Changes in Kawasaki disease incidence and phenotype during the COVID-19 pandemic

INTRODUCTION. The aetiology of Kawasaki disease (KD) remains unknown. Changes in infectious exposure during the COVID-19 pandemic owing to infection prevention measures may have affected the incidence of KD, supporting the pathogenic role of an infectious trigger. The purpose of this study was to evaluate the incidence, phenotype and outcome of KD before and during the COVID-19 pandemic in Denmark. METHODS. This was a retrospective cohort study based on patients diagnosed with KD at a Danish paediatric tertiary referral centre from 1 January 2008 to 1 September 2021. RESULTS. A total of 74 patients met the KD criteria of whom ten were observed during the COVID-19 pandemic in Denmark. Alof these patients were negative for SARS-CoV-2 DNA and antibodies. A high KD incidence was observed during the first six months of the pandemic, but no patients were diagnosed during the following 12 months. Clinical KD criteria were equally met in both groups. The fraction of intravenous immunoglobulin (IVIG) non-responders was higher in the pandemic group (60%) than in the in the pre-pandemic group (28.3%), although the rate of timely administered IVIG treatment was the same in both groups (>= 80%). Coronary artery dilation was observed in 21.9% in the pre-pandemic group compared with 0% in KD patients diagnosed during the pandemic. CONCLUSION. Changes in KD incidence and phenotype were seen during the COVID-19 pandemic. Patients diagnosed with KD during the pandemic had complete KD, higher liver transaminases and significant IVIG resistance but no coronary artery involvement.Copyright © 2023, Almindelige Danske Laegeforening. All rights reserved.

COVID-19 in patients with advanced stages of diabetic kidney disease: new onset renal replacement therapy as one of the predictors of adverse outcome

Background: patients with Diabetes Mellitus 2 (DM2) and advanced stages of Diabetic Kidney Disease (DKD) are at high risk for the lethal outcome of COVID-19. The causes of high mortality and the prognostic signifi cance of the new onset of renal replacement therapy (hemodialysis de novo, HD de novo) among these patients are still points of debate. Aim: the identifi cation of risk factors (RF) of lethal outcome in patients with DKD 4-5D stages and evaluation of the prognostic value of HD de novo in patients not receiving HD at the time of hospital admission. Methods: the patients with COVID-19 and advanced stages of DKD were included in a retrospective observational study from 04.01. to 10.30.2020. The endpoints were the outcome of hospitalization (discharge/death) and HD de novo initiation during the inpatient course. Several demographic, DM2, DKD, and COVID-19-associated signs and laboratory parameters were analyzed as independent variables. The subgroup of patients with HD de novo was selected from the general cohort. Results: 120 patients with DKD 4-5D stages were included, with a mean age of 69±10 y, females - 52%. Initially, the observation cohort was divided into subgroups: DKD 4-5 and DKD 5D on maintenance hemodialysis (MHD). The mortality among patients with DKD 4-5 was comparable with the patients on MHD (38,2% vs 38,5%, р=0,975). The independent predictors of lethal outcome in group DKD 4-5 were: age ≥65 y (OR 12,30;95% CI 1,40-33,5;р=0,009), initial prandial glycemia ≥10 mmol/l (OR 14,5;95% CI 3,7-55,4;р<0,001), albuminemia at admission ≤35 g/l (OR 5,17;95% CI 1,52-17,50;р=0,012), Charlson comorbidity index (CCI) ≥10 (OR 6,69;95% CI 1,95-23,00;р=0,002), News2 >4 at admission (OR 7,58;95% CI 2,18-26,37;р=0,001), lung damage CT 3-4 at admission (OR 3,39;95% CI 1,09-10,58;р=0,031). In subgroup DKD 5D the independent predictors of lethal outcome were prandial glycemia at admission ≥10 mmol/l (OR 28,5;95% CI 7,1-33,5;р<0,001), lung damage at admission CT 3-4 (OR 8,35;95% CI 2,64-26,40;р<0,001), CCI ≥10 (OR 6,00;95% CI 1,62-22,16;р=0,006). To determine the risk of lethal outcome predictive models were created using identifi ed risk factors and variables. The predictive value for DKD 4-5 group was 93%, and for DKD 5D was 88%. The assessment of the overall predictive value of these models was carried out using ROC analysis. The mortality among patients with DKD 4-5 without HD de novo was 21,6% vs 72,2% in patients with initiated HD de novo (р<0,001). The independent predictors of HD de novo during the inpatient course were: prandial glycemia at admission ≥10 mmol/l (OR 3,38;95% CI 1,04-10,98;р=0,050), albuminemia at admission ≤35 г/л (OR 3,41;95% CI 1,00-11,55;р=0,050), News2 >4 at admission (OR 5,60;95% CI 1,67-19,47;р=0,006), eGFR ≤20 ml/min/1,73 m2 at admission (OR 4,24;95% CI 1,29-13,99;р=0,020). HD de novo was identifi ed as an independent predictor of adverse outcomes (OR 9,42;95% CI 2,58-34,4;р=0,001). The analysis of cumulative survival demonstrated comparable results in DKD 4-5 without HD de novo group and DKD 5D group. The cumulative 55-day survival in the subgroup with HD de novo was only 10%. Conclusion: the need to start HD de novo is one of the most powerful predictors of adverse outcomes of COVID-19 in patients with advanced DKD. The comparable mortality rate in DKD 4-5 and DKD 5D groups is due to extremely high mortality in the subgroup with HD de novo. The strict control and correction of HD de novo risk factors could turn them into modifi able ones and thus improve the survival prognosis of patients with advanced stages of DKD. © 2023 JSC Vidal Rus. All rights reserved.

Association between Type 2 Diabetes Mellitus and Covid-19 Severity: A Literature Review

We conducted a review and evaluated the already documents reports for the relationship among diabetes and COVID-19. The review outcome shows that the COVID-19 severity seems to be greater among patients with diabetes as comorbidity. So, strict glycemic control is imperative in patients infected with COVID-19. Thus, world-wide diabetes burden and COVID-19 pandemic must be deliberated as diabetes increases the COVID-19 severity. Established on this, it is precise significant to follow specific treatment protocols and clinical management in COVID-19 patients affected with diabetes to prevent morbidity and mortality.Copyright © 2023 The Authors.

LANGERHANS CELL HISTIOCYTOSIS IN A CHILD WITH MULTISYSTEMIC LESIONS ASSOCIATED WITH INFECTED POLIOMYELITIS AND SARS-COV-2, FEATURES OF DIAGNOSTICS. CLINICAL CASE.

Langerhans cell histiocytosis (LCH) is an abnormal clonal proliferation of Langerhans cells. The prognosis varies depending on the form of the disease and organ damage. Any organs and systems can be involved in the pathological process in various combinations. A poor response to standard therapy and an unfavorable prognosis are characteristic of patients with a multisystem form of LCH and involvement of organs at risk. Skin lesions are a classic sign of LCH. Purpose - to describe the complexity and duration of diagnosis of LCH with multisystem damage in a boy aged 2 years and 2 months, infected with poliomyelitis and coronavirus. Clinical case. The first clinical manifestations of LCH in the child debuted with an eczematous-seborrheic rash on the scalp with spread to the limbs and trunk. The child was treated for toxicoderma, hemorrhagic vasculitis at the place of residence for 6 months. The boy lost 1.5 kg of body weight in 1 month. At the time of hospitalization, seborrheic-eczematous rashes on the skin with a hemorrhagic component, trophic-inflammatory changes in the nails of the hands, signs of protein-energy deficiency, stomatitis, gingivitis, hepatosplenomegaly, polyserositis, diabetes insipidus, osteolytic foci of the frontal bones were found. Results of the tests: anemia, thrombocytopenia, hypoproteinemia and hypoalbuminemia, coagulation disorders. The patient had the onset of lower flaccid paraparesis, muscle hypotonia. The boy was diagnosed with a number of infectious complications, including poliomyelitis (a derivative of vaccine poliovirus type 2), COVID-19. The child received LCH-III cytostatic therapy with a positive effect. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies.Copyright © 2023 Institute of Physics of the Russian Academy of Sciences. All rights reserved.

Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 (PIMS-TS) and Serous Effusions in a Child With Severe Hypoalbuminemia: A Case Report.

In April 2020, Pediatric Inflammatory Multisystem Syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 or SARS­CoV­2 (PIMS-TS) was described for the first time in children. Since then, many countries have registered hundreds of cases with clinical similarities to Kawasaki disease. We report the case of a five-year-old boy diagnosed with PIMS-TS who presented myocarditis with serous effusions (pleurisy, ascites, pericarditis) due to severe hypoalbuminemia. This case sheds light on the importance of hypoalbuminemia in evaluating the severity of PIMS-TS and preventing its complications. The patient was successfully treated with intravenous immunoglobulins and oral prednisone.

Clinical Features, Laboratory Findings Outcomes in Multisystem Inflammatory Syndrome (Mis-C) Following Covid-19 Infection - a Multicenter, Observational, Ambidirectional Cohort Study in Rio De Janeiro State, Brazil

Objectives: As of March 5th, 2022, around 1.585 cases of MIS-C and 98 deaths (6,4%) were reported in Brazil. The state of Rio de Janeiro State (RJ) having 94 cases (5,9%) and 4 deaths (4,2%)1.Our aim was to evaluate clinical and laboratory features, and management of MIS-C in seven pediatric hospitals in RJ, Brazil. Method(s): Multicenter, observational, ambidirectional cohort study in seven tertiary hospitals in RJ(Brazil), assessing medical charts of pediatric inpatients (0-18 years) diagnosed with MIS-C according to WHO/CDC criteria, from August, 2020 to February, 2022. Descriptive statistics were used to analyze distributions of continuous variables, frequencies, and proportions. Result(s): A total of 112 cases of MIS-C were enrolled. The mean age was 4.2 years and thre was male predominance (59,8%). All cases had a SARS-CoV-2 contact (29.5% close contact;31.3%:positive PCR;serology:43.8%).Only 12.5% had comorbidities. Length of stay (LOS) was 7 days.Median duration of fever was 8 days. Most common symptoms were: rash(67%);gastrointestinal (67%);conjunctivitis (42%);neurological(39.6%);cardiovascular(37.5%);cervical lymphadenopathy (36.6%), and shock/hypotension(28.6%).Co-infection occurred in 3 patients. Forty-four patients fulfilled criteria for Kawasaki disease. Most patients were admitted to PICU(12;62,5%) for amedian of 2 days. Respiratory distress was seen in 18,7%;hypotension:28,6%, and shock in 23,2%. Main laboratory findings were: high C-reactive protein in 95%;D-dimer:77%, anemia:77%, thrombocytosis:63%;transaminitis:43.8%, lymphopenia:38%;hypoalbuminemia:34%;thrombocytopenia: 29%;hypertriglyceridemia:28%, and high pro-BNP in 27%. Echocardiogram was performed in 91/112 patients;abnormal in 70,3%;exhibiting myocardial dysfunction( 25%);pericardial effusion(21%);coronary dilation/aneurysms(11%) and, valvulitis (14.5%). IVIG+corticosteroids (CTC) were administered in 59.8%(67/ 112);18.6%(18/112) IVIG only;10.7%(12/112) CTC only;3.4%(4/112)biologics, and 15(13.3%) received no treatment. ASA low dose in 77.7% (87/112) and moderate/high dose in 34.8%. Oxygen support was needed in 27,7%;vasoactive amines:18,7%;dialysis:5,3%, and transfusion:18,7%.One patient died from a cytokine storm syndrome. Conclusion(s): Our study reports a higher number of MIS-C cases in RJ than the number reported to Brazilian authorities, highlighting underreporting. Our patients were younger, had fewer comorbidities, cardiovascular/gastrointestinal/renal involvement, shortest LOS in ICU, and a higher frequency of myopericarditis.

IgM Multiple Myeloma Presenting With Diarrhea

Introduction: IgM Multiple Myeloma (MM) is a rare subtype of MM consisting of <1% cases of MM. It is distinguished from Waldenstrom Macroglobinemia, which also produces IgM, by the absence of somatic mutation MYD88. We present a patient with a chief complaint of diarrhea which unknowingly led to his hematological diagnosis Case Description/Methods: A 64 year old male with RA-SLE overlap syndrome on steroids, and recent COVID19 pneumonia, had presented with 5 episodes of watery diarrhea every day and 40 Ib weight loss within 2 months. CT revealed small bowel enteritis and stool studies, including C. diff, cultures, ova and parasites were negative. Diarrhea persisted despite antibiotics, therefore an EGD and Colonoscopy were performed which showed duodenal lymphangiectasia and a normal colon. Duodenal biopsy revealed eosinophilic deposits in the villous lamina propria which stained for IgM and stained negative under congo red ruling out amyloidosis. SPEP and a bone marrow biopsy revealed monoclonal IgMspikes and plasma cells in the bone marrow suggesting MMalong with a co-existing population of CLL. Next-generation sequencing was negative forMYD88, supporting IgM MM instead of Waldenstrom. He developed a protein-losing enteropathy with dramatic hypoalbuminemia (albumin 0.9) and lower extremity edema and DVTs. He was started on chemotherapy and frequent albumin infusions. His diarrhea completely resolved, however not in time, as his other medical comorbidities lagged behind and he developed anasarca and continued to deteriorate. Discussion(s): Plasma cell dyscrasias such as IgM MM or more commonly Waldenstrom have rarely been reported to cause GI symptoms. GI involvement can include direct GI infiltration of plasma cells, IgM deposition, or the finding of a plasmacytoma. It has been speculated that IgM deposits can lead to interstitial viscosity and obstructive lymphangiectasia leading to diarrhea and a protein-losing enteropathy as in our patient. Protein loss has led him to have hypoalbuminemia and possibly loss of antithrombotic proteins that have caused DVTs. Few case reports have suggested that treating the underlying cause with chemotherapy stops diarrhea entirely. Although our patient's diarrhea ceased, we believe that it was not in time for him to entirely recover from the later complications of the disease. We hope that this case can help clinicians to attempt prompt treatment of patients when they find GI specimens showing IgM deposits and they suspect a plasma cell dyscrasia.

Characteristics of albumin levels and liver function in patients with COVID-19 at H. Adam Malik Hospital, Medan

Background: COVID-19 (Corona Virus Disease-2019) pandemic has a high mortality rate especially in Medan, Indonesia. Serum albumin and liver function tests are believed to be predictive biomarkers for prognosis in patients with infectious diseases, including COVID-19. This study aimed to investigate the association between the mortality events and severely ill COVID-19 patients' serum albumin and liver enzymes. Method: This is a cross-sectional study using secondary data from the medical records of H. Adam Malik Hospital patients with COVID-19 who were confirmed by RT-PCR from August to December 2020. All patients were analyzed for age, sex, hypoalbuminemia, increased liver enzymes and outcome using Chi-square tests (P <0.05). Results: The average age of severe COVID-19 patients at H. Adam Malik Hospital ranged from 41 to 60 years, with more women prevalence than men. Most of the patients had hypoalbuminemia (84.2%), an increase in AST (59.4)% and ALT (45.5%). There was no significant association between hypoalbuminemia and the disease outcome (P =0.12). There was a significant association between elevated liver enzymes and mortality in severely ill COVID-19 patients (P <0.001). Conclusion: We found that hypoalbuminemia is common in patients with severe COVID-19. However, we found that albumin levels had no association with the patients' mortality rate. Liver enzymes levels appear to be a predictive biomarker for outcomes in COVID-19 patients of H. Adam Malik Hospital. We found that higher ALT and AST levels were associated with significantly higher mortality.

The role of cardiometabolic risk factors and endothelial dysfunction in serum albumin levels and capillary leak syndrome of patients with COVID-19

Background: Growing evidence focuses on the role of hypoalbuminemia in the COVID-19 course and the role of vascular inflammation in the progression to Capillary Leak Syndrome (CLS). CLS may be mediated by a derangement of endothelial barrier following vascular endothelial dysfunction. We investigated the role of cardiometabolic risk factors in the association of hypoalbuminemia with endothelial dysfunction of hospitalized COVID-19 patients. Method(s): In this cross-sectional study, patients hospitalized for COVID- 19 at the medical ward or Intensive Care Unit (ICU) were enrolled. Medical history and laboratory examinations were collected while the endothelial function was assessed by brachial artery flow-mediated dilation (FMD) between the first 24-72 hours of their admission to the hospital. According to the body mass index, history of hypertension, dyslipidemia, and diabetes mellitus, COVID-19 patients were categorized in those with Cardiometabolic Risk Factors (CRFact) or without CRFact (no-CRFact). From the study population, we excluded subjects with established cardiovascular disease. Result(s): Sixty-six patients with COVID-19 (37% admitted in ICU) were recruited. From the study population, 41 were in the group of CRFact and 25 in the no-CRFact. Patients with CFRact were older (65+/-9 years vs. 53+/-14 years, p<0.001), had more impaired FMD (1.16+/-2.13% vs. 2.60+/-2.44%, p=0.01), and lower serum albumin levels (3.10+/-0.68 g/dL vs. 3.52+/-0.26 g/dL, p=0.006) compared to the no-CRFact group. Between CRFact and no-CRFact, there was no difference in CRP and IL-6 levels. Interestingly, serum albumin in patients with CRFact was significantly lower than the lower reference limit (LRL) (=3.5 g/dl) of albumin (p=0.001), while no such finding was noted in subjects with no CRFact (p=0.64). Furthermore, regression analysis revealed that, even after adjustment for age, the presence of CRFact was associated with decreased serum albumin levels by 0.31mg/dl (95% CI 0.08 to 0.63, p=0.04). In the CRFact population, there was a correlation of albumin with FMD (R=0.29, p=0.05) and an inverse correlation with CRP (rho=-0.48, p=0.02) and IL-6 (rho=-0.66, p<0.001), while in the no-CRFact group no such correlation were observed (p=NS for all). Conclusion(s): COVID-19 patients with cardiometabolic risk factors present with low serum albumin levels early at the course of the disease, which may be driven by endothelial dysfunction and vascular inflammation. This data gives insights into the potential association of a dysfunctional endothelial layer and the progression to capillary leak syndrome. (Figure Presented).

Clinical and Laboratory Predictors of Mortality in Severe COVID-19 Pneumonia: A Retrospective Study from India

OBJECTIVE: Wide arrays of laboratory parameters have been proposed by many studies for prognosis in COVID-19 patients. In this study, we wanted to determine if the International Severe Acute Respiratory and Emerging Infections Consortium-Coronavirus Clinical Characterization Consortium score in addition to certain clinical and laboratory parameters would help in predicting mortality. We wanted to determine if a greater severity score on chest x-ray at presentation translated to poor patient outcomes using the COVID-19 chest radiography score. MATERIAL AND METHODS: This retrospective study was conducted at SDS TRC and Rajiv Gandhi Institute of chest diseases, Bangalore from March 2021 to June 2021. This study included 202 real-time-polymerase chain reaction-positive COVID-19 patients aged above 18 years admitted to the intensive care unit of our hospital. Demographic characteristics and baseline hematological and inflammatory markers (serum C-reactive protein, lactate dehydrogenase, troponin-I, ferritin, and d-dimer) were collected. Radiological severity on a chest x-ray was assessed using the validated COVID-19 chest radiography score. The International Severe Acute Respiratory and Emerging Infections Consortium-Coronavirus Clinical Characterization Consortium score was assigned to each patient within 24 hours of intensive care unit admission. Outcome studied was in-hospital mortality. RESULT(S): The overall mortality was 54.9% (111 cases). Age more than 50 years, >4 days of symptoms, peripheral oxygen saturation/ fraction of inspired oxygen ratio less than 200, elevated serum lactate dehydrogenase >398.5 IU/L, and hypoalbuminemia (<2.95 g/dL) were detected as independent predictors of mortality. A significant correlation of risk stratification with mortality (P = .057) was seen with International Severe Acute Respiratory and Emerging Infections Consortium-Coronavirus Clinical Characterization Consortium score. There was no significant correlation between the COVID-19 chest radiography score and mortality. CONCLUSION(S): Age >50 years, peripheral oxygen saturation/fraction of inspired oxygen ratio <200, mean symptom duration of >4 days, elevated serum lactate dehydrogenase, and hypoalbuminemia are independent predictors of mortality in severe COVID-19 pneumonia. International Severe Acute Respiratory and Emerging Infections Consortium-Coronavirus Clinical Characterization Consortium score was different in the survivors and deceased.Copyright © Author(s).

The modified systemic inflammation score is a predictor of ICU admission of COVID-19 patients

Objective: To evaluate the effect of the modified systemic inflammation score (mSIS) on prognosis in patients diagnosed with COVID-19. Method(s): In this retrospective cross-sectional study, 181 patients were selected and divided into two groups: patients with and without admission to the intensive care unit (ICU). An albumin level of >=4.0 g/dL and lymphocyte-to-monocyte ratio (LMR) of >=3.4 was scored 0, an albumin level of <4.0 g/dL or LMR of <3.4 was scored 1, and an albumin level of <4.0 g/dL and LMR of <3.4 was scored 2. Result(s): A total of 242 COVID-19 positive patients were initially included in this study. Of these patients, 61 were excluded and 181 patients remained. Among the 181 participants, 94 (51.9%) were female, and the median age was 61 (51, 75) years. The mSIS scale ranged from 0 to 2. After analysis, the median score was 0 (0, 0) in the non-ICU group and 2 (0, 2) in the ICU group (P<0.001). The median white blood cell, lymphocyte counts, and albumin levels were lower in the ICU group (P<0.001, P<0.001, and P<0.001, respectively). In logistic regression analysis lymphocytopenia (OR=5.158, 95% CI=1.249-21.304, P=0.023), hypoalbuminemia (OR=49.921, 95% CI=1.843-1 352.114, P=0.020), AST elevation (OR=3.939, 95% CI=1.017-15.261, P=0.047), and mSIS=2 (OR=5.853, 95% CI=1.338-25.604, P=0.019) were identified as independent predictors of ICU admission. Conclusion(s): The mSIS can be used as an independent parameter for establishing the intensive care needs of patients with COVID-19.Copyright © 2023 Authors. All rights reserved.

New Onset Renal Replacement Therapy Is a Predictor of Covid-19 Adverse Outcome in Patients with Advanced Chronic Kidney Disease Due to Type 2 Diabetes Mellitus

Introduction: The patients with diabetic kidney disease (DKD) due to type 2 diabetes mellitus (T2DM) are at a high risk of adverse outcomes of COVID-19. In some cases, rapidly progressive kidney injury requires urgent initiation of renal replacement therapy (RRT) - hemodialysis de novo (HD de novo). The objective of this study is to identify risks factors of adverse outcomes and predictive value of HD de novo in patients with DKD due to T2DM and COVID-19. Method(s): The patients with chronic kidney disease 4-5 stages (CKD 4-5) with laboratory-confirmed COVID-19 were included in the retrospective observational study. The observation period 04.01-10.30.2020. Data were collected from electronic medical database. The following independent variables were analyzed at hospital admission: age, gender, body mass index (BMI), general comorbidity (Charlson Index, CCI), the insulin demand (InsD), fasting blood glucose (FBG), glomerular filtration rate (GFR), Plasma creatinine (Pcr), serum albumin (SA), proteinuria, time from onset to admission, NEWS2-scale points, pulmonary involvement (Chest CT), Hb, WBC, lymphocytes, platelet count, LDH, CPR, ferritin, D-dimer, procalcitonin, Interleukin-6. The observation group was divided into subgroups: 1 - HD not required (HD n/r), 2 - HD de novo. Result(s): A total of 55 patients were included. Mediana age was 69 y (IQR 64;80), fe-males 59%. The overall mortality - 38.2%. In 18 patients (32.7%) HD de novo was initiated due to rapidly progressive renal failure. The results of comparative analyses of demographic, initial clinical and laboratory data are presented in Tables (*Mann-Whitney U-test;IQR, interquartile range;Me, mediana). [Formula presented] [Formula presented] The mortality in both subgroups was 21.6 % vs 72.2 % respectively (p <0,001). HD de novo was determined as an independent predictor of adverse outcome (OR 9.42;95% CI, 2.58-34.4, p = 0.001). The analysis showed that FBG >= 10 mmol/L at admission (OR, 3.38;95% CI, 1.04-10.98, p = 0.050), SA at admission <= 35 g/L (OR 3.41;95% CI, 1.00-11.55, p = 0.050), News2 >4 points (OR 5.60;95% CI, 1.67-19.47, p = 0.006), GFR <= 20 ml/min/1,73m2 at admission (OR 4.24;95%;CI 1.29-13.99, p = 0.020) were independent predictors of HD de novo. Cumulative survival in subgroup HD de novo was 10% (significantly less, than in patients HD n/r) (Fig.). [Formula presented] Conclusion(s): Approximately every third patient with advanced nondialysis DKD required new onset RRT.New onset RRT is an independent predictor of lethal outcome of COVID-19. High FBG, low SA, low GFR and high NEWS2 score at admission are the risk factors of HD initiation during hospitalization. No conflict of interestCopyright © 2023

Clinical aspects of diarrhea during the pandemia of COVID-19.

The aim. To investigate the clinical peculiarities of adult patients with diarrheal syndrome, associated with coronavirus infection COVID-19. The materials and methods. There has been carried out the analysis of 56 patients aged 26-81 years, hospitalized with acute enteric infection at the Municipal Infectious Diseases Hospital 8 (not reprofiled as hospital for the treatment of coronavirus infection COVID-19 patients) in the course of August 2020 - February 2021 and the patients with cause-effect relationship with COVID-19. There have been used the routine diagnostic methods, the analysis of feces for causative agents of diarrhea was tested by the methods of bacteriological and immunoenzymatic analysis, the analysis of feces for toxins A and B Clostridium difficile was tested method of immunochromatographic assay;the blood serum was tested by method of immunoenzymatic analysis and the analysis of nasopharyngeal swabs was tested by immunochromatographic assay and PCR test for markers SARS-COV-2. The statistical material treatment has been done using Statistical Package of IBM SPSS Statistics-22. The results. There have been registered 51,8% of cases - diarrhea as one of the clinical manifestations of COVID-19 in adult patients (the first group of patients), in 48,2% of cases - diarrhea as a result of recently treated COVID-19 and a massive course of antibiotics (the second group of patients). In the second group 12 patients have been diagnosed with clostridial infection, 15 patients - with antibiotic-associated diarrhea. There has been registered the main severity of clinical manifestations in patients with clostridial infection. The disease being characterized by severity of colitis syndrome, the blood sedimentation rate increasing, hyperleukocytosis in haemogram, hypoproteinemia and hypoalbuminemia. The aggravating factors are combined comorbidity and patients aged over 55 years. The conclusion. There should be used the differential approach for diarrheal syndrome in patients with coronavirus infection. Taking into account the massive course antibiotics' side effects, the analysis of feces for pathogenic flora must be included into the medical examinations such as Clostridium difficile and the course of probiotic and anticlostridial medicines should be done.Copyright © 2022 Authors. All rights reserved.

Clinical aspects of diarrhea during the pandemia of COVID-19.

The aim. To investigate the clinical peculiarities of adult patients with diarrheal syndrome, associated with coronavirus infection COVID-19. The materials and methods. There has been carried out the analysis of 56 patients aged 26-81 years, hospitalized with acute enteric infection at the Municipal Infectious Diseases Hospital 8 (not reprofiled as hospital for the treatment of coronavirus infection COVID-19 patients) in the course of August 2020 - February 2021 and the patients with cause-effect relationship with COVID-19. There have been used the routine diagnostic methods, the analysis of feces for causative agents of diarrhea was tested by the methods of bacteriological and immunoenzymatic analysis, the analysis of feces for toxins A and B Clostridium difficile was tested method of immunochromatographic assay;the blood serum was tested by method of immunoenzymatic analysis and the analysis of nasopharyngeal swabs was tested by immunochromatographic assay and PCR test for markers SARS-COV-2. The statistical material treatment has been done using Statistical Package of IBM SPSS Statistics-22. The results. There have been registered 51,8% of cases - diarrhea as one of the clinical manifestations of COVID-19 in adult patients (the first group of patients), in 48,2% of cases - diarrhea as a result of recently treated COVID-19 and a massive course of antibiotics (the second group of patients). In the second group 12 patients have been diagnosed with clostridial infection, 15 patients - with antibiotic-associated diarrhea. There has been registered the main severity of clinical manifestations in patients with clostridial infection. The disease being characterized by severity of colitis syndrome, the blood sedimentation rate increasing, hyperleukocytosis in haemogram, hypoproteinemia and hypoalbuminemia. The aggravating factors are combined comorbidity and patients aged over 55 years. The conclusion. There should be used the differential approach for diarrheal syndrome in patients with coronavirus infection. Taking into account the massive course antibiotics' side effects, the analysis of feces for pathogenic flora must be included into the medical examinations such as Clostridium difficile and the course of probiotic and anticlostridial medicines should be done.Copyright © 2022 Authors. All rights reserved.

The relationship between dialysis adequacy and COVID-19 onset and mortality risk: Single center experience

Aim: We primarily aimed in this study was to evaluate risk factors for COVID-19 infection and if any association between dialysis inadequacy in COVID-19 infection in maintenance hemodialysis (MHD) patients. Secondly aimed to describe prevalence and risk factors associated with long-lasting symptoms of non-deceased COVID-19 MHD patients before vaccination. Material(s) and Method(s): One hundred one MHD patients infected with COVID-19 and 100 MHD patients without the infection were enrolled in this retrospective cross-sectional study. Risk factors for mortality, need to intensive care unit (ICU) stay and long-lasting symptoms were analyzed. Result(s): The mean age of patients was 59.13+/-13.58 years. COVID-19 infected patients had significantly higher number of patients with DM, COPD, CHF. The need for ICU was found to be statistically significantly higher in patients with COPD and DM. In our results, the patients who had lower Kt/V at admission hospital had more than 5 fold higher rate of COVID-19 those have higher Kt/V. We analyzed risk factors for mortality at, one year included higher age, higher CRP and lower base-line Kt/V were diagnostic criteria. Older MHD patients had a high frequent of long-lasting symptoms. Low Kt/V, low hemoglobin level and high CRP level associated with a higher risk of long-lasting symptoms (p=0.00, p=0.001, p=0.02) Discussion: We conclude that DM, CHF, COPD, older age, obesity were poor prognostic factors for in infected with COVID-19. Dialysis adequacy parameters of Kt/V, serum albumin level, hemoglobin level were significantly lower in need to ICU and deceased patients.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Direct Application of 3-Maleimido-PROXYL for Proving Hypoalbuminemia in Cases of SARS-CoV-2 Infection: The Potential Diagnostic Method of Determining Albumin Instability and Oxidized Protein Level in Severe COVID-19.

Oxidative stress and the albumin oxidized form can lead to hypoalbuminemia, which is a predisposing factor for reduced treatment effectiveness and an increased mortality rate in severe COVID-19 patients. The aim of the study is to evaluate the application of free radical 3-Maleimido-PROXYL and SDSL-EPR spectroscopy in the in vitro determination of ox/red HSA in serum samples from patients with SARS-CoV-2 infection. Venous blood was collected from patients intubated (pO2 < 90%) with a positive PCR test for SARS-CoV-2 and controls. At the 120th minute after the incubation of the serum samples from both groups with the 3-Maleimido-PROXYL, the EPR measurement was started. The high levels of free radicals were determined through the nitroxide radical TEMPOL, which probably led to increased oxidation of HSA and hypoalbuminemia in severe COVID-19. The double-integrated spectra of 3-Maleimido-PROXYL radical showed a low degree of connectivity due to high levels of oxidized albumin in COVID-19 patients. The low concentrations of reduced albumin in serum samples partially inhibit spin-label rotation, with Amax values and ΔH0 spectral parameters comparable to those of 3-Maleimido-PROXYL/DMSO. Based on the obtained results, we suggest that the stable nitroxide radical 3-Maleimido-PROXYL can be successfully used as a marker to study oxidized albumin levels in COVID-19.

Idiopathic systemic capillary leak syndrome: a case report.

BACKGROUND: Idiopathic systemic capillary leak syndrome (ISCLS) is a rare disease characterized by recurrent episodes of acute life-threatening attacks of shock, hemoconcentration, and hypoalbuminemia. Increase in capillary permeability results in reversible plasma movement into the interstitial spaces followed by appearance of related symptoms or complications, including renal failure. This condition can be potentially life-threatening; however, it is easily misdiagnosed. CASE PRESENTATION: A 47-year-old man with no previous medical history presented to the emergency department after experiencing general weakness and abdominal pain. He developed hypovolemic shock within 3 h of presentation and initial laboratory tests showed hemoconcentration, hypoalbuminemia and acute kidney injury. Following vigorous fluid therapy and supportive care, the patient recovered, but a similar episode recurred after 4 months without any specific trigger. Based on the combined clinical manifestations and laboratory findings of both the attacks, he was diagnosed with ISCLS. Symptomatic relief was achieved via oxygen supplementation and massive volume replacement using normal saline and the patient was prescribed bambuterol 10 mg and theophylline 400 mg once-a-day. He was discharged from the hospital on day 5 of hospitalization. Thereafter, the patient has been followed for 5 years without any symptoms or recurrence of ISCLS even in the situation of COVID-19 infection. CONCLUSIONS: ISCLS is an extremely infrequent and commonly misdiagnosed disease. However, early diagnosis, treatment and prophylaxis through accumulated clinical data can prevent ISCLS recurrence and the development of related fatal complications. Therefore, clinicians need to be well aware of the variety of clinical characteristics and treatment options of this disease.

The Impact of Serum Albumin Levels on COVID-19 Mortality.

Low serum albumin (SA) correlates with mortality in critically ill patients, including those with COVID-19. We aimed to identify SA thresholds to predict the risk of longer hospital stay, severe respiratory failure, and death in hospitalized adult patients with COVID-19 pneumonia. A prospective longitudinal study was conducted at the Infectious Diseases Unit of Trieste University Hospital (Italy) between March 2020 and June 2021. The evaluated outcomes were: (1) need of invasive mechanical ventilation (IMV); (2) length of hospital stay (LOS); and (3) 90-day mortality rate. We enrolled 864 patients. Hypoalbuminemia (<3.5 g/dL) was detected in 586 patients (67.8%). SA on admission was significantly lower in patients who underwent IMV (2.9 vs. 3.4 g/dL; p < 0.001). The optimal SA cutoff predicting the need of IMV was 3.17 g/dL (AUC 0.688; 95% CI: 0.618-0.759; p < 0.001) and this threshold appeared as an independent risk factor for the risk of IMV in multivariate Cox regression analysis. The median LOS was 12 days and a higher SA was predictive for a shorter LOS (p < 0.001). The overall 90-day mortality rate was 15%. SA was significantly lower in patients who died within 90 days from hospital admission (3.1 g/dL; IQR 2.8-3.4; p < 0.001) as compared to those who survived (3.4 g/dL; IQR 3.1-3.7). The optimal SA threshold predicting high risk of 90-day mortality was 3.23 g/dL (AUC 0.678; 95% CI: 0.629-0.734; p < 0.001). In a multivariate Cox regression analysis, SA of <3.23 g/dL appeared to be an independent risk factor for 90-day mortality. Our results suggest that low SA on admission may identify patients with COVID-19 pneumonia at higher risk of severe respiratory failure, death, and longer LOS. Clinicians could consider 3.2 g/dL as a prognostic threshold for both IMV and mortality in hospitalized COVID-19 patients.

POST-VACCINATION SARS-COV-2 IGG ANTIBODY TITER IN DIALYSIS PATIENTS

Background: Dialysis patients have a higher COVID-19 fatality rate than the general population and are priority candidates for SARS-CoV-2 vaccination. However, dialysis patients are immunocompromised, suggesting that they may develop a less immune response to COVID-19 vaccination than healthy individuals. Objective and Methods: A total of 358 hemodialysis patients who were twicevaccinated with BNT162b2 were included. SARS-CoV-2 IgG antibody titer was measured within 7 days to 1 month, 1∼2 months, and 3∼4 months after the second vaccination, and factors influencing antibody titer were statistically investigated. SARS-CoV-2 IgG measurement was performed using SARS-CoV-2 IgG II Quant Reagent (Abbott), which is a reagent to quantitatively measure IgG antibodies against the receptor-binding domain of SARS-CoV-2 spike protein. Results: The patients were 240 males (67%) and 118 females, ranging from 37 to 95 years old, with a median age of 70 years. Causes of kidney failure were diabetes mellitus in 35.2%, hypertensive kidney disease in 7.3%, glomerular disease in 30.5%, and polycystic kidney disease in 4.5% of the patients. Comorbidities were hypertension in 64.3% and diabetes in 48.9%. Steroids or immunosuppressive drugs were used in 9% of the patients. SARS-CoV-2 IgG antibody titers at 7 days to 1 month, 1 to 2 months, and 3 to 4 months (median 10, 42, and 98 days) after the second vaccination have the median of 4092 AU/mL(with interquartile range: 1354, 7592), 2199 (927, 4692), and 789 (323, 1559), respectively. Post-vaccination SARS-CoV-2 IgG titers were significantly correlated with Kt/V, the presence of autoimmune diseases, the use of steroids or immunosuppressive drugs, malignancy treatment, and serum albumin and hemoglobin levels. Multivariate analysis showed that the factors that decreased post-vaccination SARS-CoV-2 IgG titer were the use of steroids and immunosuppressive drugs, the presence of malignant tumors under treatment, and hypoalbuminemia. Conclusion: Compared to healthy subjects in previous reports, dialysis patients had lower SARS-CoV-2 IgG titers after COVID-19 vaccination, suggesting that the vaccine may not be sufficiently effective. In addition, SARS-CoV-2 IgG titers are likely to be even lower in patients at high risk for decreased immune response due to medications or comorbidities. Additional vaccination may be essential for hemodialysis patients who are expected to have low SARS-CoV-2 IgG titers.

Rapid disease progression after enzyme replacement therapy interruption in a patient with cholesteryl ester storage disorder

Lysosomal acid lipase deficiency (LALD) has two clinical phenotypes: an infantile-onset form - Wolman disease (WD) presented by severe malabsorption, cholestasis, malnutrition, hepatosplenomegaly and early death, and a later-onset form - cholesteryl ester storage disorder (CESD) with hepatosplenomegaly, dyslipidemia, malabsorption and variable disease severity manifestation. Enzyme replacement therapy (ERT) with sebelipase alfa was approved by the Brazilian Health Regulatory Agency (ANVISA) in 2017. We report the deleterious effect of ERT interruption in a CESD patient. Male, 16y, diagnosed at 7y, positive familiar history with mother, grandfather and three siblings affected. He was enrolled in the phase 3 clinical trial from age 9-12y under the 3 mg/Kg dose regimen. Then he enrolled in the post-study donation program under the same dose. Due to personal, importation and supply issues, and the COVID-19 pandemic restrictions, he had a progressive decrease in treatment adherence rate: 68% at 12y, 27% at 13y, 30% at 14y and after that he had an interruption of 1 entire year. At 15y he presented with generalized edema, severe fatigue, tachycardia, was hospitalized, diagnosed low serum iron, albumin and protein, acute anemia (hemoglobin: 6.2 g/dL - normal range of 12,5-13,5), and received blood transfusion. In the next year, still without ERT, he was hospitalized again due to generalized edema, acute anemia (Hemoglobin = 6.9 g/dL) and worsening of hypoalbuminemia and iron deficiency, and received blood transfusion. Although our patient has the CESD phenotype, the ERT interruptions did not worsen the liver involvement nor the dyslipidemia, but caused a severe malabsorption which is classically described in WD phenotype. In conclusion, this case serves as an alert that when ERT is interrupted, there is a rapid clinical deterioration. Acknowledgements: to IGEIM, and Drs Felippe Raphael e Oliveira Previdi and Ana Eduarda Saraiva Pereira Campos for clinical assistance of the patient.