Personalized approach to the management of a patient with COVID-19 with a complicated comorbid background

The aim of the work is to form the principles of a personalized approach to the management of patients with COVID-19 with a complicated comorbid background. Material and methods. The article describes a clinical case of successful recovery of an 87-year-old patient from a new coronavirus infection COVID-19, complicated by pneumonia involving 36% of the lung parenchyma area. Along with age, the situation was aggravated by the comorbid status of the patient: the presence of chronic lymphocytic leukemia, hypertension, mechanical prostheses of the mitral and aortic valves, postinfarction cardiosclerosis, paroxysmal atrial fibrillation, type 2 diabetes mellitus, stage 4 CKD, anemic syndrome, and subclinical hypothyroidism. Results. The C-reactive protein level at admission was 114.46 mg/L. The patient refused hospitalization. Baricitinib 4 mg, favipiravir according to the scheme, vitamin D 2000 units were prescribed for the previously taken therapy. Already after 3 days, C-reactive protein decreased by 4.6 times, and by the 8th day by 15.5 times and amounted to 7.38 mg/ml. The temperature returned to normal on day 2 from the start of baricitinib. In dynamics, a decrease in creatinine level to 177.0 mumol/l was noted, the glomerular filtration rate increased to 30 ml/min/1.73 m2, which corresponded to stage 3b of CKD (a pronounced decrease in glomerular filtration rate). Conclusion. Despite the age of the patient, many comorbidities, each of which could be fatal, the timely use of baricitinib on an outpatient basis made it possible to stop the progressive course of the disease.Copyright © Eco-Vector, 2023. All rights reserved.

Personalized approach to the management of a patient with COVID-19 with a complicated comorbid background.

The aim of the work is to form the principles of a personalized approach to the management of patients with COVID-19 with a complicated comorbid background. Material and methods. The article describes a clinical case of successful recovery of an 87-year-old patient from a new coronavirus infection COVID-19, complicated by pneumonia involving 36% of the lung parenchyma area. Along with age, the situation was aggravated by the comorbid status of the patient: the presence of chronic lymphocytic leukemia, hypertension, mechanical prostheses of the mitral and aortic valves, postinfarction cardiosclerosis, paroxysmal atrial fibrillation, type 2 diabetes mellitus, stage 4 CKD, anemic syndrome, and subclinical hypothyroidism. Results. The C-reactive protein level at admission was 114.46 mg/L. The patient refused hospitalization. Baricitinib 4 mg, favipiravir according to the scheme, vitamin D 2000 units were prescribed for the previously taken therapy. Already after 3 days, C-reactive protein decreased by 4.6 times, and by the 8th day by 15.5 times and amounted to 7.38 mg/ml. The temperature returned to normal on day 2 from the start of baricitinib. In dynamics, a decrease in creatinine level to 177.0 mumol/l was noted, the glomerular filtration rate increased to 30 ml/min/1.73 m2, which corresponded to stage 3b of CKD (a pronounced decrease in glomerular filtration rate). Conclusion. Despite the age of the patient, many comorbidities, each of which could be fatal, the timely use of baricitinib on an outpatient basis made it possible to stop the progressive course of the disease.Copyright © Eco-Vector, 2023. All rights reserved.

The Perspectives of Individuals with Comorbidities Towards COVID-19 Booster Vaccine Shots in Twitter: A Social Media Analysis Using Natural Language Processing, Sentiment Analysis and Topic Modeling

Individuals with comorbidities (i.e., Diabetes Mellitus, hypertension, heart diseases) are more likely to develop a more severe form of coronavirus disease 2019 (COVID-19), thus, they should take necessary precautions to avoid infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and its emerging variants and subvariants by getting COVID-19 vaccination and booster doses. In this regard, we used text analytics techniques, specifically Natural Language Processing (NLP), to understand the perception of Twitter users having comorbidities (diabetes, hypertension, and heart diseases) towards the COVID-19 vaccine booster doses. Understanding and identifying Twitter users' perceptions and perspectives will help the members of medical fraternities, governments, and policymakers to frame and implement a suitable public health policy for promoting the uptake of booster shots by such vulnerable people. A total of 176,540 tweets were identified through the scrapping process to understand the perception of individuals with the mentioned comorbidities regarding the COVID-19 booster dose. From sentiment analysis, it was revealed that 57.6% out of 176,540 tweets expressed negative sentiments about the COVID-19 vaccine booster doses. The reasons for negative expressions have been found using the topic modeling approach (i.e., risk factors, fear of myocardial fibrosis, stroke, or death, and using vaccines as bio-weapons). Of note, enhancing the COVID-19 vaccination drive by administering its booster doses to more and more people is of paramount importance for rendering higher protective immunity under the current threats of recently emerging newer Omicron subvariants which are presently causing a rise in cases in a few countries, such as China and others, and might lead to a feasible new wave of the pandemic with the surge in cases at the global level. Copyright © The Author(s) 2023.

Bioinformatic-based study on genes and micrornas predisposing Covid-19-related cardiovascular injuries

Background and Aim: Apart from the direct and immediate invasion of coronavirus to vital tissues such as the heart, the virus is also capable of damaging these tissues based on the host's genetic susceptibility. The present bioinformatic- based study aimed to determine the genes and related microRNAs that most likely to be associated with susceptibility rates for virus-induced cardiovascular vulnerabilities. Method(s): A deep search was scheduled in databases including Pubmed (Medline), Google Scholar, Web of Science, and Scopus databases to assess all microRNAs and targeted genes related to cardiovascular defects induced by the coronavirus. The bioinformatic professional software systems were employed to assess gene-microRNAs interactions and mechanisms involved in cardiovascular injury. Result(s): The coronavirus can induce cardiovascular defects by the three mechanisms of inducing cardiac fibrosis (by up-regulating miR-367-3p and down-regulating hsa-miR- 5692a), inducing hypertension (by up-regulating miR-18b- 5p), and inhibiting microvascular angiogenesis (by up-regulation of miR-18b-5p and down-regulating hsa-miR-5692a). Such processes can be triggered by the effects on NFAT5, CD69, and HGF expression. Conclusion(s): Considering the central role of the revealed microRNAs and their targeted genes in cardiovascular injuries induced by coronavirus, such microRNAs can be applied for finding a way to stabilize the host against virus attacks as well as genetically based treatment for the affected host. (Figure Presented).

Interdisciplinary Approach Is Essential for Sufficient Diagnosis and Therapy in Igg4-Related Disease Involving Multiple Organs

Introduction: IgG4-related disease (IgG4-RD) is a systemic, chronic inflammatory syndrome, with enlargement of involved organs, elevated serum levels of IgG4, dense lymphoplasmocytic infiltrates, rich in IgG4-positive plasma cells, and fibrosis in involved organs. The most frequently involved organs are the pancreato-hepatobiliary tract, salivary and lacrimal glands, the retroperitoneum, kidneys, lungs, and aorta. Often multiple organ systems are involved. As an initial treatment, glucocorticoids are recommended. In patients with relapse along with glucocorticoid dose reduction, various immunosuppressive agents have been reported. Aims & Methods: We reviewed 98 patients (2019-now) who were treated in the special outpatient unit for IgG4-RD at the University Hospital of Essen and identified 10 patients with IgG4-RD involving multiple organ systems. Result(s): The first patient is a 65-year-old male diagnosed with an IgG4- RD involving parotitis, lymphadenitis, sialadenitis with orbitopathy and elevated IgG4 serum level (7400 mg/l). Clinically response to therapy with steroids was documented. The second patient is a 63-year-old man with an IgG4-positive pancreatitis, sialadentis, lymphadenopathy, and elevated IgG4 serum level (3960 mg/l). Immunosuppression with tacrolimus leaded to clinical benefit. As the third patient, we report a 48-year-old man with IgG4-related inflammatory condition in pancreas and kidneys with high IgG4 serum levels. The patient was successfully treated with azathioprine and prednisolone. As the fourth patient, we demonstrate a 34-year-old man with IgG4-related autoimmune hepatitis, lymphadenitis, and pancreatitis. After treatment with tacrolimus in combination with rituximab, a significant decrease of IgG4-level was detected. The fifth patient, a 65-year-old man, was diagnosed with IgG4-related fibro- inflammatory pseudotumors in the liver, esophagitis, and lymphadenopathy combined with high serum levels of IgG4 (12000 mg/l). Clinically response to therapy with steroids and azathioprine was reported. As the sixth patient we demonstrate a 29-year-old male with IgG4-related lymphadenopathy, recurrent myocarditis, and pancreatitis. The patient has symptom-free episodes under low-dose prednisolone. We also found an IgG4-RD with multiple organ involvement in our seventh patient. A 54-year-old man with IgG4-related cholangitis, pancreatitis, prostatitis, and very high serum level of IgG4 (26700 mg/l) were treated with steroids and azathioprine. As our eight case, we present a 23-year-old man with congenital hepatic fibrosis, after living-donor liver transplantation, who developed an IgG4- related disease with high IgG4 serum levels (45300 mg/l) after infection with SARS-CoV-2. Pathologically enlarged lymph nodes were detected. In a biopsy of retroperitoneal lymph nodes, IgG4-positive plasma cells were detectable. Intestinal biopsies have shown numerous positive plasma cells in the IgG4-staining (40 IgG4 positive plasma cells/HPF). Treatment with rituximab is planned. The ninth patient is a 56-year-old woman with lymphadenitis and cholangitis, who clinically responded to a treatment with budesonide. As the last patient we present a 59-year-old man with an IgG4-related aortitis, cardiac fibrosis, cholangitis, hepatitis, exocrine pancreatic insufficiency and Hashimoto's thyroiditis responding very sufficient to rituximab. Conclusion(s): An interdisciplinary approach is essential for a sufficient diagnosis and therapy in IgG4-RD involving multiple organs. This collective is extremely heterogeneous, and treatment is often based on individual concepts.

GETTING TO THE HEART OF THE MATTER

CASE: 45-year-old woman with PMHx systemic sclerosis presents with fever, weight loss, chest tightness, weakness and altered mental status for 2 weeks. Home meds are prednisone, mycophenolic acid, lasix. On presentation she is febrile to 38.9C, HR 110, BP 97/64, SpO2 96% on RA. Exam shows telangiectasis, normal cardiopulmonary exam, mild sclerodactyly. Oriented only to self, has bilateral LE 3/5 weakness. Labs with WBC 2.6K, Hgb 7.1, plts 126K. Cr normal. Liver enzymes mildly elevated. BNP 3900. Trop 251. Lactate 4.9 Blood cultures negative, CMV/EBV negative, COVID-19 negative, Ferritin > 15,000, Triglycerides 274 LDH 495, Fibrinogen 274, D-Dimer 755, ANA 1:1280, + dsDNA, low titer Smith, + RNP, + SSA, + RNA Pol III. TTE with EF 27% and diffuse hypokinesis. Cardiac MRI with myocardial fibrosis no active myocarditis, suggestive of scleroderma. Lumbar puncture with high protein, borderline increased oligoclonal bands, elevated IgG index but elevated synthesis rate, suggestive of CNS inflammation. Patient is in cardiogenic shock secondary to hemophagocytic lymphohistiocytosis/macrophage activating syndrome (HLH/MAS) related to systemic sclerosis/scleroderma with SLE overlap requiring inotropes and aggressive diuresis. She develops severe pain and bright red purpura on bilateral legs. Hypercoagulable w/u showed low protein C/S, low complement, negative cryoglobulin. Skin biopsy showed vaso-occlusive process c/w HLH/MAS. Receives IV methylprednisolone for empiric treatment of HLH/MAS and IV cyclophosphamide for possible lupus cerebritis. Patient improves and is discharged on long-term milrinone, Plaquenil, and steroids. IMPACT/DISCUSSION: Secondary HLH or MAS is a life-threatening condition of extreme inflammation that can occur in autoimmune conditions, infection, or malignancy Diagnosing HLH requires high clinical suspicion - >10K ferritin level is highly sensitive and specific for diagnosis of HLH This patient has multisystem involvement of autoimmune disease given history of scleroderma The LP studies raise concern for lupus cerebritis, specifically the IgG index and IgG synthesis rate are helpful for this diagnosis Underline subtype of systemic sclerosis-overlap syndromes and here particularly scleroderma lupus overlap Highlight the utility of cardiac MRI in characterizing myocarditis / fibrosis Discuss need for high alert for necrotizing fasciitis with painful palpable purpura Overview treatment of HLH/MAS with high dose steroids Reflection on high mortality of HLH/MAS and question of recovered heart function CONCLUSION: Teaching Point 1: Secondary HLH is a syndrome of extreme inflammation caused by underlying malignancy, autoimmune condition, or infection. Teaching Point 2: HLH and MAS have a great deal of symptom/clinical presentation overlap. Ferritin level > 10,000 is highly sensitive and specific for diagnosis of HLH Teaching Point 3: Systemic sclerosis can present in a variety of ways including cardiac, lung, skin involvement.

Features of the course of cardiovascular diseases against the background of COVID-19

Based on the analysis of 308 electronic medical records of patients with a confirmed diagnosis of a new coronavirus infection COVID-19, the features of the course of cardiovascular diseases at the regional level were studied. It was found that in patients with cardiovascular diseases, the severity of the course and mortality are higher than in patients without cardiac pathology.

Late-Breaking Basic Science Abstracts From the American Heart Association's Scientific Sessions 2021

The proceedings contain 34 papers. The topics discussed include: combinatorial maturation of patient stem cell-derived atrial cardiomyocytes unmasks mechanism of atrial fibrillation induced by NPPA gene mutation;the pathogenesis of Covid-19 myocardial injury: an immunohistochemical study of postmortem biopsies;mitochondrial optogenetic-mediated preconditioning protects cardiomyocytes from stress-induced injury;the aldose reductase inhibitor At-001 improves cardiac efficiency and decreases diastolic dysfunction in an animal model of diabetic cardiomyopathy: comparative and add-on studies versus SGLT-2 inhibition;cardiomyocyte specific deletion Of Trpv4 offers cardio-protection independent of cardiac fibrosis following pressure overload-induced hypertrophy;and sacubitril-valsartan protects against aortic aneurysm progression via regulating neprilysin-induced vascular smooth muscle cell apoptosis.

Activation of immune system may cause pathophysiological changes in the myocardium of sarscov-2 infected macaque model

Background: Recent reports suggest the presence of the SARS-CoV-2 virus in the myocardium of patients who died from the COVID-19 disease. Cardiovascular injury in COVID-19 patients is an established extra-pulmonary manifestation of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection which may lead to induction of arrhythmia, acute heartfailure, thickening of ventricular wall, reduced ejection fraction and thromboembolism. Non-human primates (NHP) provide a useful model to study cardiovascular changes due to their homology to the ACE2 receptor in humans. Aim: The aim of this study is to characterize the pathological changes in the heart of SARS-CoV-2 infected NHPs. Methods: In the present study, SARS-CoV-2 infected primates via aerosol route (n=4), multi-routes (i.e., oral, nasal, intratracheal and conjunctival) (n=4), and a control group (n=5) were included. Heart tissue samples were collected and the left ventricular tissue was analyzed by hematoxylin and eosin, trichrome, and immunohistochemical staining specific to CD3, CD68 andSARS-CoV-2 nucleocapsid protein.Results: Several pathological findings were observed in the heart, including cardiomyocyte disarray, mononuclear infiltrates of inflammatory cells as well as hypertrophy. Collagen specific staining showed development of cardiac fibrosis in the interstitial as well as in the perivascularregion in the hearts of infected primates. Moreover, the myocardial tissue samples displayed multiple foci of inflammatory cells positive for T lymphocytes and macrophages within the myocardium. Additionally, SARS-CoV-2 nucleocapsid protein staining detected the presence of virus particles in the myocardium. Conclusion: COVID19 infection is characterized by exaggerated inflammatory immune response in the heart which possibly contributes to myocardial remodeling and subsequent fibrosis. These findings suggest progression of disease which could lead to development of severe complications including heart failure.

COVID-19 temporally related multisystem inflammatory syndrome (MIS-C) and cardiovascular involvement assessed with cardiac magnetic resonance (CMR). Experience of the children hospital of Palermo

Introduction: MIS-C is a hyperinflammatory syndrome that follows exposure to SARS-CoV-2 by 2-6 weeks. However, some aspects remain unclear, such as cardiac involvement. Objectives: to evaluate the role and effectiveness of cardiac magnetic resonance (CMR) in heart involvement in children affected by MIS-C;to review the expert groups' clinical experience in the field. Methods: we describe a case series of 7 children (age: 2-11 years), admitted to the tertiary care Children Hospital G. Di Cristina, Palermo, between December 2020 and May 2021 with clinical symptoms meeting the criteria for the diagnosis of MISC-C. All the patients showed findings of cardiac involvement without coronary artery lesions. Transthoracic echocardiography demonstrated temporary systolic dysfunction that lasted for 2-5 days. CMR was performed during the recovery phase or after the discharge (the median time to CMR was 10-30 days after the onset of illness). CMR was performed with a 1,5 Tesla scanner (GE Signa Explorer). 5/7 didn't undergo CMR study during the acute phase because they were clinically unstable and needed general anesthesia or sedation. The protocol included, before intravenous contrast media injection, retrospective ECG-Gated fiesta cine sequences (short axis, 4, 3 and 2 chamber views), sequences for edema, and hyperemia T2 -short tau inversion recovery (Stir) (repetition time =1689ms, echo time55.10 ms). Myocardial edema was evaluated by following the Lake Louise criteria. Because normal value in native T1 mapping and T2 relaxation time in children have poor reference, myocardial edema was characterized by increased signal intensity on T2-weighted imaging and myocardial damage by non-ischemic patterns late gadolinium enhancement. Study for evaluating myocyte necrosis and fibrosis: Late gadoliniumenhanced 2D inversion recovery sequences performed at 6 min following intravenous contrast medium administration (0,2 mmol/kg). Results: In 5/7 patients, T2-Stir sequences didn't show myocardial edema and hyperemia. Mean indexed left ventricular end-diastolic volume (iLVEDV), indexed left ventricular end-systolic volume (iLVESV), and indexed left ventricular stroke volume (iLVSV) were within normal range corrected for BSA. In 2 patients CMR showed late gadolinium enhancement in non-ischemic pattern. 1 patient, studied in subacute phase, after steroids and IVIG treatment, showed ventricular apical septum and lateral wall myocardial oedema, without fibrosis and an imaging compatible with focal acute myocarditis. Ventricular systolic function was normal. 1 patient, studied 1 month after the acute phase, and showed myocardial fibrosis. Conclusion: international literature reports that children with MIS-C develop a transitory myocardial impairment, resembling myocarditis, with full recovery in most of them. Until now, the pathophysiology of the event is still object of debate. CMR is an excellent noninvasive diagnostic tool for the diagnosis and follow-up of myocarditis. Furthermore, CMR can predict prognosis and recognize children at high risk to develop arrhythmias and unfavorable events. CMR is a codified method highlighting specific features of myocardial damage: inflammation, edema, necrosis, contractile scar impairment, and pericardial effusion. 6/7 didn't demonstrate myocardial oedema, probably because the CMR was performed during the recovery.