Novel Cellular Stress Models with Implications in Understanding and Treating ENT Pathologies

Interaction with the world around us requires extracting meaningful signals to guide behaviour. The mammalian senses of olfaction, vision, somatosensation, hearing, balance and taste facilitate extraction of sense-specific information. Most sensory organs in the vertebrate head originate from cranial placodes (CPs). CPs are formed embryonically through a series of differentiation steps arising at the boundary between neural and non-neural ectoderm, and they can be divided into anterior, posterior and intermediate groups depending on their place of origin in the developing embryonic head. Anterior CPs include adenohypophyseal, olfactory and lens placodes;intermediate CPs include the trigeminal placode, which gives rise to the sensory neurons of the ophthalmic and maxilla-mandibular divisions of the trigeminal ganglion;posterior CPs are comprised of the otic, lateral line placode and the epibranchial placodes that give rise to the inner ear, lateral line organs (in fish and amphibian) and sensory neurons of the geniculate, petrosal and nodose ganglia, respectively. The complexity of neural plate border specification in vitro poses a major limitation to gain deeper mechanistic insights into the developmental cues driving efficient placodal differentiation;hence generation and establishment of in vitro cellular models with improved cranial placode differentiation are challenging. Our group is interested in the establishment of cranial/sensory placodes in vitro using novel cellular stress stem cell reprogramming models with translational implications in sensorineural hearing loss regeneration and modelling COVID-19-associated anosmia. We are primarily interested in building the otic placodes that can form viable otic vesicles in vitro, which can be further directed to generate cochlear/vestibular systems of inner ear and the sensory neurons of its associated vestibulocochlear ganglion. Given the copious involvement of serine proteases in COVID-19 pathogenesis, we are also encouraged to leverage our proteolytic stress cellular models towards establishment and characterization of novel olfactory epithelial neurospheres housing supporting cells, progenitor cells and sensory neurons for investigating cellular and molecular targets of COVID-19-associated anosmia. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022.

Stellate Ganglion Block for Complex Regional Pain Syndrome Treatment After SARS-CoV-2 Vaccine: A Case Report.

Complex regional pain syndrome (CRPS) is a poorly understood neuropathic pain syndrome that may have different etiologies. Reports of this syndrome after vaccination are rare. We report a female patient with a medical history of acute stroke of the right carotid artery in the previous four months who developed hyperalgesia, allodynia, edema, and color changes in the upper left member compatible with CRPS one day after SARS-CoV-2 vaccination. A multimodal therapeutic approach was adopted, including a stellate ganglion block, with favorable results, including pain score reduction and increased mobility of the affected member.

L-Ornithine-L-Aspartate and Intermittent Renal Replacement Therapy in Fulminant Hepatitis A: A Case Report

Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).

OLFACTORY FUNCTION AND BRAIN STRUCTURAL EFFECTS FOLLOWING SARS-CoV-2 INFECTION

Background: SARS-CoV-2 infection is accompanied by acute olfactory disturbance in as high as 70% of cases. This loss is associated with decreased olfactory bulb volume. As time passes, the anosmia tends to subside, but the OB volume decrease does not. Volume reductions in primary and secondary olfactory cortex are also seen following SARS-CoV-2 infection. Nevertheless, concurrent SARS-CoV-2 infection effects on olfactory discrimination, olfactory bulb volume, primary olfactory cortex and its targets have not been investigated. To explore this possibility, we measured olfactory discrimination, olfactory bulb volume, primary olfactory cortex and basal ganglia volume in patients who had SARS-CoV-2 infection more than 12 weeks previously, who were then divided into COVID and long-COVID groups on the basis of selfreported fatigue and concentration complaints. Method(s): This cross-sectional study included 25 post-infection and 19 demographically-matched, no-COVID control participants, we investigated effects on olfaction using NIH Toolbox Odor Identification Test and the Monell Smell Questionnaire. GM structure was assessed with voxel-based morphometry and manual delineation of high resolution (1mm3), T1- and T2-weighted MRI data. Linear regression was used to model group effects on GM structure, adjusting for age, sex, education and total intracranial volume. CAT12/SPM12 and R were used for image processing and statistical modeling. Result(s): Results. The NIH Toolbox Odor Identification Test failed to show differences among the groups. In contrast, the Monell Smell Questionnaire revealed persistently diminished and distorted smell in 50% of the long-COVID sample. Olfactory bulb volume was lower in the long-COVID group (p=0.02). Primary olfactory cortex volume was reduced in the long-COVID group (p=0.004). Caudate volume was also lower in the long-COVID group (p=0.04). Conclusion(s): Conclusions. In the absence of olfactory discrimination problems, long-COVID, but not COVID, patients experience persistent olfactory loss and distortion. These perceptual problems are associated with lower olfactory bulb, primary olfactory cortex, and caudate volume, suggesting that the effects of SARS-CoV-2 infection can extend beyond the olfactory periphery in some cases to affect central targets. (Figure Presented).

Hyperkinetic movement disorder following Covid-19 Temporal correlation or Coincidental

Objective: Hypokinetic movement disorder and parkinsonian picture has been well described in literature following covid-19 but hyperkinetic MDS are very in global literatures. To investigate the epidemiology,clinical picture,the diagnostic and therapeutic challenges in patients hyperkinetic MDS in this context and to know the time schedule of the onset of the MDS with exploring the possible pathogenesis Background: Infections are up to 20% of movement disorders.The most frequent agents are beta-hemolytic streptococcus,and flavivirus causing Japanese encephalitisThe role of the viral stimulation of microglial activation in neuroinflammation has regained attention in the context of covid19 Methods: Patients of MDS attended the clinic from 31st march 2020 to March 2022,with recent onset of hyperkinetic movements were screened. Subjects had medical history either prior to the study or medical history reviewed by physicians suggestive of covid.PCR +VE or Presence of covid antibody in blood or csf in patients with recent onset hyperkinetic MDS within 6-12 weeks of onset of symptoms except.Ventilatory cases Other markers were used to rule out other viral infections causing MDS.MRI brain and EEG as a routine in all Immune markers in very selected cases in suspected immuomediated MDSThe attempted treatment were symptomatic and immunotherapy Results: In last 2 years 50 cases of new onset Hyperkinetic MDS are recorded, out of which only 9 cases were directly or indirectly linked to Covid,Nystagmus, orofacial dyskinesia and segmental or generalized myoclonus and ataxic gait associated delirium,tremors and ocular movement disorders along with epileptic seizures are also seen.Positive EEG findings are in the form of diffused bihemispheric slowing or periodic complexes with polyspikes at irregular interval and delta brush in few cases .MRI findings varied between non-specific changes to bitemporoparietal hyperintensities in flair and T2 both cortical and subcortical or bilateral basal ganglia. Treatment response in all the cases are statisfactory Conclusion(s): observational study revealed MDS in covid do happen Myoclonus is the most Frequent movement disorder associated with COVID-19 followed by dystonia and tremors .pathophysiology included neuro inflammation, autoimmune mechanisms and small vessels thrombosis hence not be co-incidental , response to steroid also s/o immune mediated.

A Case Report of Herpes Zoster of the Trigeminal Ganglion after Coronavirus 2019 Vaccination in a 22-year-Old Male

Introduction. Herpes zoster is an acute viral syndrome caused by the reactivation of latent varicella-zoster virus from a previous infection. It is characterized by a painful, unilateral vesicular rash which is distributed over the territory of a dermatome. It is a significant global burden with the incidence very common in the Asia Pacific region. The frequency is closely related with increasing age and is the most common risk factor for reactivation of varicella-zoster virus. Herpes zoster does not often appear after administration of vaccination. But in the advent of increasing vaccinations for COVID-19, there have been reports of herpes zoster following COVID-19 vaccination. Case: This is a case of a 22-year-old healthy male with a previous history of varicella-zoster virus infection during childhood who developed headache, unilateral vesicular rash over the territory of the left trigeminal nerve and left-sided facial pain and numbness. The patient had previously received the COVID-19 vaccine four days prior to the onset of symptoms. The diagnosis of herpes zoster was made on clinical grounds with no need for additional laboratory work-up to confirm the diagnosis. The patient was treated with herpes zoster antiviral therapy and analgesics where improvement of the patient's condition was noted with eventual crusting of the lesions and without development of complications. Conclusion(s): Herpes zoster is a common disease with a benign course in immunocompetent adults. There is a need for further studies to identify risk factors and explain the possible relationship between COVID-19 vaccination and the development of herpes zoster. Due to the increasing COVID-19 vaccination of the population worldwide, there is a possibility of an increase in the number of herpes zoster cases following COVID-19 vaccination.Copyright © 2022, Philippine College of Physicians. All rights reserved.

Determinants of e-waste workers' intention to wear respiratory protective equipment at work in Hong Kong

IntroductionE-waste workers in Hong Kong are exposed to more chemicals because more e-waste needs to be handled locally. However, studies suggested that many e-waste workers are unwilling to wear respiratory protective equipment (RPE) for different reasons. This study aimed to identify the determinants of e-waste workers' intention to wear RPE in Hong Kong.Material and MethodsWe recruited 109 e-waste workers from June 2021 to September 2022. A workplace RPE intention scale (WRPIEs) was developed based on validated Robertsen's RPE behavior intention model and Hong Kong Occupational Safety Culture Index. The WRPIEs was consolidated by exploratory factor analysis and further enhanced by confirmatory factor analysis. Multivariate linear regression was used to test the association between the identified domain factors and the intention to use RPE at work.ResultsMost of the participants were aged over 40 years (76%), had middle school or below educational degrees (83%), wore RPE (94%) at work, and had increased time of wearing RPE after the Covid-19 pandemic (69%). Four domain factors (containing 17 manifest variables) were confirmed, including ‘subjective norms (SN)', ‘supportive working conditions (SWC)', ‘autonomy', and ‘occupational safety and health'. The enhanced WRPIEs had good indices in internal consistency reliability (Cronbach's α ranged: 0.78–0.94), good composite reliability (range: 0.79–0.95), and model fit (SRMR=0.05, RMSEA=0.03, CFI=0.99). Among the identified domain factors, SN (β=0.36) and SWC (β=0.30) significantly increased e-waste workers' intention to wear RPE at the workplace.ConclusionsThis newly validated WRPIEs scale can help capture Chinese e-waste workers' intention to wear RPE. Results from this study also suggested that various stakeholders could enhance SN and SWC to facilitate workers' willingness to wear PPE. (Acknowledgements: GRF/RGC-165056653 & VCDFIII-136366853. Ethics approval: CREC 2020.039;*shelly@cuhk.edu.hk)

Using DTI tractography to guide tDCS interventions in a complex acquired brain Injury neurorehabilitation protocol - a case report

51-year-old man (C.P.) had a diffuse-axonal-injury after falling from a 5-meter height, followed by a 22-minute anoxia due to a cardiac arrest. In the ICU, he tested positive to COVID-19, and needed intubation. After coronavirus infection, C.P. presented Guillain-Barre syndrome. 2months after discharge, he was admitted to rehabilitation. DTI tractography for evaluation of the structural integrity of white matter tracts revealed: i) Lesions in the basal ganglia;ii) Sequelary lesions in the right frontal, cortical, subcortical, temporal, parieto-occipital and cerebellar hemispheres;iii) Asymmetry of the corticospinal tracts - less fibers on the left;iv) Poor definition of the fibers of the right arcuate fasciculus;v)Asymmetrical thinning of the cortico-ponto-cerebellar tracts, worse on the left, and more discreetly in the spinocerebellar tracts. Based on this, C.P. underwent 4 different 30-session tDCS protocols consisting of twice-daily 20min 2mA sessions (10min interval), 5days/week (120sessions total), combined with physiotherapy, cognitive, swallowing and speech therapy. Montages: Pr1 (anode: Cz - 5x10cm;cathode: 10th Thoracic Vertebra - 5x7cm);Pr2 (1 - anode:C3;cathode:Fp2 / 2 - anode: Cerebellum;cathode:Fp2);Pr3 (anode:F3;cathode:Fp2) and Pr4 (anode:Cp5;cathode:Fp2). Except for Pr1, electrode size for all protocols were 5x7cm. We used the Coma Recovery Scale (CRS-R) and Rancho Los Amigos Scale (RLAS) for clinical assessments at the baseline and after every 10 sessions until the end of the intervention. At the baseline, C.P. presented a minimal responsive state of consciousness (CRS-R: 3;RLAS: Level 1) and tolerated well the tDCS interventions. CRS-R scores gradually improved in various domains during the treatment. At the end, RLAS score was level 5 and CRS-R, 19. Our preliminary results suggest DTI tractography may be a potential biomarker to guide more personalized tDCS interventions for complex cases of patients with acquired brain injuries. A second DTI tractography will be made in the future for comparison purposes. Research Category and Technology and Methods Clinical Research: 9. Transcranial Direct Current Stimulation (tDCS) Keywords: Acquired Brain Injury, Traumatic Brain Injury, COVID-19, Guillain Barre SyndromeCopyright © 2023

Neuropsychiatric Manifestations of COVID-19 in Hospitalized Pediatrics: A Multicenter Cross-sectional Study

Background: The large proportion of coronavirus disease 2019 (COVID-19) patients has been associated with a large number of neu-ropsychiatric manifestations. Despite the high prevalence of COVID-19, few studies have examined such manifestations, especially in children and adolescents. Objective(s): This study investigated neuropsychiatric manifestations in hospitalized children and adolescents admitted for COVID-19 infection in Iran. Method(s): This prospective observational study included admitted children and adolescents (4-18 years old) diagnosed with COVID-19 infection, pediatric neurologists, child and adolescent psychiatrists, and infectious disease specialists, and assessed 375 infected patients during August and December 2021. Result(s): Of the 375 patients, 176 (47%) were female, with a mean age of 9.0 +/- 3.39 years. Psychiatric and neurological manifestations were reported in 58 (15.5%) and 58 (15.5%) patients, respectively. The most prevalent psychiatric disorders were separation anxiety disorder (SAD) (5.1%), major depressive disorder (MDD) (3.5%), generalized anxiety disorder (GAD) (2.7%), insomnia (2.4%), and op-positional defiant disorder (ODD) (2.4%). Regarding neurological complications, seizures were the most prevalent (13.1%), followed by encephalitis (1.9%), transverse myelitis (0.3%), acute ischemic stroke (0.3%), and Guillain-Barre syndrome (0.3%). There was no significant relationship between the duration of COVID-19 infection (P = 0.54) and ICU admission (P = 0.44) with the emergence of psychiatric symptoms. Conclusion(s): The most prevalent neurologic and psychiatric complications among children and adolescents with COVID-19 infection were seizures and the symptoms of anxiety/mood disorders, respectively.Copyright © 2023, Author(s).

Isolated cerebral mucormycosis in post-COVID-19 pneumonia

Background: Rhino-orbital-cerebral and isolated cerebral involvement of basal ganglia by mucormycosis are two different manifestations of CNS mucormycosis. The former variant caused by inhaled fungal spores and is common with immunosuppressive conditions. The latter form is caused by intravascular inoculation of spores as seen in intravenous drug abusers. Case report: Here we describe a case of young, non-addict patient with a history of recent mild COVID-19 pneumonia who presented with isolated cerebral mucormycosis involving bilateral basal ganglia. Discussion(s): The pulmonary vasculitis associated with COVID-19 is probably the cause of direct intravascular entry of inhaled fungal spores leading to direct isolated cerebral involvement. Such condition may rapidly turn fatal. Conclusion(s): This is the first reported case of isolated cerebral mucormycosis following post-COVID-19 infection. Early tissue diagnosis and intravenous amphotericin B is the key management.Copyright © 2022

A Review of Stellate Ganglion Block as an Adjunctive Treatment Modality.

Peripheral nerve blocks are becoming increasingly used as adjunctive treatment modalities for a variety of conditions refractory to medical management. Right or left stellate ganglion blocks (SGB) are a specific type of peripheral nerve block that target the sympathetic blockade of neuronal impulses using the injection of local anesthetic and steroids into nerve bundles in the cervical area. This review article is intended to summarize the common uses of stellate ganglion blocks and explain the procedural technique, which has evolved with technological advances in ultrasonography. The similarities between these disease processes are centered around sympathetic hyperactivity. This sympathetic overdrive state is created by increased levels of nerve growth factor (NGF), which causes a cascade of sympathetic sprouting resulting in increased norepinephrine (NE) systemically. Reversal of this cascade by local anesthetic injection into the stellate ganglion thereby reduces NGF and sympathetic sprouting subsequently lowering overall norepinephrine levels. This is the unifying theory by which SGB is able to provide resolution for the varied clinical conditions described in this article.  This review article discusses the physiology of several conditions where stellate ganglion blocks are being investigated as an adjunct treatment modality, including anosmia, PTSD, long-COVID, chronic fatigue syndrome, menopausal hot flashes, and ventricular tachyarrhythmias. Overall, the current literature supporting the use of stellate ganglion blocks for several esoteric conditions is limited; however, case reports to date have shown promising evidence-based results supporting their use as an adjunctive treatment among patients with refractory symptoms to existing treatment algorithms. In conclusion, SGB should be considered among patients with refractory symptoms for medical management in the conditions discussed in this article. Further research is needed to delineate which patients will benefit from the use of SGB, the use of subsequent blocks and timelines in between injections, and unilateral versus bilateral blockade.

Aldosterone as a possible contributor to eye diseases.

Aldosterone, an effector molecule of the renin-angiotensin-aldosterone system (RAAS), has been receiving more attention in the field of ophthalmology because of its possible role in the pathogenesis of various eye diseases or abnormalities; potentially, it may even become a target for their treatment. Primary aldosteronism, a typical model of a systemic aldosterone excess, may cause vision loss due to various ocular diseases, such as retinal vein occlusion, central serous chorioretinopathy, and possibly, glaucoma. RAAS components are present in various parts and types of cells present in the eye. Investigations of local RAAS in various animal models of diabetic macular edema, retinal vein occlusion, retinopathy of prematurity, central serous chorioretinopathy, and glaucoma have found evidence that aldosterone or mineralocorticoid receptors may exacerbate the pathology of these disorders. Further studies are needed to elucidate whether the modulation of aldosterone or mineralocorticoid receptors is an effective treatment for preventing vision loss in patients with eye diseases.

Evaluation of acute effects of pulmonary involvement and hypoxia on retina and choroid in coronavirus disease 2019: An optic coherence tomography study.

PURPOSE: We investigated the acute subclinical choroidal and retinal changes caused by Coronavirus Disease 2019 (COVID-19) in patients with and without pulmonary involvement, using spectral domain optic coherence tomography. METHODS: This prospective case-control study included COVID-19 patients: 50 with pulmonary involvement and 118 with non-pulmonary involvement. All patients were examined 1 month after recovering from COVID-19. The changes were followed using optic coherence tomography parameters such as choroidal and macular thickness and retinal nerve fibre layer and ganglion cell complex measurements. RESULTS: All choroidal thicknesses in the pulmonary involvement group were lower than in the non-pulmonary involvement group and the subfoveal choroidal thickness differed significantly (p=0.036). Although there were no significant differences between the central and average macular thicknesses in the two groups, they were slightly thicker in the pulmonary involvement group (p=0.152 and p=0.180, respectively). A significant decrease was detected in the pulmonary involvement group in all ganglion cell complex segments, except for the outer nasal inferior segment (p<0.05). In addition, a thinning tendency was observed in all retinal nerve fibre layer quadrants in the pulmonary involvement group compared to the non-pulmonary involvement group. CONCLUSION: In COVID-19 patients with pulmonary involvement, subclinical choroidal and retinal changes may occur due to hypoxia and ischemia in the acute period. These patients may be predisposed to ischemic retinal and optic nerve diseases in the future. Therefore, COVID-19 patients with pulmonary involvement should be followed for ophthalmological diseases.

Last year challenge of Nuclear Medicine: medical radioisotopes supply

Aim/Introduction: 99mTc is used in about 80% of the convencional diagnostic nuclear imaging procedures and represent yearly approximately 30 million examinations/year worldwide a year in diagnostic tests in hospitals, among others by oncology, cardiology and neurology.The production of radiopharmaceuticals for use in Nuclear Medicine has a complex system. It involves carefully calculated production schedules that take into account supply, demand and many logistical operations.The aim of this study is to show how our nuclear medicine department manage the impact of the shortly 99Mo supply chain and consequently, in the 99mTc availability and other radiopharmaceuticals produced in nuclear reactora. Material(s) and Method(s): European nuclear medicine organizations had just pay attention to how the COVID-19 pandemic might affect different parts of the 99Mo supply chain when had to dealt again faced with a new problem;the shortness 99Mo production. There are only five nuclear reactors involved in the production of 99Mo on industrial scale. These aging reactors are subject to unscheduled shutdowns and longer maintenance periods making the 99Mo supply chain vulnerable. In the last few months at our nuclear medicine department we had to reinvent ourselves so as not to completely stop carrying out the previously scheduled exams and therapies. Result(s): The use of technetium generators in Europe represents about 17% - 25% of the worldwide consumption of 99Mo, representing 30,000 exams per day and about 1.1 million doses per month. The main consequences at the IPO-Porto was;Delays in diagnosis/staging, rescheduling exams, change of surgery dates (Sentinel Ganglion and Myocardial Perfusion Cardiacs), weeks of overbooking, delay in follow-up of Glomerular Filtration Rate in pre- or post-transplant patients, postponement of 131I Therapies, Scintigraphy and Whole Body Scintigraphy in patients who were already in hypothyroidism. we had to reinvent the use of 99mTc generators, change exams appointments times, reagroup exams types by defined days and other radiopharmaceutical management tools that were not commonly used. Conclusion(s): Approximately 2/3 of scheduled exams were postponed and we had to deal with weekly and daily stock updates. Our department suggest some measures and procedures that could help with future 99Mo shortages, in order to be ready in future situations and to avoid shortness of production: the creation of a centralized European radiopharmacy system, European policies to encourage long-term investment, homogenization of marketing specifications in the Member States, solid databases of radiopharmaceuticals used/ available in Europe and encouraging cooperation between other countries outside the European Union.

Mineralizing angiopathy: an underrecognized clinicoradiologic entity

Case Report: Initial History/Presentation: A term vaccinated 7-month-old male with a history of eczema presents with two hours of right-sided hemiplegia and hemidystonia. Parents deny loss of consciousness, altered mental status, or facial symptoms. He has no known history of recent or remote head trauma. Patient may have had COVID two months prior when he had upper respiratory symptoms, with his mother testing COVID+ at that time. Of note, he received a Moderna COVID vaccination one day prior to onset of symptoms. Physical Exam: Pertinent exam findings include CN II-XII intact, right-sided upper and lower extremity strength 3/5, sensation intact, and truncal ataxia while seated. Physical exam is otherwise unremarkable. Diagnostic Evaluation: Initial lab work revealed leukocytosis (20.9), but otherwise a reassuring CMP, triglycerides, HDL, and LDL. PTT was elevated, but normal on recheck. Protein C antigen and activity were low, but deemed non-concerning by hematology. All other hypercoagulable labs were normal. On imaging, CT Brain showed linear calcifications in bilateral basal ganglia suggestive of mineralizing angiopathy. HisCTA head/neckwas negative.MRI Brain revealed an acute infarct of the body/tail of the left caudate nucleus, posterior limb of internal capsule, and posterior putamen. Clinical Course/Follow-up: Our patient was started on Aspirin 4 mg/kg daily. Throughout the course of his 3-day inpatient stay, he had mild improvement of right-sided strength and function, and continued improvement upon follow-up with his pediatrician. Given the short interval between receiving his COVID vaccination and onset of symptoms, his case was reported to the Vaccine Adverse Event Reporting System. Conclusion(s): From a radiological perspective, mineralizing angiopathy is an uncommon but familiar finding seen in up to 5% of all neonatal head ultrasounds and increasing to nearly 20% in preterm infants. It is most commonly associated with infection, hypoxia, and chromosomal abnormalities but is usually of minimal clinical significance. However, there are numerous reports of basal ganglia and thalamic strokes following minor head trauma in children with mineralizing angiopathy. For radiologists, this association is important to recognize and relay to the primary team so targeted history and MRI, if indicated, may be obtained to expedite definitive diagnosis and initiation of treatment to preserve precious brain tissue. Without a history of head trauma, in this case, stroke provocation is unclear, and other infectious or inflammatory disorders could appear similarly if they induced vasospasm or blood pressure lability. A short-interval timeframe between COVID vaccine administration and symptom onset is likely incidental, but research to exclude or illicit any link may be of benefit. Findings of mineralizing angiopathy on CT in the appropriate clinical setting should prompt further evaluation with emergent MRI to determine the presence of basal ganglia or thalamic stroke. Copyright © 2023 Southern Society for Clinical Investigation.

Last year challenge of Nuclear Medicine: medical radioisotopes supply

Aim/Introduction: 99mTc is used in about 80% of the convencional diagnostic nuclear imaging procedures and represent yearly approximately 30 million examinations/year worldwide a year in diagnostic tests in hospitals, among others by oncology, cardiology and neurology.The production of radiopharmaceuticals for use in Nuclear Medicine has a complex system. It involves carefully calculated production schedules that take into account supply, demand and many logistical operations.The aim of this study is to show how our nuclear medicine department manage the impact of the shortly 99Mo supply chain and consequently, in the 99mTc availability and other radiopharmaceuticals produced in nuclear reactora. Material(s) and Method(s): European nuclear medicine organizations had just pay attention to how the COVID-19 pandemic might affect different parts of the 99Mo supply chain when had to dealt again faced with a new problem;the shortness 99Mo production. There are only five nuclear reactors involved in the production of 99Mo on industrial scale. These aging reactors are subject to unscheduled shutdowns and longer maintenance periods making the 99Mo supply chain vulnerable. In the last few months at our nuclear medicine department we had to reinvent ourselves so as not to completely stop carrying out the previously scheduled exams and therapies. Result(s): The use of technetium generators in Europe represents about 17% - 25% of the worldwide consumption of 99Mo, representing 30,000 exams per day and about 1.1 million doses per month. The main consequences at the IPO-Porto was;Delays in diagnosis/staging, rescheduling exams, change of surgery dates (Sentinel Ganglion and Myocardial Perfusion Cardiacs), weeks of overbooking, delay in follow-up of Glomerular Filtration Rate in pre- or post-transplant patients, postponement of 131I Therapies, Scintigraphy and Whole Body Scintigraphy in patients who were already in hypothyroidism. we had to reinvent the use of 99mTc generators, change exams appointments times, reagroup exams types by defined days and other radiopharmaceutical management tools that were not commonly used. Conclusion(s): Approximately 2/3 of scheduled exams were postponed and we had to deal with weekly and daily stock updates. Our department suggest some measures and procedures that could help with future 99Mo shortages, in order to be ready in future situations and to avoid shortness of production: the creation of a centralized European radiopharmacy system, European policies to encourage long-term investment, homogenization of marketing specifications in the Member States, solid databases of radiopharmaceuticals used/ available in Europe and encouraging cooperation between other countries outside the European Union.

Analysis of brain metabolism using FDG-PET/CT in patients with acute Covid-19

Aim/Introduction: Neurological sequelae of Covid-19 have been widely documented by anatomic and functional methods [1,2]. Brain metabolism studies using 18F-FDG PET/CT during the subacute phase of the disease have also been published [1]. On the other hand, there is a lack of information about the influence of SARS-Cov2 infection on brain metabolism during the acute phase of the disease. The aim of this study was to identify and quantify changes in brain metabolism during the acute onset of Covid-19. Material(s) and Method(s): We studied 23 patients (13 women, median age 55.5[33-78] years) hospitalized with positive nasopharyngeal swab test (RT-PCR) for Covid-19 and requiring supplemental oxygen. Dedicated PET/CT images of the brain were acquired for 10 minutes, 1h after injection of 4.4 MBq/kg of 18F-FDG. Visual analysis was performed by two nuclear medicine specialists and one radiologist. Quantitative analysis was performed using dedicated software. 18F-FDG uptake in multiple brain regions was evaluated and the standard deviation (SD) of brain uptake in each region was automatically calculated in comparison with a group of normal subjects. More than 2 SD above or below the control group was considered significant in each area. Result(s): Serum C-reactive protein at admission ranged from 6.43 to 189.0 mg/L (mean 97.0 +/- 55.5 mg/L). The mean supplemental oxygen demand was 2.8 +/- 1.5 L/min. PET/CT images were acquired between 4 and 20 days of symptoms (mean 12.9 +/- 3.8 days). The images showed increased glycolytic metabolism in basal ganglia and relatively reduced brain metabolism in cortical regions. Basal ganglia metabolism was bilaterally increased in 18/23 (78.3%) and normal in 5 (21.7%) patients. Lenticular nucleus presented increased metabolism in 21/23 (91.3%) and was normal in 2 (8.7%) patients. Frontal and parietal lobes metabolism was respectively reduced in 9/24 (37.6%) and 8/23 (34.8%) patients. The whole brain metabolism was normal in 20/23 (86.9%) patients. Olfactory cortex metabolism was normal in 18/23 (78.3%) patients. Conclusion(s): Brain metabolism is clearly affected during the acute phase of SARS-Cov2 infection. The most frequent finding was increased basal ganglia metabolism, with most patients presenting marked lenticular nucleus hypermetabolism. Frontal and parietal lobes presented reduced metabolism in some patients. Interestingly, olfactory cortex is not affected in most patients, suggesting that anosmia, reported by some patients, is not related to the direct involvement of the brain by the disease.

Unmasking of a Relapsing Encephalomyelitis After SARSCoV- 2 Infection and COVID-19 Vaccination

Objective NA. Background Prior case studies suggest that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its vaccines may unmask neuroinflammatory conditions. We present a case of relapsing steroidresponsive encephalomyelitis after SARS-CoV-2 infection and subsequent COVID-19 vaccination. Design/Methods NA. Results A 47-year-old man with a history COVID-19 presented with subacute lower extremity weakness, erectile dysfunction, and gait instability with falls. His symptoms started several weeks after COVID-19 vaccination which he underwent 3 months afterCOVID-19 infection. His initial exam demonstrated weakness at the knees and ankles and extensor plantar responses. MRI demonstrated innumerable enhancing lesions involving the subcortical white matter, basal ganglia, thalami, brainstem, cerebellum, and the entire spinal cord parenchyma. CSF testing revealed a lymphocytic pleocytosis (10 WBC, 88% lymphocytes), and transient matched serum and CSF oligoclonal bands. Testing was unremarkable for infections, malignancies, primary demyelinating conditions, etc. He responded dramatically to five days of high dose methylprednisolone but had recurrence of symptoms with weaning of oral prednisone, requiring another pulse of IV steroids. After 2 months, his steroids were weaned again, with clinical and radiographic recurrence, requiring another course of IV steroids. He was subsequently transitioned to mycophenolate as a steroidsparing agent. Literature review identified 20 additional cases of CNS neuroinflammatory disease after either SARS-CoV-2 infection or vaccination (11 transverse myelitis, 6 optic neuritis, 3 encephalomyelitis). Conclusions Our patient's steroid-dependency and relapsing course suggests unmasking of an underlying CNS neuroinflammatory condition. Temporal associations of neurological conditions with vaccinations or infections do not prove causality despite previous reports of such sequelae. Vaccines containing SARS-CoV-2 antigens may enhance autoimmunity by mechanisms including polyclonal activation, epitope spreading, or molecularmimicry. This case highlights that the resulting inflammation may be insidious and extensive, though treatable. As COVID-19 constitutes a life-threatening infection in some patients, the benefits of vaccination outweigh the smaller risk of unmasking an immune-related condition.

Bilateral Cerebral Strokes and Adrenal Hemorrhage Associated with Mis-A

INTRODUCTION: Multisystem Inflammatory Syndrome in Adults (MIS-A) is an underrecognized post-infectious manifestation of COVID-19.We report a case of a 21-year-old male with MIS-A who presented with adrenal hemorrhages, acute kidney injury (AKI) and cerebral strokes leading to multiorgan system failure and death. DESCRIPTION: A 21-year-old, morbidly obese male presented at an outside hospital with COVID-19 and abdominal pain. His abdominal CT demonstrated bilateral adrenal hemorrhages, he was discharged home on hydrocortisone. A month later was readmitted with fever, diarrhea, thrombocytopenia and AKI. Laboratory work revealed creatinine 5.49mg/dL, ferritin 701ng/ml, BNP 3020 pg/ml and D-Dimer 17,650 ng/ml. He received hydrocortisone, intravenous immunoglobulin and enoxaparin. Fever subsided and renal function normalized. On day 7 he developed acute altered mental status and recurrent AKI. Head CTA showed multiple short stenotic segments in the anterior circulation, diminutive appearance of several intracranial arteries and basal ganglia hypodensities. Brain MRA demonstrated extensive bilateral acute/subacute strokes, no evidence of sinus thrombosis and markedly decreased caliber of internal carotid, left middle and anterior cerebral arteries without evidence of thrombus. He received aggressive neurocritical care management including decompressive craniectomy and pulse steroids for suspected vasculitis. Due to the severity of his neurological injury and poor neurologic prognosis family elected to withdraw support. His autopsy demonstrated hepatomegaly, acute tubular necrosis, bilateral adrenal hemorrhages and hypercellular bone marrow with myeloid predominance. Neuropathology showed severe segmental stenosis of the carotid arteries and bilateral vertebral arteries. DISCUSSION: Stroke is a potentially life-threatening complication of COVID-19 including large vessel occlusion and less frequently vasculitis-like phenotype with vessel wall enhancement. Despite initial improvement, our patient developed an acute extensive ischemic stroke leading to a devastating neurologic injury. The neuropathology findings suggest SARS-CoV-2 associated vasculitis. Stroke in the context of COVID-19 may have different pathogenetic mechanisms, clinical characteristics and complications that warrant further investigation.

Cerebral Vasculopathy-Associated Ischemic Stroke in the Setting of Bacterial Meningitis

INTRODUCTION: Bacterial Meningitis is known to have high morbidity and mortality rates. A less recognized complication from this disease includes acute ischemic stroke, which conveys a worse prognosis. DESCRIPTION: A 37-year-old previously healthy woman presented to the hospital with progressive encephalopathy associated with ataxia and dysarthria. Her immediate past travel history revealed a trip to Europe where she endured a COVID19 infection three weeks before her admission. Nevertheless, she recovered without any complications. However, she developed fatigue and headaches, prompting a diagnosis of post-COVID19 syndrome by her primary care physician. Over the course of several days, her ability to carry out her normal daily activities and perform work-related duties deteriorated as she developed severe fatigue accompanied by a painless diffuse skin rash. She presented to the ED once she started having symptoms of dysarthria, abasia, and truncal ataxia. An emergently obtained CSF sample was consistent with bacterial meningitis. Standard empiric antibiotics and steroids were administered. The patient's condition acutely decompensated soon after antibiotics administration. A follow-up head CT showed global cerebral edema and hydrocephalus, triggering an EVD placement for ICP monitoring. An MRI brain showed multiple bilateral acute ischemic strokes in the brainstem and basal ganglia. A head CT angiography showed diffuse narrowing of the cerebral arteries. The patient ultimately completed a course of antibiotics (Neisseria PCR was positive). We used TCD-guided blood pressure augmentation to prevent the progression of cerebral ischemia. The patient was discharged on long-term steroid therapy for presumed post-infectious vasculopathy. A follow-up MRI brain did not reveal a progression of cerebral ischemia. DISCUSSION: Bacterial Meningitis is a severe disease with significant complications. One such complication is ischemic stroke. However, the exact pathophysiology is unknown. Understanding the risks of developing cerebral ischemia and the related pathophysiology could help improve patient outcomes with better treatment modalities. The interplay between COVID19 infection and conventional infectious pathogens is an ongoing area of interest.