Trends in eyebrow makeup after COVID-19 and long-COVID era.

Background and Objectives: The coronavirus disease-19 (COVID-19) pandemic, which began in 2019, is threatening millions of people around the world. Coronavirus, a severe acute respiratory syndrome, made it mandatory to wear masks, it was carried out through public awareness and review of changes in cosmetics. Methods: This literature review paper was written by referring to keywords such as "Eyebrow," "Permanent Make-up," "Microblading," "Make-up," and "COVID-19." The study selected a total of 485 references using representative journal search sites such as PubMed, Google Scholar, ResearchGate, RISS, DBPia, and CrossRef, of which a total of 43 papers were selected at the final stage from 2000 to 2022 using PRISMA flow diagram. Results: With the wearing of a mask due to COVID-19, we are paying attention to the change in the makeup trend caused by the preference for easy eye makeup. Conclusions: This narrative review understands that eyebrow makeup has a significant impact on human images due to changes in makeup methods after the COVID-19 pandemic. It is expected to be used as important data for the rapidly growing semi-permanent makeup market.

Multisystem inflammatory syndrome associated with COVID-19 in children: Risk factors of severe life-threatening course of the disease

Background/Purpose: Multisystem inflammatory syndrome in children (MIS-C), associated with COVID-19 infection is a life-threatening condition, required intensive care. The aim of this study was to determine risk factors for severe/life-threatening course of MIS-C. Method(s): The retrospective study included 166 children (99 male, 67 female), aged from 4 months to 17 years (median 8.2 years), who met the WHO criteria for MIS-C. The criterion of severity was the fact of the ICU admission. The analysis of the obtained data was performed using the STATISTICA software package, version 10.0 (StatSoft Inc., USA). Result(s): To assess the factors associated with the severe course of MIS-C, patients were divided into two groups: those who were hospitalized in the ICU (n = 84;50.6%), and those who did not (n = 82;49.4%). Patients with a more severe course of MIS-C were significantly older. They had a high frequency of signs such as rash, edema, hepatomegaly, splenomegaly, neurological and respiratory symptoms. Hypotension/shock and myocardial damage were much more common in patients hospitalized in the ICU. Among the laboratory changes there were significant differences in the levels of hemoglobin, leukocytes and platelets, CRP, creatinine, troponin and D-dimer. The presence of macrophage activation syndrome was higher in patients, admitted in the ICU. Children, required intensive care required high dose corticosteroids and IVIG more often (table 1). FIGURE: 1) The first symptoms of progeria in infancy: scleroderma-like changes in the skin of the lower extremities and stiffness of knee joints at the age of 2 months. 2) Girl at the age of 3 years 5 months. Almost total alopecia with the absence of eyebrows and eyelashes. Pronounced venous pattern in the forehead, nasal bridge and nasolabial triangle. Conclusion(s): MIS-C is potentially a severe life-threatening condition, in which more than half (50.6%) of patients needed the ICU admission. The main factors determining the severity of MIS-C were: cardiovascular, resiratory and central nervous system disorders. It has been found that factors such as hepatomegaly, splenomegaly, D-dimer >2568 ng/ml, troponin >10 pg/ml, make it possible to identify a group of patients with high risk of severe MIS-C who may potentially need hospitalization in the ICU.

SEVERE HYPONATREMIA AS A MANIFESTATION OF A NEUROLOGIC DISORDER ASSOCIATED WITH THE COVID-19 VACCINE

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: More reports are indicating a temporal association between Bell's palsy and the mRNA vaccine for coronavirus disease 2019 (COVID-19). Therefore, collecting vaccine history is becoming important in post-marketing surveillance to monitor the safety of vaccines in real-world settings. We report the case of concomitant occurrence of Bell's palsy and glossopharyngeal neuralgia leading to severe symptomatic hyponatremia in a previously healthy patient. CASE PRESENTATION: A 60 year-old-female without significant medical history presented to the hospital with odynophagia, and generalized weakness for two weeks. She decreased her oral intake due to stabbing pain in the back of her throat triggered by swallowing. She reported hyperacusis and frequent shooting pain in the left cheek managed with non-steroidal anti-inflammatory drugs. The symptoms occurred several days after the first dose of the mRNA vaccine for COVID-19. She denied previous COVID-19 infection and herpes zoster. Examination revealed dry mucosa, left facial muscle weakness, inability to raise the left eyebrow or lift the labial commissure, effacement of the nasolabial fold, and left-sided frontal wrinkles. Laboratory investigation revealed sodium of 110. Computerized Tomography of the brain revealed negative findings for intracranial abnormalities. Severe symptomatic hyponatremia was managed with hypertonic saline. The neurologist made the diagnosis of Bell's palsy and glossopharyngeal trigeminal neuralgia leading to poor oral intake. We initiated acyclovir, prednisone, and gabapentin. The patient recovered from hyponatremia and experienced improvement of neurological symptoms with initiated medications. DISCUSSION: High morbidity and mortality of patients with COVID-19 accelerated the development and production of the vaccines. During the pandemic, mRNA COVID-19 vaccines reduced asymptomatic and prevented severe symptomatic COVID-19 infection and its complications. Although the benefits and protective effects of the COVID-19 vaccines outweighed the risks associated with them, we have reports of associations between vaccines and certain disorders such as Bell's palsy. Glossopharyngeal neuralgia is defined as sudden severe brief pain in the distribution of the glossopharyngeal nerve. It can be described as transient stabbing pain experienced in the ear, tonsillar fossa, and base of the tongue. Unusual presentation is fear to eat as this can be a precipitating cause of the pain. It overlaps with trigeminal neuralgia and can create a diagnostic dilemma. CONCLUSIONS: In summary, it is unknown what causal relationship exists between the mRNA COVID-19 vaccine and neurological diseases such as Bell's palsy and glossopharyngeal neuralgia. Glossopharyngeal neuralgia is frequently overlooked as a diagnosis. This is a unique case of concomitant glossopharyngeal neuralgia and Bell's palsy that is coincidental with a history of COVID-19 vaccine. Reference #1: El Sahly HM, Baden LR, Essink B, et al. Efficacy of the mRNA-1273 SARS-CoV-2 Vaccine at Completion of Blinded Phase. New England Journal of Medicine. 2021;385(19):1774-1785. doi:10.1056/NEJMoa2113017 Reference #2: Singh PM, Kaur M, Trikha A. An uncommonly common: Is glossopharyngeal neuralgia. Ann Indian Acad Neurol. 2013;16(1):1-8. doi:10.4103/0972-2327.107662 Reference #3: Cellina M, D'Arrigo A, Floridi C, Oliva G, Carrafiello G. Left Bell's palsy following the first dose of mRNA-1273 SARS-CoV-2 vaccine: A case report. Clin Imaging. 2022;82:1-4. doi:10.1016/j.clinimag.2021.10.010 DISCLOSURES: No relevant relationships by Nemanja Draguljevic No relevant relationships by Katherine Hodgin No relevant relationships by Kristina Menchaca No relevant relationships by Catherine Ostos Perez

BUT WHAT ABOUT THE RASH?

SESSION TITLE: Severe and Unusual Blastomycosis Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: This is a case of a patient 74-year-old immunosuppressed woman presenting with a one-week history of skin lesions. CASE PRESENTATION: A 74-year-old woman with Crohn's disease (on weekly adalimumab);pulmonary hypertension (RVSP 76 mmHg);OHS/OSA, on home BPAP 17/7 cmH2O;and morbid obesity presented with a one-week history of skin lesions. She was seen by her primary care physician two days prior with skin lesions, shortness of breath, and decreased vision. She was hypoxic during the visit and given doxycycline for empiric treatment of pneumonia. She denied recent travel or exposure to animals. On admission, she was afebrile (36.9C) and saturating 98% on 2 L nasal cannula. She appeared chronically ill with mouth ulcers and an eroded nodule with overlying hemorrhagic crusting and peripheral pustular area above her right eyebrow (figure 1). Throughout her skin, she had multiple erythematous papules, some with overlying vesicles/pustules. Labs were significant for a leukocytosis of 19.3 with left shift, lactate of 3.5, serum creatinine of 1.9 (likely higher than patient's previous baseline of 1.7 with previous history of recurrent AKIs on CKD), elevated inflammatory markers, and normal ALT/AST. Influenza and COVID were negative. A CT chest showed consolidations and numerous pulmonary nodules highly suspicious for an infectious or inflammatory process (figure 2). She was treated empirically with vancomycin, piperacillin-tazobactam, valacyclovir, and amphotericin B, the latter given the concern of blastomycosis. During her hospitalization, she had further respiratory failure requiring intubation and multiorgan failure. Disseminated blastomycosis was confirmed via a skin biopsy which demonstrated pyogranulomatous inflammation with numerous broad-based budding yeasts (figure 3) and supported with a bronchoalveolar lavage (BAL) culture growing the same. Given her continued decline, her medical decision maker decided to transition the patient to hospice care. DISCUSSION: Blastomycosis is a systemic pyogranulomatous infection that is caused from the inhalation of the conidia form of the dimorphic fungus. It can manifest as asymptomatic infection, acute or chronic pneumonia, or extrapulmonary disease. BAL yields a positive diagnosis in 92% of patients and definitive diagnosis requires growth of the organism from a clinical specimen. Without appropriate treatment of amphotericin B or one of the azole antifungals, the disease had a 90% mortality rate. CONCLUSIONS: Prompt recognition of multiorgan failure secondary to blastomycosis is important for early treatment and improved survival in immunocompromised patients Reference #1: 1)Chapman, S W et al. "Endemic blastomycosis in Mississippi: epidemiological and clinical studies.” Seminars in respiratory infections vol. 12,3 (1997): 219-28. Reference #2: 2)Saccente, Michael, and Gail L Woods. "Clinical and laboratory update on blastomycosis.” Clinical microbiology reviews vol. 23,2 (2010): 367-81. doi:10.1128/CMR.00056-09 Reference #3: 3)Chapman, Stanley W et al. "Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America vol. 46,12 (2008): 1801-12. doi:10.1086/588300 DISCLOSURES: No relevant relationships by Jennifer Duke No relevant relationships by Ashley Egan

New Diagnosis of Myasthenia Gravis in the Setting of COVID-19 Infection

Objective: To report a patient presenting with bulbar symptoms in the setting of COVID-19 infection leading to a new diagnosis of Myasthenia Gravis. Background: There have been many reports of neurological complications in patients with COVID-19 infection including Guillain Barre syndrome, Bell's palsy and transverse myelitis. There are limited case series describing the effects of COVID-19 in patients with known Myasthenia Gravis, but there have only been rare reports of new onset Myasthenia Gravis in the setting of COVID-19 infection. Design/Methods: Electronic medical records of the patient were reviewed. Results: 78 year old man presented to the hospital with new onset of dysphagia, dysarthria, bilateral ptosis and left facial droop. The patient was given intravenous alteplase for possible stroke. On admission the patient also tested positive for COVID-19. His symptoms persisted post-alteplase. On exam he was noted to have fatigable ptosis, weakness of brow elevation, eye closure, horizontal movements of the tongue and intermittent dysarthria, raising the concern for myasthenia gravis. A trial of Mestinon led to improved symptoms. Serum acetylcholine receptor antibodies were positive, confirming the Myasthenia Gravis diagnosis. He received 5 sessions of intravenous immunoglobulin (IVIG) due to persistent bulbar symptoms. He initially responded well to treatment but later decompensated with respiratory failure requiring intubation. He was then treated with plasmapheresis for 5 days with symptom improvement and was successfully extubated. Conclusions: Our patient with a new diagnosis of myasthenia gravis with simultaneous COVID-19 infection eventually progressed into myasthenic crisis. This case raises the possibility of myasthenia and/or myasthenic crisis being a neurological complication of COVID-19 infection. Mechanisms behind this have been postulated to include molecular mimicry, the inflammatory cascade of COVID-19 leading to immune dysregulation, or viral illness triggering previously asymptomatic patients. Awareness of new onset myasthenia associated with COVID-19 infection can lead to earlier diagnosis and treatment.

Anatomical Proposal for Botulinum Neurotoxin Injection for Glabellar Frown Lines.

Botulinum neurotoxin injection for treating glabellar frown lines is a commonly used method; however, side effects, such as ptosis and samurai eyebrow, have been reported due to a lack of comprehensive anatomical knowledge. The anatomical factors important for the injection of the botulinum neurotoxin into the corrugator supercilii muscle has been reviewed in this study. Current understanding on the localization of the botulinum neurotoxin injection point from newer anatomy examination was evaluated. We observed that for the glabellar-frown-line-related muscles, the injection point could be more accurately demarcated. We propose the injection method and the best possible injection sites for the corrugator supercilii muscle. We propose the optimal injection sites using external anatomical landmarks for the frequently injected muscles of the face to accelerate effective glabellar frown line removal. Moreover, these instructions would support a more accurate procedure without adverse events.

eP455: Fetal ultrasound presentation and neonatal diagnosis of Freeman-Sheldon syndrome in son of previously undiagnosed adult male

Background: Freeman-Sheldon syndrome [distal arthrogryposis type 2A (OMIM #193700), DA2A, Freeman-Burian syndrome] is a rare autosomal dominant multiple pterygium syndrome caused by alterations in MYH3. The phenotypic features, particularly of the face, are distinct and easily recognizable, and the diagnosis can be confirmed with molecular gene analysis. Fetal ultrasound imaging may provide important diagnostic clues to facilitate the diagnostic process. Informed consent and parental permission were provided by the parents. Case presentation: The infant’s mother presented for a Maternal Fetal Medicine genetic counseling telehealth appointment (due to COVID-19 pandemic restrictions) as a G7P2132, 32-year old female who had insulin-dependent diabetes and thrombocytosis. Her partner was a 24-year old male with a history of hearing loss, a V-shaped palate, and a lower lip cleft. Gestational age was 14 4/7 weeks and the indications were: increased nuchal translucency, paternal complex medical history, maternal G6PD heterozygote, and recurrent pregnancy loss. During the genetic counseling session, the following were addressed: 1) Maternal heterozygote status for G6PD indicated that if the fetus was male, there was a 50% chance he would be affected with G6PD-deficiency;2) Increased nuchal translucency on fetal ultrasound (US) with measurement at 98th percentile is associated with an increased risk of chromosomal abnormalities, microdeletion/duplications, and Noonan syndrome. The patient reportedly had low risk cell-free DNA but results were not available to the counselor at the time of consult. The option for additional genetic screening and diagnostic testing was declined;3) Three first trimester pregnancy losses with the father of this baby (FOB) were addressed, and parents deferred chromosome analyses at the time;4) Mother shared FOB’s complex history of bilateral sensorineural hearing loss, V-shaped cleft palate, lower lip cleft, and micrognathia. However, father was not present during the telehealth encounter. Mother was counseled regarding the possibility of an autosomal dominant condition with the potential risk to the pregnancy of up to 50%. It was recommended that the FOB have a clinical genetics evaluation, which could potentially provide a specific diagnosis and inform recurrence risk and management guidance. Follow-up MFM genetic counseling telephone visit occurred with the mother at 31 6/7 weeks gestation due to multiple congenital anomalies evident on fetal ultrasound. A 25 week fetal ultrasound revealed hypotelorism and a thickened nuchal translucency. A repeat study at 29 weeks revealed a V-shaped palate with a possible cleft, micrognathia, and midline mandibular cleft. FOB’s history was revisited. It was determined that he had 3 previous “no shows” to Genetics clinic appointments and did not pursue evaluation after the last counseling appointment. Again, it was emphasized that in order to best make a diagnosis for the family, an affected person would need to undergo a thorough evaluation, including medical and family history review, physical examination, and any indicated genetic testing. The parents were comfortable with the likelihood that the baby had the same condition as the father, but variable expressivity and broad range pf phenotypic presentation were explained. Recommendations for postnatal evaluation of the infant and pertinent genetic testing were provided. Consultative Genetics evaluation of the infant at 2 days of age revealed a short, broad forehead with supraorbital fullness leading to a horizontal brow indentation;mask-like facial appearance;hypotelorism;very deep set eyes with blepharophimosis;deep, creased nasal bridge;small, upturned nose with hypoplastic alae and narrow nares;microstomia with pursed lips;glossoptosis;micrognathia;2 deep vertical chin creases;short neck with excess nuchal skin;inverted and wide spaced nipples;clenched hands with 5th digits overlying 4th and 2nd overlying 3rd, bilaterally;bilateral vertical talus;2nd toes longer and overlying rd toes;clinodactyly of 4th and 5th toes bilaterally;and deep gluteal crease with no visible sinus. There were no evident contractures. The father has a complex history with no medical assessments prior to age 18. He reported that he did “not look like anyone else” in his family. He has a diagnosis of autistic spectrum disorder, a submucous cleft, vision issues, hearing loss necessitating a hearing aid on the left, and a history of cholesteatomas and of mastoidectomy. On brief examination, he had a mask-like face, blepharophimosis, left microphthalmia, left esotropia, narrowing of his midface, deep vertical crease on the mandibular region, microstomia, broad great toes, single flexor creases on the thumbs, and contracture of right thumb. Maxillofacial CT of the infant revealed hypoplastic mandibular body, ramus, and condyles bilaterally with micrognathia and retrognathia;hypoplastic maxilla bilaterally;and enophthalmos with retracted appearance of globes in the bony orbits bilaterally. Multiple facial bone abnormalities were seen, including microsomia, micrognathia, retrognathia, orbital hypotelorism and enophthalmos Genetic testing was performed via a custom Whole Exome Slice at GeneDx laboratories and included the MYH3 and TNNI2 genes. Results revealed a heterozygous pathogenic change in MYH3 (c.2015 G>A;p. R6724) consistent with the diagnosis of Freeman-Sheldon syndrome. Conclusion: The presentation of “midline mandibular cleft” on fetal ultrasound was the most specific prenatal finding. This is a very rare fetal finding. Thus, it should prompt further evaluation to assess for true clefting versus ridging or creasing. Additionally, targeted assessment for other findings or clinical clues for Freeman-Sheldon syndrome, such as contractures, “windmill vane” hand, and mouth size, could aid in the differential diagnosis considerations and the diagnostic process. Admittedly, these are position and quality dependent, and are challenging to assess even in ideal situations. The phenotype of the father was immediately recognizable. However, due to COVID-19 pandemic restrictions, prior to the infant’s birth, only telehealth visits were conducted and the father’s participation was by telephone. This limited the ability to narrow the differential diagnosis without visualization of his distinct phenotypic features. Finally, missed opportunities to diagnose the father prior to this pregnancy occurred. Many clinics send “no show” letters to referring providers and patients, as we do. Emphasizing the importance of diagnosis prior to pregnancy for individuals concerned about having a genetic disorder should be considered as part of the information shared in these letters.