Cognitive impairments and COVID-19.

Cognitive dysfunction is one of the manifestations of the neurological complications in coronavirus infection. In this article, we have collected material on the state of cognitive functions after suffering a coronavirus infection with aspects of possible pathogenetic mechanisms and a discussion on the prospects for treatment and rehabilitation. The COVID-19 pandemic, having manifested itself in December 2019, remains one of the most controversial topics in the world to the day. The growing number of reports about damage to the nervous system during coronavirus infection suggests that the virus is neurotropic. In the clinical picture of the disease, less attention is paid to such symptoms as severe weakness, fatigue, memory impairment. At the same time, it is this symptomatology that most often accompanies patients in the postcovid period and significantly reduces their quality of life, thereby making it difficult to adapt to social and work activities. The search was conducted for literatures published within the period from 2020 to the third quarter of 2021, domestic and foreign sources from the Web of Science, PubMed databases were analysed. The search queries were the following ones: "COVID-19", "cognitive impairment", "postcovid syndrome".Copyright © 2022, Krasnoyarsk State Medical University. All rights reserved.

Novel Framework for Neurocognitive Covid-19 Assessment

Background The neurotrophic effects of Covid-19 are becoming increasingly recognized, with altered mental state now being the second most common presenting complaint insert numbers. A key question is whether this has long term consequences. Cognitive problems are commonly reported in patients 3 months after acute infection as part of the so called Long-Covid syndrome. However, the underlying cause is not well understood. Candidate explanations include legacy from encephalitis and stroke;however, other complications such as the sequelae, delirium, remain underexplored. Furthermore, little consideration has been given to functional cognitive disorders and the cognitive consequences of depression, anxiety and fatigue. Aims We propose a structured approach to clinical assessment for clinicians reviewing late cognitive complaints after COVID 19. Methods We created our own unique framework for neurocognitive Covid assessment based upon a review of the literature. Results Covid status- Any positive test. If not review of core symptoms such as breathlessness, headache, anosmia, nasal obstruction, cough, myalgia, or gustatory dysfunction;duration, extent of exposure to Covid confirmed cases. Consider rapid antibody testing. Neuropsychiatric history- Part 1 symptoms at onset- in particular disruptions of consciousness and altered mental state. Acute memory impairment, anterograde/retrograde and with/ without a temporal gradient. neurocognitive function. ITU admission and oxygen requirements. Part 2 Current cognitive and mental state- in addition to standard history seek evidence of internal inconsistency of memory symptoms and attentional dysregulation. Has social cognition and meta-cognition been affected. Note attribution bias i.e. no Im not depressed, I cant enjoy anything because of my symptoms Background history- subtle suggestion of neurodegeneration and depression, anxiety and functional symptoms should be explored. MRI findings- signal changes in the medial temporal lobe, nonconfluent multifocal white matter hyperintense lesions, and isolated white matter microhemorrhages. Novel biomarkers IL-6, MCP-1, and IP-10. Conclusion Cognitive symptoms are common after confirmed and assumed COVID exposure. We propose a framework for neuropsychiatric assessment and the use of adjuvant imaging and potential biomarkers.

Post COVID syndrome in health care workers in Tunisia: is there any correlation with SARS-CoV-2 IgG level?

Introduction: The correlation between the level of IgG titers and disease severity during the acute phase of COVID19 is well described. However, rare data are available on possible association between IgG titre and post COVID syndrome (PCS). Method(s): It was a prospective study. HCW who presented to the post-COVID outpatient clinic, 3 months after recovery were included. HCW were asked about the acute phase of COVID-19 and PCS symptoms and had serum samples for SARS-CoV-2 IgG. Aim(s): analyse the incidence of PCS among health care workers (HCW) and correlation with SARS-COV2 IgG level. Result(s): 108 HCW were included (mean age: 42.12+/- 10.31 years, sex ratio was 0,4). Initially, 4.6% experienced severe disease. PCS was detected in 63% of cases. Main symptoms were memory impairment (36.8%), fatigue (35.3%), dry cough (32.4%), dyspnea (32.4%) and asthenia (29.4%). The incidence was 100%, 57,1% and 62,7% in patients with severe pneumonia, mild pneumonia and without pneumonia, respectively (p=0,079, p=0,45 and p=0,92) (The incidence was 7,4%, 23,5% and 69,1% in patients with severe pneumonia, mild pneumonia and without pneumonia, respectively (p=0,079, p=0,45 and p=0,92)). At Follow up, the IgG level was positive in 70.4% of cases with an average rate of 8.44. HCW with PCS, were more likely to have a positive IgG level (67% vs 32%;p=0,41). Moreover, IgG rate was higher in this population (9.06 vs 7,48;p=0,38). Patients with no IgG had 40% less possibility to have PCS symptoms. Conclusion(s): The present study confirmed a high incidence of PCS in HCW. These symptoms were associated to a higher level of IgG suggesting immunological mecanisms. Further studies are needed to confirm these data.

Characteristics of post-covid syndrome in elderly patients with rheumatic diseases

Purpose: To compare the frequency of occurrence of various symptoms of post-covid syndrome (PCS) in groups of patients with rheumatic diseases (RD) of the elderly to young. Material(s) and Method(s): The study involved 89 patients with RD who underwent COVID-19, verified by RT-PCR for SARS-CoV- 2 RNA, for the period from 05/15/2020 to 12/01/2021. Participants in the study, after talking with the research physician, completed questionnaires on past COVID-19 and post-COVID syndrome (PCS). The information was supplemented with data from discharge records after inpatient treatment for COVID-19. Result(s): The data obtained were differentiated depending on the age of the participants: <60 years (group 1), N = 69 and >=60 years (group 2), N = 20. Both groups were dominated by women (82.6% and 85%). The average age in group 1 was 41.9 +/- 11.6 years, in group 2 -68.5 +/- 5.1 years. 33 (47.8%) patients in group 1 and 10 (50%) in group 2 noted the development of PCS. In group 1, the following symptoms of PCS prevailed: memory impairment -in 17 (51.5%) patients, fatigue, weakness -in 14 (42.4%), problems with concentration -in 14 (42.4%), arthralgia -in 12 (36.4%) %, shortness of breath during physical exertion -in 11 (33.3%), drowsiness -in 10 (30.3%), irritability -in 9 (27.3%). In group 2, the most common memory impairment -in 8 (80%) patients, weakness, fatigue -in 7 (70%), arthralgia -in 7 (70%), problems with concentration -in 6 (60%), weight loss -in 5 (50%), irritability -in 5 (50%), sleep disturbance -in 5 (50%). The frequency of occurrence of different manifestations of PCS did not differ significantly between the groups. On average (median), each patient in group 1 noted 4 [2;8], group 2 -10 [8.25;12.5] symptoms of PCS at the same time, but the differences did not reach statistical significance. Conclusion(s): The frequency of occurrence of various clinical manifestations of PCS did not have statistically significant differences between the study groups. In a comparative assessment, the group of elderly patients noted a greater number of symptoms of PCS at the same time.

SLEEP-DISORDERED BREATHING AND LONG-HAUL COVID-19: A CASE REPORT

SESSION TITLE: Uncommon Presentations and Complications of Chest Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: The correlation between long-haul Coronavirus 2019 (COVID-19) and sleep disorders remains poorly understood. In this report, we present a case of newly diagnosed central sleep apnea (CSA) and symptoms starting after a COVID-19 infection as part of a long-haul COVID-19 presentation. CASE PRESENTATION: A 69-year-old male presented to a sleep medicine clinic for evaluation of hypersomnia. He had a history of hypertension and pulmonary embolism. He contracted COVID-19 eight months prior to his presentation. He was not hospitalized, but received Remdesivir and prednisone. He complained of long-haul COVID-19 symptoms since his infection which included headaches, fatigue, cough, dyspnea, anosmia, poor appetite, dysgeusia, and memory impairment. He also started noticing nocturnal apneic episodes that frightened him and woke him up from sleep. His symptoms started after his infection and were not present prior. He went to the emergency department for evaluation and no etiology was identified. He was then referred to sleep medicine for further evaluation. A home sleep apnea test was done and showed severe sleep apnea with an Apnea-Hypopnea Index of 35.7 events per hour. His sleep apnea was predominantly central with a central apnea index of 15.3 events per hour. Cardiac testing showed no evidence of ischemia or cardiomyopathy with an ejection fraction of 52%. A CT angiogram showed no evidence of PE. Brain MRI showed no acute abnormalities. He was started on positive airway pressure therapy but could not tolerate it so he was sent for a phrenic nerve stimulator implantation. DISCUSSION: Long-term sequelae of COVID-19 infection have been increasingly recognized. However, the etiology and pathophysiology is poorly understood (1). Symptoms of long-haul COVID-19 include fatigue, dyspnea, cognitive manifestations, thrombosis and sleep disturbances (1). Sleep apnea was found in some studies to be a risk factor for severe COVID-19 illness and worse outcomes (2). The relationship between COVID-19 and sleep apnea in the post-viral syndrome remains unknown. Only few case reports have found obstructive sleep apnea as a new diagnosis and a possible cause of fatigue in post COVID-19 infection (3). There is no report of a relationship between CSA and COVID-19 in the literature. It is hypothesized that long-COVID can lead to brainstem dysfunction and dysautonomia, which can affect the ventilatory control mechanisms and lead to an unstable respiration (4–6). Our patient's nocturnal symptoms started after his infection as part of long-haul COVID-19. While we cannot determine if CSA was a result of COVID-19 infection or not, it is important to evaluate for sleep disordered breathing (SDB) in patients presenting with long-COVID symptoms to better understand the association. CONCLUSIONS: More research is need to better understand the correlation between SDB and long-haul COVID-19. Reference #1: 1. Mehandru S, Merad M. Pathological sequelae of long-haul COVID. Nat Immunol. 2022 Feb;23(2):194–202. 2. Miller MA, Cappuccio FP. A systematic review of COVID-19 and obstructive sleep apnoea. Sleep Medicine Reviews. 2021 Feb;55:101382. Reference #2: 3. Koczulla AR, Stegemann A, Gloeckl R, Winterkamp S, Sczepanski B, Boeselt T, et al. Newly detected rapid eye movement associated sleep apnea after coronavirus disease 2019 as a possible cause for chronic fatigue: two case reports. J Med Case Reports. 2021 Dec;15(1):211. 4. Barizien N, Le Guen M, Russel S, Touche P, Huang F, Vallée A. Clinical characterization of dysautonomia in long COVID-19 patients. Sci Rep. 2021 Dec;11(1):14042. Reference #3: 5. Yong SJ. Persistent Brainstem Dysfunction in Long-COVID: A Hypothesis. ACS Chem Neurosci. 2021 Feb 17;12(4):573–80. 6. White DP. Pathogenesis of Obstructive and Central Sleep Apnea. Am J Respir Crit Care Med. 2005 Dec;172(11):1363–70. DISCLOSURES: No relevant relationships by Amer Als ekh Mousa No relevant relationships by University of Arizona at Banne Institute No relevant relationships by Joyce Lee-Iannotti No relevant relationships by Anas Rihawi No relevant relationships by Amr Salem No relevant relationships by Mohanad Soliman No relevant relationships by Kristen Trimble

Donepezil Beyond Alzheimer’s Disease? A Narrative Review of Therapeutic Potentials of Donepezil in Different Diseases

Donepezil hydrochloride is an acetylcholine esterase inhibitor studied and approved to treat Alzheimer’s disease (AD). However, this drug can have positive therapeutic potential in treating different conditions, including various neurodegenerative disorders such as other types of dementia, multiple sclerosis, Parkinson’s disease, psychiatric and mood disorders, and even infectious diseases. Hence, this study reviewed the therapeutic potential of this drug in treating Alzheimer’s and other diseases by reviewing the articles from databases including Web of Science, Scopus, PubMed, Cochrane, and Science Direct. It was shown that donepezil could affect the pathophysiology of these diseases via mechanisms such as increasing the concentration of acetylcholine, modulating local and systemic inflammatory processes, affecting acetylcholine receptors like nicotinic and muscarinic receptors, and activating various cellular signaling via receptors like sigma-1 receptors. Despite many therapeutic potentials, this drug has not yet been approved for treating non-Alzheimer’s diseases, and more comprehensive studies are needed.

CHARACTERISTICS of POST-COVID SYNDROME in PATIENTS with RHEUMATOID ARTHRITIS

Background: Almost two years after the start of the pandemic, it has become clear that the severity of COVID-19 is not limited to the manifestations of the acute phase of SARS-CoV-2 infection. The so-called post-covid syndrome (PCS) can occur even in patients who have experienced mild or moderate COVID-19 and includes long-term symptoms that may be associated with residual infammation, organ damage, non-specifc effects of hospitalization or prolonged ventilation, social isolation, or comorbid diseases. In October 2021, the WHO defned PCS as a condition that occurs in individuals with a history of probable or confrmed infection with the SARS-CoV-2 virus, usually within 3 months of the onset of COVID-19, and is characterized by the presence of symptoms for at least 2 months, as well as the impossibility of explaining them with an alternative diagnosis. Objectives: To conduct a comparative assessment of clinical and demographic indicators in groups of patients with rheumatoid arthritis who underwent COVID-19, with and without PCS. Methods: The material of the questionnaires flled in by patients of the V.A. Nasonova Research Institute of Rheumatology, who underwent COVID-19, ver-ifed by RT-PCR for SARS-CoV-2 RNA. The information was supplemented with data from discharge records after inpatient treatment for COVID-19. Statistica program (version 12) was used for statistical processing. The results of correlation analysis were considered signifcant at p<0.05. Results: The study included 23 adult patients (over 18 years of age) with a reliable diagnosis of rheumatoid arthritis (ACR/EULAR). Of these, 11 (47.8%) patients noted the development of PCS (Group 1), and 12 patients underwent COVID-19 without consequences (Group 2). Both groups were represented predominantly by women (90.9% and 91.7%, respectively). The average age in both groups did not differ sig-nifcantly and amounted to 56.73±14.79 years in group 1, and 48.17±19.59 years in group 2. The median number of comorbid diseases was 2 [1;4] in group 1 and 0.5 [0;2.5] in group 2. PCS was presented by the following symptoms: weakness, increased fatigue-in 6 patients, problems with attention, concentration-in 7, memory impairment-in 6, sleep disturbances-in 7, increased pain in the joints-in 7, shortness of breath during exercise-in 6, fuctuations in blood pressure-in 5, tachycardia-in 4. On average (median), each patient noted 10 [6.5;12] symptoms of PCS at a time. When assessing the number of symptoms in the infectious phase, in group 1, patients reported 20 [16;23], and in group 2, 10 [7;12] symptoms of COVID-19. At the time of development of COVID-19, the severity of RA symptoms, assessed by VAS, was 5.64±3.26 in group 1 and 4.75±2.99 in group 2. In group 1, 5 (45.5%) patients needed hospitalization, 3 of them needed oxygen support. In group 2, 4 (33.3%) patients were hospitalized, two of them needed oxygen support. 3 patients in group 1 suffered COVID-19 again on average 9.33±2.52 months after the frst illness. One of them has been vaccinated. All patients in this group were treated as outpatients, while the frst case of COVID-19 required one hospitalization and oxygen support. Statistical assessment of signifcant differences (p<0.05) between groups in terms of sex, age, number of comorbid diseases, number of COVID-19 symptoms in the infectious phase, severity of RA symptoms, and hospitalization rate was not revealed. Conclusion: Even though when assessing the socio-demographic characteristics, no statistically significant differences were found between the study groups, the average age, the number of comorbid diseases, and the severity of RA symptoms at the time of COVID-19 were higher in the group of patients with RA and PCS. Patients with PCS reported higher rates of hospitalizations and more severe COVID-19. There were also repeated cases of COVID-19 in this group. It is necessary to continue the study on a larger cohort.

EFFECT OF COVID-19 CORONAVIRUS INFECTION ON THE COURSE OF RHEUMATOID ARTHRITIS

To date, there are numerous studies on the effect of COVID-19 on the course of autoimmune rheumatic diseases and the value of vaccination in preventing this dangerous viral infection. Objective: to assess the effect of coronavirus infection on the course of rheumatoid arthritis (RA), the severity of infection, the effect of current baseline therapy on infection outcomes, and the role of vaccination against COVID-19. Patients and methods. 134 patients with a reliable diagnosis of RA were interviewed and their outpatient records analysed during the pandemic period from January 2020 to July 2021. Results. Most of the patients were in the older age group (62.7 years on average), had an average disease duration of 13 years, low to moderate RA activity, comorbidities including arterial hypertension, excess body weight, type 2 diabetes mellitus, etc. All patients received synthetic basic anti-inflammatory drugs (BАID) and glucocorticoids (GC). Thirty-seven (27.6%) patients were vaccinated with the Sputnik V vaccine. Their adverse events were represented by soreness at the injection site (n=6) and transient flu-like syndrome (n=6). Worsening of joint syndrome was reported by 1 patient. COVID-19 was suffered by 43 patients, none of whom were vaccinated. 7 patients were hospitalized, 3 patients died (all had severe comorbidities). In the post-infection period, weakness (64%), memory impairment (48.7%), reduced ability to work (38.5%) persisted for a long time (42 days on average), which was due to the long withdrawal of BАID. Conclusion. No exacerbations of the disease were noted in those vaccinated with Sputnik V. COVID-19 was detected in 43 (32.1%) patients, 7 of whom required hospitalization and 3 died. Exacerbation of RA in the post-infection period was associated with prolonged withdrawal of BАID.

Longitudinal Evaluation of Neuro-PASC Symptoms

Objective: A longitudinal study (NeuCovid) was created at UC San Diego to compare the long-term neurological outcomes of SARS-CoV-2 infection in two cohorts, patients with and without prior neurologic disease. Background: While cross-sectional analyses have demonstrated the prevalence of neurological symptoms in the Post-Acute Sequelae of SARS-CoV-2 infection (PASC), the evolution of these symptoms over time has not yet been well-described. Design/Methods: Participants with neurological symptoms post-acute infection with SARS-CoV-2 were recruited. Team members conducted assessments including a detailed SARS-CoV-2 infection history, neurologic review of systems (scored on 10-point severity scale), neurologic exam, MoCA exam, and self-reported neuropsychiatric questionnaires, at baseline (conducted after acute infection resolved) and at 3-,6-, and 12-month follow-ups. As appropriate, participants were referred for imaging and neuropsychological testing. We report 6-month data, but 12-month data will be available in 2022. Results: 61 participants (69% female, mean age 50.2 years) were enrolled, 18 with prior known neurological disease. Acute COVID-19 disease severity was largely described as mild (44.4%) or moderate (48.1%). To date, 27 participants (74% female, mean age 52.6 years) completed baseline and 6-month follow-up visits. At baseline, the most common symptoms included fatigue (85.2%), headaches (74.1%), memory impairment (59.3%), insomnia (55.6%), and decreased concentration (48.1%). Complete symptom resolution was reported in 33.3% at 6-month follow-up. In the remaining participants at 6 months, persistent memory impairment (68.8%), decreased concentration (61.5%), fatigue (52.2%), insomnia (46.7%), and headache (45.0%) were reported. Average severity score decreased for fatigue (69.4%), headache (64.3%), insomnia (51.3%), decreased concentration (47.6%), and memory impairment (38.6%). Average MoCA scores improved from baseline (n=19, 26.4 to 28.0). Conclusions: Early in neuro-PASC, fatigue and headache were the most common reported symptoms. At 6-month follow-up, memory impairment and decreased concentration were most prominent. Only a third of participants had complete resolution of neuro-PASC symptoms at 6 months.

How did the Early COVID 19 Pandemic Lockdown Affect Care of Memory Disorder Patients?: Caregiver views

Objective: To evaluate caregiver views of care changes in memory disorder patients during early COVID 19 pandemic lockdown Background: Memory disorder patients often depend on caregivers for oversight of medical and daily care. The early lockdowns of the COVID 19 pandemic included restrictions which may have affected such care. Design/Methods: We developed a questionnaire to assess caregiver views on change in care of memory disorder patients during the early lockdowns of the COVID 19 pandemic. The questionnaire assessed caregiver views on 1: changes in daily care quality in patients living at home vs. a community care setting (skilled nursing, assisted living);2: changes in communication with physician offices;and 3: telehealth experiences. Patients had an established diagnosis, a virtual telehealth visit 4/06/2020 - 9/06/2020, and a caregiver able to survey by phone. Results: 89 patients met criteria, 69 living at home, 20 in community settings. 1. Regarding perceived quality of daily care, for patients living at home, 81% of caregivers saw no change, 12% worsening and 6% improvement. For patients living at community facilities, 50% of caregivers saw worsening, 5% improvement and 45% no change. 2. Regarding physician office communication, 67% of caregivers saw no change, 16% worsening, and 17% improvement. 3. Across all patients, 46% had a video telehealth physician visit. Of these, caregivers of 80% were satisfied with the encounter, 17% neutral, and 2% dissatisfied. 53% of caregivers were likely to choose future telehealth physician visits for the patient, 21% were neutral, and 17% unlikely. Conclusions: For memory disorder patients in the early pandemic lockdowns, for those living at community facilities, most caregivers perceived worse quality of daily care, but the average caregiver saw no change in physician office communication. Most caregivers were satisfied with, and would choose, video telehealth physician visits for follow up.

SPM analysis of a brain 18F-FDG PET/CT in a patient with neurological impairment after covid-19 infection

Background-Aim: A 46 years old housewife patient with a bachelor's degree in Law contracted Covid-19 at the end of March 2021. She had a flu-like form with associated asthenia and drowsiness and no lack of sense of smell. It has been resolved in 25 days. Later, she developed progressive immediate memory loss, word-finding issues, motor and thinking slowing down. Methods: CT brain scan appeared as within the norm as well as liver enzymes, TSH, Vitamin B12, Folate and Rapid Plasma Reagine. Anti- ENA DNA ANA HIV TPO TG were negative too. In October, the patient had a further neuropsychological assessment that showed an overall picture characterized by partial orientation to space, working memory disorders, writing and comprehension (of complex tasks) issues, and immediate memory loss (possible sign both of attention span and concentration reduction). The auto-antibodies were assessed in November and they resulted negative. Moreover, the brain MRI scan and EEG (dated at the end of November) were both within the range. CSF neurodegenerative biomarkers and anti-neuronal antibodies appeared in the norm too. Results: Ultimately, in December 2021 she underwent an 18F-FDG PET brain scan and the SPM analysis showed an extensive hypometabolism in the bilateral frontal cortex and bilateral straight gyrus. Spared the cingulate cortex. Conclusions: The patient contracted Covid in March 2021. She developed neurological deterioration identified by FDG-PET. Negative autoantibodies and CSF biomarkers. PET scan was the only exam to define the brain damage in the patient above. Symmetrical bilateral frontal cortex and bilateral straight gyrus hypo-metabolism have been observed, the last one at the direct level of the olfactory bulb. In this area, in patients who died from Covid-19 it has been histologically demonstrated (data to be published) the presence of cellular inclusions named Corpore Amylacea. They would be a small hyaline mass that functions as a waste container that accumulates in the human brain in aging and in neurodegenerative and infectious processes. It is hypothesized to be that it can be involved in a sort of brain cleaning process1. Recently it has been described that they contain some neoepitopes that are recognized by natural IgMs, revealing a possible link between them and the natural immune system2. However, to now in our patient, the only diagnostic tool to evaluate the brain condition has been the 18F-FDG PET.

Characteristics of patients referred to a cardiovascular disease clinic for post-acute sequelae of sars-cov-2 infection

Introduction: There is limited literature on the cardiovascular manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC). Methods: All consecutive adult patients presenting to the cardiology clinic at Yale-New Haven Hospital since July 2020, with positive COVID-19 serologic testing, were included. Results: Of 71 patients, average age was 46 years (range 19-74 years), 44 (62%) were female. 51 (72%) were White. 19 (27%) patients were hospitalized for COVID-19 (Table). Comorbidities included Hypertension (27%), hyperlipidemia (25%), diabetes (24%), and obesity (30%). On average, patients presented four months after COVID-19 diagnosis. The most common symptoms at presentation were dyspnea (45%, almost all exertional), palpitations (49%), and chest pain/pressure (49%). Patients also had memory impairment (20%), fatigue (39%), and headache (14%). There was no significant difference in cardiopulmonary symptoms (dyspnea, palpitations, and chest pain/pressure) by hospitalization status (p=0.70). TTE was abnormal in 13 of 62 patients and cardiac MRI was abnormal in 10 of 17 patients. Women experienced more cardiopulmonary symptoms (p=0.02) than men. Hospitalized patients were more likely to have ventricular dysfunction than non-hospitalized patients, although there were no significant differences in abnormal MRI findings (p=0.38). Diagnostic yield included: nonischemic cardiomyopathy (6%);new ischemia (3%);coronary vasospasm (1%);new atrial fibrillation (1%);possible myocarditis based on symptoms, MRI LGE (8%) or inflammation (3%). Two people met POTS criteria;majority of patients had evidence of sinus tachycardia and exertional fatigue consistent with orthostatic intolerance and deconditioning. Conclusions: In this cohort of patients referred to a cardiology clinic for PASC, cardiopulmonary symptoms did not differ by hospitalization status, however women were more likely to experience these symptoms than men.

Primary sjögren's syndrome VS MS: Overlap or misdiagnosis?

Case report-IntroductionPrimary Sjögren's syndrome (PSS) is a systemic autoimmune disease that mainly affects exocrine glands. Central nervous system (CNS) involvement in primary SS is extremely rare. In 10-20% of patients diagnosed with PSS, there are lesions in the central nervous system analogous to those presented in multiple sclerosis. We report a case of a 58-year-old female, diagnosed as PSS and multiple sclerosis (MS) (2007), but later, all neurological manifestations turned out to be related to PSS rather MS. This case illustrates how difficult it could be, distinguishing Sjögren's with CNS involvement from MS, even to an expert clinician.Case report-Case descriptionA 58-year-old lady presented to Rheumatology clinic in 2010 with polyarthralgia, sicca symptoms and Raynaud's. Immunology tests (positive anti-RO &anti-LA antibodies) and lymph node biopsy were highly suggestive of primary Sjögren's. She was commenced initially on HCQ and prednisolone. Then Methotrexate was added in because she continued to struggle with inflammatory arthritis.Her Sicca symptoms got gradually worse despite being on Acetylcysteine, Hylo Forte, cyclosporine and Dexamethasone eye drop. Therefore, autologous serum eye drops were tried with good response.Her past medical history included Hypertension and knee OA. She has been under Neurology since 2007 for MS. Her original neurological symptoms were imbalance, dizziness, headaches, and tremor of the right arm which seem to be persistent with no definite relapses. MRI brain and spine were reported as normal with a few non-specific white matter areas, but the lumbar puncture result was positive for unmatched bands in the CSF.Clinical examination revealed action tremor in the right upper limb. She had diminished vibration, pinprick, and cold temperature perception in a stocking distribution.InvestigationsWBC 2.0, lymphocyte 0.62, DsDNA 1, C3 0.061, C4 0.01. CRP <5, PV 1.63, APS screen was negative NCS: evidence of sensory and axonal neuropathy predominantly affecting lower limbs. CTCAP 2018-showed calcification of parotid. No evidence of lymphoproliferative disorder.The latest MRI 2019 showed two new lesions (right corpus &right striatum lesion) which according to Neuro-radiology MDT discussion were not typical of MS and more likely related to underlying CTD.Based on these MRI findings and the recent history of skin vasculitis, the deterioration in her neurological condition was put down to primary Sjögren's. Therefore, her treatment was escalated to cyclophosphamide during the COVID-19 pandemic with a particularly good outcome. She was then switched to MMF and her condition remained stable.Case report-DiscussionNeurological disorders are one of the rare manifestations of primary Sjögren's. The first reports regarding the involvement of the nervous system in PSS were published in 1980. Distinguishing between multiple sclerosis and CNS-SS is not easy.Not only because of similarities of the MRI findings, but also the course of the disease can be like MS, either chronic or relapsing and remitting. This usually leads to missing or delaying in the diagnosis as shown in this case.However, Peripheral neuropathy is far much common in PSS rather MS which can help in differentiating these two conditions. Distal axonal sensory polyneuropathy is the most usual form of neuropathy in PSS as illustrated in this case. Furthermore, up to 75% of patients with SS and active CNS disease have been shown to have concomitant active peripheral vasculitis affecting the skin, muscles, and nerves. Our patient later developed skin vasculitis and peripheral neuropathy which made us think that all the neurological findings including the lesions on the brain are more likely to be related to PSS rather MS.Cognitive disorders are common manifestations of CNS-SS such as attention disorder and memory deficit. Dementia-related to CNS-SS seems to be reversible after immunosuppressive treatment. A second MDT discussion took place and after considering the risk-benefit ratio, the decision was made to give cyclophospham de. Patient was given all the information to make an informed decision. Patient asked for more time to think and discuss with her partner, but eventually, she had decided to have cyclophosphamide despite all the risks and uncertainties around the COVID-19 pandemic. Our patient has noticed significant improvement regarding cognition after completing cyclophosphamide treatment and she was pleased with this outcome.Case report-Key learning points1/Distinguishing between multiple sclerosis and CNS-SS is difficult2/neurophysiological tests should be considered even in asymptomatic patients as they contribute to the detection of early and subtle damage to the nervous system. 3/Successful outcome being achieved with intensive immunosuppression despite all the uncertainties around the COVID-19-19 pandemic.4/This case highlights the importance of communication and openness in shared decisions, especially while confronting uncertainties such as in COVID-19 pandemic.