure ventilation (NIPPV); however, a few patients have poor tolerance to the devices, leading to poor compliance and eventual worsening respiratory symptoms leading to intubation. In the current case report, we detail how a patient was able to successfully be self-proned with proper tolerance to HFNC and NIPPV while using dexmedetomidine, leading to discharge without the need for further oxygen supplementation at home.

Heterogeneous Perfusion in COVID-19 and High Altitude Pulmonary Edema: A Review of Two Cases Followed by Implications for Hypoxic Pulmonary Vasoconstriction, Thrombosis Development, Ventilation Perfusion Mismatch and Emergence of Treatment Approaches.

Coronavirus disease 2019 (COVID-19) has been compared to high altitude pulmonary edema (HAPE). Multiple similarities between the two conditions were drawn in the past. This article seeks to further clarify potential underlying mechanisms related to hypoxia and pulmonary vascular responses. It does so by looking at perfusion imaging of patients with COVID-19 and comparing them with patterns observed in HAPE and hypoxic exposure. Two separate clinical cases are reviewed. The salient aspect of each case that is emphasized is the perfusion scintigraphy results that revealed heterogeneous perfusion patterns in both patients. Heterogeneous or non-homogeneous perfusion is also observed in HAPE. A detailed clinical course of each patient is described. Medications utilized to treat the conditions are outlined as well as laboratory parameters and clinical findings. Interestingly, both of these patients were treated with calcium channel blockers and this class of medications is utilized to prevent HAPE as well. Discussion following the case presentations attempts to contextualize possible implications of this and other studies on the broader pathophysiology of COVID-19 disease. Findings related to pathophysiologic patterns and treatment strategies are also described. Micro-thrombi formation has been reported in both COVID-19 and HAPE as well and may be an accessory complication of perfusion compromise. In a separate study, vasodilatation with calcium channel blocker (CCB) therapy has been associated with improved mortality in COVID-19 and potential pathophysiologic mechanisms were previously presented. This case report provides further clinical findings that support the notion that perfusion deficits are an integral component of hypoxia in COVID-19. It also advances the basis for use of vasodilator therapy as part of treatment regimens in COVID-19. Vasodilators may improve micro-perfusion. In this way, oxygenation may be promoted by decreasing impedance and improving flow via the alveolar-capillary unit.

Humidifier Use and Prone Positioning in a Patient with Severe COVID-19 Pneumonia and Endotracheal Tube Impaction Due to Highly Viscous Sputum.

COVID-19 can lead to severe pneumonia, requiring mechanical ventilation. While increased sputum secretion could cause airway obstruction during mechanical ventilation, there are few reported cases in the literature. We report a case of a 65-year-old man with diabetes and severe COVID-19 pneumonia requiring mechanical ventilation and treated with hydroxychloroquine, azithromycin, nafamostat, and prone positioning. Initially, mechanical ventilation consisted of a heat moisture exchanger, endotracheal tube aspiration, and subglottic secretion drainage using a closed suction system. However, endotracheal tube impaction by highly viscous sputum occurred during this mechanical ventilation system. Replacing the endotracheal tube, the use of a humidifier instead of a heat moisture exchanger, and prone positioning contributed to the patient being weaned off mechanical ventilation. Although anti-aerosol measures are important for severe COVID-19 pneumonia, attention should be given to potential endotracheal tube impaction during mechanical ventilation.