ABSTRACT
Introduction: Diabetic peripheral neuropathy (DPN) is the most common neuropathic syndrome seen in patients with diabetes. Roughly 30% of the diabetes patient population1 experience painful DPN symptoms including bilateral stabbing or burning pain in addition to numbness in the feet and lower legs. Traditionally painful DPN symptoms have been treated with conventional medical management (CMM) including glycemic control, general risk factor management, as well as pharmaceutical agents. These treatment approaches are often unsuccessful in the long-term1. Spinal cord stimulation (SCS) has been demonstrated as an effective treatment for painful DPN of the lower extremities with multiple publications dating back to 1996 showing benefits of SCS for pain relief and improved Quality of Life (QoL) in DPN patients (Figure 1)2-18. Method(s): A systematic literature review of the robust body of evidence for SCS in the treatment of painful DPN was conducted. Publications were selected for inclusion by two independent reviewers using defined selection criteria. Additional relevant publications from outside the search dates were included. Result(s): SCS was first documented as an effective treatment for DPN in three single-arm studies published between 1996 and 20122,4,5, one of which was followed-up to thirty-six months18, and another to seven-years3. These studies paved the way for two RCTs published in 20146,7, one of which was followed-up to five-years in two publications8,10, and another7 was followed-up with analyses on QoL9 and an evaluation of the effects of burst SCS17. Two meta-analyses were published in 2020 and 202111,12. A post-hoc analysis of a multi-center single-arm study on high frequency (10kHz) SCS to treat DPN was published in 202013 and followed by an RCT published in 202114 with additional 1-year follow-up15,16. Collectively these studies demonstrate that SCS is an effective therapy for patients with painful DPN by reducing pain and increasing QoL for DPN patients (Figure 1). Conclusion(s): This review of a large body of evidence shows a decades-long history of the effectiveness of SCS for symptom relief in patients suffering from painful DPN. Future research on the effectiveness of new waveforms and novel methods of energy delivery to the spinal cord are needed. The study of outcomes in addition to pain relief is also needed, which may better illustrate the breadth of effects of SCS therapy on the underlying disease factors. Increasing awareness of the current evidence is essential to increasing therapy adoption by expanding payer support and influencing referring health care provider behavior. Disclosure: Eric Grigsby, MD: AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Medtronic: Consulting Fee: Self, SPR Therapeutics: Consultant: Self, Tenex Health: Consultant: Self, Voyager Therapeutics: Consultant: Self, Xalud: Consulting Fee: Self, AE Mann Foundation: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Bioness Inc.: N/A: Self, Medallion Therapeutics: N/A: Self, SPR Therapeutics: N/A: Self, Abbott / St. Jude Medical: N/A: Self, Tenex: N/A: Self, Vertos: N/A: Self, Xalud: N/A: Self, AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medtronic, Inc.: N/A: Self, Collegium Pharmaceutical, Inc.: Trustee: Self, Flowonix Medical: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Trustee: Self, Spinal Restoration, Inc.: Trustee: Self, Jazz Pharmaceuticals: N/A: Self, Alfred Mann Foundation: N/A: Self, Boston Scientific: N/A: Self, CNS Therapeutics: N/A: Self, Collegium Pharmaceutical, Inc.: N/A: Self, Flowonix Medical: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: N/A: Self, Myoscience: N/A: Self, NeurAxon Inc.: N/A: Self, Spinal Restoration, Inc.: N/A: Self, St. Jude Medical, Inc.: N/A: Self, Abbott Laboratories: Consultant: Self, Alfred Mann Foundation: Consulting Fee: Self, Cervel Neurotech, Inc.: Consultant: Self, CNS Therapeutics: Consultant: Self, Covidien: Consultant: Self, Cumberland Pharmaceuticals, Inc.: Consultant: Self, Flowonix Medical: Consultant: Self, Jazz Pharmaceuticals: Consultant: Self, Mainstay Medical: Consultant: Self, Medtronic, Inc.: Consultant: Self, Myoscience: Consultant: Self, NeuroPhage Pharmaceuticals: Consultant: Self, Nevro Corp: Consultant: Self, Palyon: Consultant: Self, Spinal Modulation: Consultant: Self, SPR Therapeutics: Consultant: Self, St. Jude Medical, Inc.: Consultant: Self, Tenex Health, Inc.: Consultant: Self, VertiFlex Inc.: Consultant: Self, Vertos Medical, Inc.: Consultant: Self, Xalud Therapeutics, Inc.: Contracted Research: Self, Medtronic, Inc.: Served on speakers' bureau: Self, Flowonix Medical: Served on advisory board: Self, Medtronic, Inc.: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Nevro Corp: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Rachel Slangen, PhD: None, Lisa Johanek, PhD: Medtronic: Salary/Employee: Self, Maddie LaRue, PHD: Medtronic: Employee:, Cecile de Vos, PhD: None, Melissa Murphy: Medtronic: Consulting Fee:, Relievant: Consulting Fee:Copyright © 2023
ABSTRACT
A 59-year-old white female who was previously fit and well, developed gradual tightening and thickening of the skin on her forearms progressing to the abdomen, chest and lower legs associated with restricted movement. She also noticed bruise-like patches on her trunk. There were no systemic symptoms and no history of Raynaud syndrome. Since the beginning of the COVID-19 lockdown, the patient had engaged in increasing amounts of exercise compared with normal;this included yoga once weekly for 75 min, high-intensity interval training for 20 min on alternate days, running three times weekly for 45 min, lifting 2.5 kg weights for the arms every day and regular long walks. Examination showed a 'groove' sign on her forearms and a peau d'orange appearance of the skin with a woody induration and hardness on palpation. Symmetrical and circumferential involvement on the forearms and lower legs and bruise-like indurated patches on the abdomen were noted. Differential diagnoses included eosinophilic fasciitis (EF), morphoea, EF/morphoea overlap, scleroderma, scleromyxoedema and nephrogenic systemic fibrosis. Blood investigations showed an eosinophilia of 1.2 x 109 cells L-1, erythrocyte sedimentation rate of 31 mm h-1, a C-reactive protein of 20 mg L-1 and negative autoimmune and viral serology. She underwent two incisional biopsies down to fascia. The first was taken from the back, which showed an interstitial inflammatory cell infiltrate composed of lymphocytes, plasma cells and very occasional eosinophils. The subcutaneous septa were minimally thickened. The second biopsy taken from the left forearm showed striking thickening of the subcutaneous septa, with an associated inflammatory cell infiltrate, composed predominantly of lymphocytes and plasma cells. This process was deeper and more established than that seen in the biopsy from the trunk. The appearances were clearly those of a sclerosing process of the dermis and subcutis and consistent with eosinophilic fasciitis. Our diagnosis was EF with morphoea overlap and she was treated with oral methotrexate 15 mg weekly and oral prednisolone 50 mg once daily (weight 60 kg), reducing the dose by 5 mg every 2 weeks. An 80% improvement was seen in functionality within 3 months, but the skin remained tight and thickened and therefore the patient was referred for phototherapy [ultraviolet A 1 (UVA1)] as combination therapy. We present a rare case of EF, which appears to have been triggered by intensive exercise. Other causes include insect bites, radiation, infections (Mycoplasma and Borrelia) and paraneoplastic. Haematological associations have been seen, including aplastic anaemia and lymphoma. Treatment options for EF include prednisolone, UVA1/psoralen + UVA, immunosuppressive systemic agents (including ciclosporin and methotrexate), biological agents (including infliximab and rituximab) and physiotherapy.
ABSTRACT
Coronavirus disease 19 (COVID-19) is the worst pandemic ever recorded in history, as of this day more than 545 million people infected and more than 6 million cumulative deaths. COVID 19 is primarily respiratory disease, however non-respiratory presentations that could be manifested are venous and arterial thromboembolic events. Both pulmonary embolism (PE) and deep vein thrombosis (DVT) are the most frequently thrombotic events in COVID-19. Knee arthroscopy surgery is the one of the most common orthopedic surgical procedures nowadays, with the most common procedures are meniscectomy, meniscal repair and cruciate ligament reconstruction. Although knee arthroscopy is known to be a safe procedure, several complications could be found with the 3 most common complications are DVT, effusion and synovitis, and PE. We reported a case series of four patients with DVT post knee arthroscopy anterior cruciate ligament reconstruction during 2021. The DVT diagnosis was retained on clinical presentation and elevated of D-dimer testing. The patient's mean age was 35,25 years, and all of the patients had no risk factors of DVT, although they had COVID-19 infection within 3 months before surgery. The most common clinical presentation was swelling on the lower leg (around the ankle) with slightly pain and numbness. Only one patient had severe pain around the thigh. All of the patients had elevated D-dimer testing result with mean of D-dimer 1250 (normal value < 500). Only one patient had sonography testing and found proximal DVT. One of the patients had DVT at post operative day (POD) 3, one at POD 4 and the other two at POD 5. Three of the patients improved with oral anticoagulant therapy using rivaroxaban (XARELTO). In one patient the symptom was not improved after two days oral anticoagulant therapy and underwent thrombectomy by vascular surgeon. DVT is the most common complication of knee arthroscopy and also the most common non-respiratory events of COVID-19 infection. Routinely administration of thromboprophylaxis agent was not recommended, pre-operative risk assessment of DVT should be used, especially in post-COVID 19 patients.
ABSTRACT
Background/Purpose: IgA vasculitis is the most common vasculitis affecting children. Vasculitis can be associated with the inflammatory process following infections, involving single or multiple organs. COVID-19 associated vasculitides have been reported variously, mostly Kawasaki-like features, livedo reticularis and rarely cutaneous small vessels vasculitis. Recently, there have been reports of IgA vasculitis following COVID-19 infection in children, although data among Asians are scarce. Method(s): Case report Results: We herein report a case of a previously healthy 6-year- old Thai boy with history of COVID-19 infection 4 weeks earlier, with only mild upper respiratory tract symptoms treated by a 5 day-course of favipiravir and supportive medication. He presented with rash over both lower limbs with difficulty to bear weight for a week. He denied fever, abdominal pain, nausea, vomiting, or any abnormal urinary symptoms. Physical examination revealed palpable purpura distributed on both lower legs with pain in his left foot and difficulty in bearing weight. His blood pressure was unremarkable for age at 97/67 mmHg. The initial investigations showed complete blood count with white cell count of 8.9 x 103/muL (neutrophils 47.3% and lymphocytes 42.4%), hemoglobin of 13.6 g/dL, which had no anemia for his age and platelet count of 297 x 103/muL. His urinalysis showed 2-3 red blood cells and 0-1 white blood cells per high power field without proteinuria and normal renal function. The erythrocyte sediment rate was 11 mm/hr and c-reactive protein was 3.9 mg/L, which were in normal range. He was diagnosed as IgA vasculitis and non-steroidal anti-inflammatory drug was prescribed to alleviate arthralgia of left foot. A week later, he revisited due to pain and swelling at his left scrotum. He was diagnosed as orchitis, one of the clinical manifestations of IgA vasculitis that can occur in boys. He had ongoing palpable purpura on the legs but pain at the left foot subsided. He then received oral prednisolone for the indication of orchitis at the dosage of 1 mg/kg/day with subsequent tapering for total duration of 3 weeks. All of his symptoms completely resolved. Conclusion(s): We present the interesting case of a Thai boy clinically diagnosed with IgA vasculitis following COVID-19 infection, having the clinical manifestations of palpable purpura, arthralgia, and orchitis. There are very limited data about post COVID-19- associated IgA vasculitis in children, especially in the Asian population. We would like to highlight this condition for physicians and to raise the awareness in the COVID-19 era.
ABSTRACT
Case 1 was an 81-year-old man undergoing treatment for the nummular eczema of the lower leg. The day after being administered the first dose of a COVID-19 vaccine, the patient developed generalized pruritus, multiple serous papules, and erythema on the trunk, upper extremities, and palms, as well as worsening of pre-existing eczema on the lower legs. The serum TARC level of the patient was 1,383 pg/mL. After taking oral antihistamines and topical steroids for two weeks, the erythema faded, papules crusted, and serum TARC level normalized. Case 2 was a 22-year-old woman who had been treated with topical steroids for contact dermatitis by poultices on the ankles. On the same day as she received the second dose of COVID-19 vaccine, erythema with pruritus on the dorsum of the feet appeared and gradually expanded to papules and edematous erythema on the face, extremities, and trunk. The serum TARC level of the patient was 2,090 pg/mL. After taking 15 mg/day oral prednisolone and topical steroids for 10 days, overall erythema became hyperpigmented, and the erythema on the dorsum of the hands and fingers persisted for approximately 2 weeks and then became pigmented. Serum TARC level normalized after the skin rash reformed. Case 3 was a 74-year-old woman with a history of asthma. She received SBT/ABPC therapy for acute cholangitis for one week. Ten days after treatment, she received the first COVID-19 vaccination dose. Two days after vaccination, the patient became aware of pruritus on the extremities ipsilateral to the vaccination site, and small erythematous patches appeared all over the body in a disseminated pattern. Her serum TARC level was 3,862 pg/mL. After taking oral antihistamines and topical steroids for 3 weeks, the erythema completely faded, and the serum TARC level normalized. The DLST showed positive by SBT/ABPC, but the result of drug challenge test was negative. There have been no previous case reports of rash with a high TARC level after vaccination. In the future, it is necessary to accumulate patients with a high TARC level by vaccination and analyze the clinical and pathological trends including immunological mechanisms. Copyright © 2022 Osaka University Medical School. All rights reserved.
ABSTRACT
Background: Case Report: Conclusion(s): Leukocytoclastic vasculitis (LCV) can lead to both dermatological and neuropathic symptoms with many patients ultimately meeting criteria for complex regional pain syndrome (CRPS). While there are accepted treatments for both LCV and CRPS, when these treatments fail, there is very limited evidence for next steps in management. A 34-year-old woman with a history of COVID exposure-induced LCV presented to the pain medicine clinic with back and left lower leg pain. The patient failed medical management and initial conservative interventions. Ultimately lumbar sympathetic nerve block resulted in significant and lasting improvement in her symptoms. Sympathetic blockade shows promise in the treatment of refractory vasculitis and chronic pain. More extensive research with a larger sample size and longer patient follow-up is necessary to determine the true efficacy of sympathetic nerve block in both CRPS and vasculitis. Copyright © 2022, American Society of Interventional Pain Physicians.
ABSTRACT
CASE: A 30-year-old previously healthy male presented with three weeks of progressively worsening pain, erythema, swelling in his left thigh, inability to bear weight and associated fatigue, fever, and dyspnea on exertion. Four weeks prior, he experienced 1 week of anosmia, fatigue, and “even worse” dyspnea on exertion with a resting heart rate in excess of 110 bpm and felt he most likely had had COVID. He self-treated for symptoms, rested, isolated and felt he had improved from COVID. The pain and swelling in the left leg increased over the prior three weeks and he sought care. On exam the left thigh was warm to touch, erythematous, and painful. Ultrasound imaging revealed left lower extremity deep venous thrombosis (DVT) extending from his upper thigh to lower leg. Abdominal/thoracic CT w/ contrast noted diffuse pulmonary emboli and May-Thurner Syndrome (MTS). Treatment was started with IV heparin followed by thrombolytic therapy with higher dose heparin and alteplase for 3 days. Shortly after this therapy was initiated, he developed significant hypoxia and was transferred to the ICU. He was stabilized and on the final day of thrombolytic therapy, a left common iliac vein stent was placed and he was discharged two days later on Apixaban and aspirin. IMPACT/DISCUSSION: May-Thurner syndrome (MTS), is an anatomical variant that may lead to venous outflow obstruction due to extrinsic compression by the iliac arterial system against bony structures in the iliocaval venous territory. Most common in the left leg, MTS is present in about 20% of the population and is more commonly found in women. It can result in venous hypertension and venous thromboembolisms (VTE). In serious and untreated cases, these VTEs can progress to pulmonary embolisms with resultant serious injury, hospitalization, and death. In this case, a recent COVID infection unearthed an MTS anomaly. The activated proinflammatory state induced by COVID is known to result in blood clots in hospitalized patients and appears to be related to a cytokine storm. This inflammatory state induces endothelial damage, microvascular thrombosis, and possibly pro-thrombotic antiphospholipid antibodies. In hospitalized patients with more severe disease VTE is commonly diagnosed, however the risk of COVID related coagulopathy in the outpatient setting is unknown. It appears that when blood clots do develop in outpatients, 1/5 have had a recent COVID infection which indicates an association between inflammation from infection contributes to VTE. In this case, the COVID complication helped to uncover a May-Thurner anomaly. CONCLUSION: - Delayed presentation can exacerbate COVID-related complications, even after acute symptoms have diminished - more should be done to educate patients on the dangers of post COVID thromboembolic disease. - Despite its prevalence in females, May-Thurners Syndrome should be in the differential for males with DVT.
ABSTRACT
Objective: To describe a case of a 58-year-old patient who presented to the hospital with Acute Inflammatory demyelinating Polyneuropathy (AIDP) as the first symptom of SARS COVID-19 infection without other classic manifestations of COVID-19 infection. Background: COVID-19 associated Guillain Barre syndrome is now widely reported. In our literature review, the majority of GBS patients had preceding respiratory symptoms of COVID19 but our patient had no other systemic involvement, and his symptoms started noticeably within a short duration of exposure. Design/Methods: Case report. Results: 58-year-old male patient presented to the hospital with bilateral lower extremity weakness, facial diplegia and dysphagia. Patient was tested positive for COVID-19 infection three days prior to the symptom onset due to a work-related exposure. He denied having any flu-like symptoms except generalized weakness. Patient reported progressive lower leg weakness started three days back with associated numbness and radicular pain up to T4 level. On examination, the patient had facial diplegia, areflexia and bilateral lower limb ataxia with the strength of about 3/5. CSF analysis showed albuminocytological dissociation. MRI brain and spine showed faint enhancement of lower lumbar roots. GQ1b antibody was positive on Ganglioside panel. With the clinical criteria and laboratory evidence, patient was diagnosed with AIDP. Patient was started on IVIG but due to lack of improvement after four doses patient was switched to therapeutic plasma exchange. He underwent a total of 7 sessions of plasmapheresis with improvement of motor and sensory symptoms. Conclusions: Although most cases were symptomatic for COVID-19, patients without respiratory or systemic symptoms raises a significant healthcare concern, namely the importance of SARS COVID-19 testing in all patients with suspected GBS during this global pandemic. Early diagnosis of COVID-19 associated GBS is also essential for rapid case isolation.
ABSTRACT
Introduction: The SARS-CoV2/COVID-19 pandemic represented an unprecedented emergency prompting a drive to minimise non-essential patient contact and the need for a virtual fracture clinic (VFC);an uncommon practice in paediatric units. Management of paediatric fractures requires a greater degree of vigilance to safeguard children. The current climate has created social challenges that theoretically increase the risk of harm and exploitation to children. This study investigates VFC in the management of paediatric fractures to determine the efficiency of such a process and the risk of safeguarding. Method: A protocol was devised in affiliation with BSCOS for the immediate management and streamlining of paediatric fractures into VFC. We retrospectively audited 235 VFC consults over a 1-month period. Patient sex was roughly evenly distributed, and age ranged from 9 months to 16 years (mean 8.4 years). Results: 42% of patients were recalled for a face-to-face (F2F) review (26% expedited), primarily for clinical assessment, plaster complaints and imaging requirements. 33% were discharged and 15% continued follow-up in VFC. All clavicle fractures were discharged. Forearm, hand, foot and elbow injuries were more likely to be discharged. Lower leg, upper arm and knee presentations more frequently required a F2F review. 2.3% of cases required safeguarding reviews. Conclusions: Given the rapid transition to VFC without the use of triage we have determined a number of non-complex fractures safely managed and discharged via VFC. The low percentage of recall due to safeguarding concern highlights this may not be a barrier to the continuation of virtual care outside of the context of a pandemic.
ABSTRACT
Case report-IntroductionCOVID-19 pandemic affected medical practise significantly and caused difficulties in accessing necessary investigations at the appropriate time. As of March 2020, NHS England issued measures to redirect staffs and resources in preparation for the rising cases of coronavirus. As a result of this, non-urgent tests/treatments were put on hold. We present a new case of EGPA admitted to our district general hospital during the COVID-19 pandemic to highlight the challenges faced. The diagnosis was reached based on clinical judgment in the absence of some confirmatory tests as well as the decision of starting immunosuppressant treatment during the pandemic.Case report-Case descriptionA 41-years-old lady with a background of well-controlled asthma, presented with five days history of paraesthesia and swelling in both legs. She also reported mild pleuritic chest pain, which radiated to her left arm. Physical examination revealed left foot drop. She had reduced sensation on the L5-S1 dermatomal distribution with absent ankle reflex and reduced knee reflex of her left leg. Her left calf was swollen and tender. The rest of her examination was unremarkable.Baseline blood revealed raised WCC of 19.3 with significant eosinophilia (10). CRP and ESR were 135 mg/L and 48mm/hr, respectively. Electrocardiogram showed new T-wave inversion in the anterolateral leads with significantly raised troponin levels. There was ground glass appearance in both lungs, keeping with suspected COVID-19 and no evidence of pulmonary embolus was found on CTPA. MRI spine confirmed no evidence of cauda equina compression. Deep vein thrombosis was also excluded with US doppler.She was treated as myocarditis and pneumonia secondary to probable COVID-19 infection. Echocardiogram revealed severe LVSD (EF < 35%) with no LV hypertrophy. Three days later, she became acutely breathless and required high flow oxygen. New bilateral basal crackles were found on auscultation. Her antibiotic regimes were escalated to intravenous infusion.A revised CT report suggested the findings may correlate with eosinophilic pneumonia or EGPA. MRI of lower legs proved muscular oedema in bilaterally, which was suggestive of myositis with fasciitis. There was no significant change on the thigh musculature. CK level was slightly elevated (403 IU/L). Urinalysis was positive for blood (3+). Given the strong clinical suspicion of EPGA, a decision to start high dose steroid therapy was made, despite the pending immunology results. After the third dose of the methylprednisolone, pulsed cyclophosphamide was started along with high dose oral prednisolone. The patient was discharged home following significant clinical improvement.Case report-DiscussionThis patient has fulfilled 4 out of 6 criteria of ACR 1990 classification for EGPA, which are eosinophilia, bronchial asthma, mononeuritis multiplex and pulmonary infiltrates on radiological images. However, in the context of current pandemic, these changes on chest CT findings could also be suggestive of COVID-19 pneumonitis.At present, there is no reliable test for COVID-19. Even though RT-PCR testing has been the gold standard for diagnosing suspected cases, the clinical sensitivity and specificity of these tests are variable. A negative test may not rule out infection. In our case, the patient was tested twice at separate times to rule out the possibility of COVID-19 infection.During the pandemic, there is extremely limited access to some confirmatory tests. We were not able to perform nerve conduction studies on our patient as the service was suspended, instead, we sought neurologist's review to confirm the mononeuritis multiplex. We also sought advice from haematologist to rule out the possibility of hyper-eosinophilic syndrome as bone marrow biopsy was unavailable. The screen for atypical pneumonia, aspergillosis, viruses, and tuberculosis were negative. By excluding the alternative diagnoses related to eosinophilia, we concluded that this was likely to be a case of first presentation EGPA.Our next obstacle was intr ducing remission-induction regimens during COVID-19 pandemic. BSR does not recommend starting new treatment due to the increased risk of infection. We had to weigh out the benefits and risks of initiating immunosuppression. Our patient was made aware of the potential risks involved which include severe infection with COVID-19. She was also shifted to a side room with strict infection control precautions and PCP prophylaxis prescribed before starting pulsed methylprednisolone and cyclophosphamide. Fortunately, her neurological symptoms resolved after three days of steroid therapy. Eosinophils count dropped within 1 day to zero, after the first dose of IV methylprednisolone.Case report-Key learning pointsDespite the rising cases of COVID-19 infection, it is essential to keep an open mind and consider alternative diagnosis if a patient did not respond to conventional treatment. As EGPA and COVID-19 pneumonia share similar clinical and radiological presentation, clinical judgement is essential when making the diagnosis as the treatments for both conditions are vastly different. When EGPA is suspected, a multidisciplinary team should be involved in the evaluation of different organ involvements as well as ruling out other causes of eosinophilia. The role of specialists' inputs is extremely important in reaching the diagnosis, especially with limited access to the usual confirmatory tests due to reduced services during the pandemic.In addition, when there is an increased risk of infection such as during the COVID-19 pandemic, it is essential to weigh up the benefits and risks of commencing immunosuppressant treatment carefully. Patients need to be involved in the decision-making process as well as take precautions to minimise the risk of infection. The decision to start remission induction regimes should not be delayed if there is a presence of life or organ threatening disease manifestations in EGPA patients. Our patient has had a life-threatening disease because of multi-organ involvements (cardiac, pulmonary, and neurological systems).