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Case Report: A 28 year old male with a past medical history of hypothyroidism and positive ANA presented to an outpatient dermatology clinic with a diffuse pruritic rash two weeks after the administration of his first Moderna COVID booster vaccine. He denied any other accompanying symptoms such as fever or chills as well as any similar rashes to prior doses of the Moderna COVID vaccine. The rash consisted of pink erythematous minimally scaly papules, thin plaques and patches involving the left and right dorsal hands, forearms, wrists, face, neck and left shoulder. The remainder of the patient's skin including the bilateral lower extremities, the eyelids, conjunctiva and oral mucosa was clear. The patient denied any similar rashes in the past. The patient denied any allergies to medications, or food or environmental allergies. He denied any notable contact allergen exposures, including to soaps, lotions, and cosmetic products. The patient also denied any significant family history or past surgical history. The patient was on Armour Thyroid for hypothyroidism and testosterone for low levels since age eighteen. The patient was started on cetirizine 10 mg once daily for the rash with minimal improvement. Autoimmune workup for the rash was notable for an elevated anti-RNP and as the patient's past medical history included Raynaud's phenomenon and ANA positivity for ten years, the patient was diagnosed with mixed connective tissue disease (MCTD). Autoimmune conditions can often have an indolent course, where symptoms progressively develop and worsen. MCTD is an autoimmune overlap syndrome that can consist of the following three connective tissue diseases: systemic lupus erythematosus, scleroderma, and polymyositis. Millions of individuals across the world are receiving COVID vaccines to protect themselves and members of their community, and it is of utmost importance that we continue to investigate adverse events. Although of low incidence, these rare effects have the ability to impact large numbers of people within both healthy and immunocompromised populations. It is critical that we examine and document them in a rigorous manner, to ensure safe vaccine delivery and reassure the public about vaccine safety overall.
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Introduction. The connection between the health of the oral cavity and general health is well known, because oral diseases can impair general health, but the health of the oral cavity can also be impaired due to the existence of a systemic disease. The structures of the oral cavity can be affected directly by the disease or indirectly due to the influence of drugs or due to the patient's behavior. Oral manifestations affect hard dental tissues, supporting tissues and oral mucosa. The changes that occur can lead to pain and discomfort, cause concern for the child and parents, and can be completely asymptomatic. Doctors of dental medicine are often the first to suspect the presence of a disease during a routine examination, because the area of the oral cavity is easily accessible for early detection of pathological changes. That way, they can directly influence the course and therapy of the systemic disease by early recognition and referring the patient to further tests. Aim of the lecture is to present oral manifestations of gastrointestinal diseases, diabetes, blood diseases, bacterial diseases and viral diseases with a special focus on COVID-19.
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Health professions preventing and controlling coronavirus disease 2019 are prone to skin and mucous membrane injuries, which may cause acute and chronic dermatitis, secondary infections and aggravation of underlying skin diseases. This is a consensus of Chinese experts on measures and advice on hand cleaning- and medical glove-related hand protection, mask-and goggles-related face protection, ultraviolet-related protection, as well as eye, nasal and oral mucosa, outer ear and hair protection. It is necessary to strictly follow standards on wearing protective equipment and specifications on sterilizing and cleaning. Both insufficient and excessive protection will adversely affect the skin and mucous membrane barrier. At the same time, using moisturizing products is highly recommended to achieve better protection.Copyright © 2020 by the Chinese Medical Association.
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Case report Introduction: Toxic epidermal necrolysis (TEN), is an immune-mediated disease characterized by severe mucocutaneous symptoms and is the result of an inflammatory response that leads to keratinocyte necrosis and perivascular lymphocyte infiltration, mostly drug-related. Case report: A 35-year- old male, with a history of recently diagnosed systemic lupus under treatment with prednisone, hydroxychloroquine, mycophenolate and cotrimoxazole forte evolves with persistent proteinuria, it is decided to add losartan, chlorthalidone and atorvastatin. Nevertheless despite immunosuppression, proteinuria and skin involvement persisted, so mycophenolate was suspended and a bolus of cyclophosphamide 1 g was administered. Eight weeks after adjusting treatment, the patient went to the emergency department due to a confluent, pruritic, maculopapular rash with blistering lesions on the trunk, upper limbs, face, and oral mucosa, associated with fever over 38degreeC, that evolved during one week. On admission, the following was confirmed: confluent erythematous macular exanthem associated with multiple flaccid blisters on the chest, upper limbs and neck, Nikolsky's sign (+), keratoconjunctivitis and dryness on the lips. Admission tests included complete blood count with no leukocytosis or eosinophilia, ESR 29 mm/hr, C-RP 19.8 mg/L, no liver profile abnormalities, creatinine 0.8 mg/dl, and urine test with proteinuria 300 mg/dl. Negative infectious study for mycoplasma, herpes 6 virus, cytomegalovirus, Epstein barr virus, hepatitis A, B, C, E and SARS-COV2 virus. Due to severe mucosal skin involvement, TEN/SJS was suspected v/s (TEN)-like Lupus presentation, drugs used prior to admission (chlorthalidone, losartan, atorvastatin) were discontinued, and treatment was started with Hydrocortisone 100 mg every 8 hours IV, Immunoglobulin 2 g/kg daily IV for 4 days, plus skin and mucous membrane care. Patient had a favorable evolution, with resolution of skin and mucosal lesions and no signs of infection. Skin biopsy showed necrotic epidermis, necrotic basal keratinocytes, and sparse lymphocytic inflammatory infiltrate in the papillary dermis, consistent with erythema multiforme/toxic epidermal necrolysis. Conclusion(s): Extensive mucosal involvement is one of the cardinal signs of the presentation of SJS/ETN and given its severity, a high index of suspicion is important with the consequent suspension of suspected drugs and support management for a favorable evolution. In this case the suspected culprit drug was the combination of cyclophosphamide and chlorthalidone, due to reports of increased toxicity of cyclophosphamide in combination with diuretic drugs.
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This study aimed to review zinc's effectiveness as an antivirus in treating herpes simplex virus infection. The authors use international journals published from 2000-2022, and use search engines such as Google Scholar, PubMed, and Science Direct with the keywords "zinc and herpes simplex virus". The herpes simplex virus that often causes symptoms in humans are HSV type 1 and type 2. The lesions appear as vesicles which then rupture into ulcers. Zinc is one of the most abundant nutrients or metals in the human body besides iron. Studies about the effects of zinc on HSV have shown that it has the function of inhibiting the viral life cycle. HSV attaches to the host cells to replicate and synthesize new viral proteins. Zinc can inhibit this process by depositing on the surface of the virion and inactivating the enzymatic function which is required for the attachment to the host cell, disrupting the surface glycoprotein of the viral membrane so it could not adhere and carry out the next life cycle, it can also inhibit the function of DNA polymerase that works for viral replication in the host cell. This article showed that zinc has effectiveness as an antivirus against the herpes simplex virus, therefore, patients infected with HSV can be treated with zinc as an alternative to an antivirus drug.Copyright © 2022 The Authors. Published by Innovare Academic Sciences Pvt Ltd.
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Paediatric patients comprise a small proportion of the SARS-CoV-2 infected population. They usually present with mild symptoms, however a small proportion of them may require intensive care due to shock and multi-organ failure related to Paediatric Inflammatory Multisystem Syndrome temporally associated with SARS-CoV-2 (PIMS-TS). This review article summarises the oral mucosal lesions in children with COVID-19 and PIMS-TS. The most common sites affected are the tongue and lips. Commonly reported lesions include cheilitis, dry and red lips, and tongue swelling. This article is of importance to all healthcare professionals involved in the multidisciplinary care for this group of patients.Copyright © 2021 The Authors
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SESSION TITLE: Autoimmune Diseases Gone Wild: Rare Cases of Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Post-Covid-19 Multisystem Inflammatory Syndrome (MIS) is a severe hyperinflammatory syndrome associated with either the acute or recovery phase of covid-19 infection affecting multiple organ systems requiring hospitalization. This syndrome has been described in both children (MIS-C) and adults (MIS-A). Several case reports and systematic reviews have reported an association between post-covid-19 MIS-A and several autoimmune diseases. CASE PRESENTATION: We herein report a case of a 27-year-old female with no known chronic medical condition and a non-contributory family history who was diagnosed with post-covid-19 multisystem inflammatory syndrome in adults (MIS-A). She presented with generalized partial thickness erythematous skin ulcerations with tender blistering and painful erosion of her mucus membranes (oral and vaginal mucosa). This was diagnosed as Steven Johnsons syndrome. She was pulsed with intravenous methylprednisone. During this therapy, she progressed to severe acute respiratory distress syndrome (ARDS) requiring mechanical ventilation (fig 1). Bronchoscopy revealed mild pulmonary hemorrhage fig 2a&b). Serological testing heralded a new onset systemic lupus erythematosus in light of positive antinuclear antibodies, anti Ds DNA and anti Smith antibodies. Her course was complicated by significant proteinuria and an active renal cast suggestive of lupus nephritis. This necessitated further treatment for active lupus. She was successfully extubated and discharged home. DISCUSSION: We arrived at the diagnosis of post-covid-19 multisystem inflammatory syndrome in adults (MIS-A) in light of her presenting with fever, hypotension, persistent sinus tachycardia and new onset atrial fibrillation), acute pancreatitis, acute kidney injury, elevation in transaminases, new onset skin rash, elevated inflammatory markers and a recent history of positive SARS-CoV-2 infection. Covid-19 has been reported to induce wide spread vasculitis resulting in MIS-A or MIS-C by triggering type 3 hypersensitivity (1). Also, multiple case reports and systemic reviews have reported a direct association between MIS-A and several autoimmune diseases including SLE, SJS (2). The patient recovered with high dose corticosteroid and supportive therapy indicating her severe ARDS was most likely due associated to SJS, SLE and MIS-A. Clinicians should also keep in mind that SARS-CoV-2 PCR swab may be negative at the time patient presents with symptoms of MIS-A as the infection might have occurred about 4-5weeks prior just as in our patient(3) CONCLUSIONS: We cannot underscore enough the importance of clinicians having a high index of suspicion for this syndrome in patients with acute or recent covid-19 infection, with or without a positive PCR covid-19 test. Early involvement of a multidisciplinary approach and appropriate management is essential to mitigate morbidity and mortality in these patients. Reference #1: Roncati L, Ligabue G, Fabbiani L, Malagoli C, Gallo G, Lusenti B, et al. Type 3 hypersensitivity in COVID-19 vasculitis. Clin Immunol Orlando Fla. 2020 Aug;217:108487. Reference #2: Gracia-Ramos AE, Martin-Nares E, Hernández-Molina G. New Onset of Autoimmune Diseases Following COVID-19 Diagnosis. Cells [Internet]. 2021 Dec 20 [cited 2022 Mar 22];10(12):3592. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8700122/ Reference #3: Morris SB. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020. MMWR Morb Mortal Wkly Rep [Internet]. 2020 [cited 2022 Mar 22];69. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6940e1.htm DISCLOSURES: No relevant relationships by Isaac Ikwu No relevant relationships by Anthony Lyonga Ngonge No relevant relationships by Alem Mehari No relevant relationships by Noordeep Panesar no disclosure on file for Vis al Poddar;No relevant relationships by Emnet Yibeltal
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SESSION TITLE: Occupational and Environmental Lung Disease Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Chlorine gas is a pulmonary irritant with pungent odor that damages the respiratory tract. Chlorine gas exposure occurs in industrial or household exposures,Chlorine gas has two forms either a liquid or gas, toxicity of chlorine gas depends on the dose and duration of exposure. Chlorine gas used in manufacturing products like paper, insecticides, Chlorine is used to treat bottled and swiming pool water. CASE PRESENTATION: A 37 Y.O Male, no PMH presents with progressive dyspnea for three days worse with activity,decreases with rest, denied cough fever or chest pain he is vaccinated for COVID,no smoking history. The patient worked at a chlorine gas factory in the Dominican Republic for 15 years. Exam: Vitals: BP 124/72 mmHg. HR 100 BPM. RR 21 BPM. SpO2 84%. General: acute distress. Heart: normal S1, S2. RRR. Lung: wheeze bilaterally. Abdomen: Soft. Musculoskeletal: no pitting edema. he was placed on 6 LPM NC saturation improved to 90%. CBC and Chemistry were unremarkable, he was started on steroid, breathing treatment with antibiotics. ABG showed hypoxemia. he was placed on Venturi mask and his saturation improved to 95%.CTA was negative for PE. EKG, troponin were unremarkable. A proBNP normal. The antibiotics were discontinued because of a negative workup. A TTE study was normal. HRCT scan of the chest, showed atelectasis and infiltrates of lower lobes. No interstitial fibrosis.A PFT showed obstructive airway disease. He was discharged on oral and inhaled steroids.Hi new onset obstructive airway could be due to chlorine gas exposure. DISCUSSION: Chlorine gas causes cellular injury through oxidative damage but further damage results from activation and recruitment of inflammatory cells with subsequent release of oxidants and proteolytic enzymes. Humans can detect chlorine gas odor at a concentration between 0.1-0.3 ppm. At 1-3 ppm,it causes irritation of oral,eye mucosal membranes. At 30-40 ppm causes cough, chest pain, and SOB. At 40-60 ppm, toxic pneumonitis and pulmonary edema and can be fatal at 430 ppm concentration or higher within thirty minutes. Chronic exposure to chlorine gas lead to chest pain, cough, sore throat, hemoptysis, recurrent asthma. Physical exam findings include tachypnea cyanosis, wheezing, intercostal retractions, decreased breath sounds. Pulmonary function tests may reveal obstructive lung function disease. Chronic exposure to a low level was found to be associated with an increased risk of asthma in swimmers. CONCLUSIONS: Chlorine exposure results in direct chemical toxicity to the airways with acute airways obstruction or airways hyperreactivity, presentation varies from acute overwhelming intoxication with acute lung injury and or death, occupational exposure increase the likelihood of chronic bronchitis or isolated wheezing attacks. Treatment for chlorine exposure is largely supportive. Reference #1: 1- Center of disease control and prevention website/emergency preparedness and response/ https://emergency.cdc.gov/agent/chlorine/basics/facts.asp Reference #2: 2- C- Morim A, Guldner GT. Chlorine Gas Toxicity. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537213/. Reference #3: A- Gummin DD, Mowry JB, Beuhler MC, et al. 2020 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021;59(12):1282-1501. doi:10.1080/15563650.2021.1989785 DISCLOSURES: No relevant relationships by Abdallah Khashan No relevant relationships by Samer Talib no disclosure on file for Matthew Yotsuya;
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Severe acute respiratory syndrome coronavirus 2 is a widespread worldwide public health malady due to a viral COVID-19 infection. The World Health Organization has affirmed this malady as a pandemic and Public Health Emergency of International Concern. A wide array of oral lesions has been reported in patients with COVID-19. Oral lesions can be an initial sign of COVID-19 or an alarming sign of peripheral thrombosis. However, there is a scarcity of published literature on the oral manifestations of COVID-19 in hospitalized patients. We present four different types of oral lesions in hospitalized patients with moderate-to-severe COVID-19 disease. This article proposes that a detailed examination of the oral cavity in patients admitted to COVID-19 intensive care unit/high dependency units will help to understand the significance of the oral lesions in the management of the disease. Dental professionals should be a part of the multidisciplinary treatment protocol, thus, emphasizing a detailed and meticulous oral examination and oral health amelioration of COVID-19 patients. © 2022 Wolters Kluwer Medknow Publications. All rights reserved.
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Introduction: Covid-19 infection has been spreading worldwide since December 2019. Skin manifestations are common as 60% of patients had skin involvement such as rashes, chilblains, urticaria, purpura and vasculitis (1). Toxic Epidermal Necrolysis (TEN) is a life-threatening dermatological disease with > 30% of body surface area involved. TEN pathophysiology is linked to immune system activation triggered by drugs or infections or unknown causes (2). We are reporting a case of biopsy confirmed TEN in pediatrics patient with history of recent Covid19 infection. Case Description: A 6-year-old boy with history of mild Covid 19 infection two weeks ago presented with fever, oral ulcers and maculopapular rash on the trunk and extremities for 2 days. He was admitted for supportive care. His skin rash was progressing to violaceous targetoid lesions on the trunk and extremities with genital erosion, Nickolsky sign was positive. He had purulent conjunctivitis and crusted lips lesions with deepithelization of the oral mucosa. SCROTEN score was 2 for detachment more than 30%, low bicarbonate of 19. All virology tests came out negative including respiratory and blood PCR testing. A 4-mm punch skin biopsy histopathology was consistent with TEN. He was treated with supportive care, IVIG 1 g/Kg daily for 5 days, IV dexamethasone shifted later to oral Prednisolone, Cyclosporin 3 mg/kg/day. His rash and oral mucositis improved within 1 week and he was discharged in stable condition. He was seen in the clinic after 1 month of discharge and recovery of the skin, oral and eye mucosa was observed. Discussion: This report presented a case of a child with TEN and history of recent Covid-19 infection. Most cases of TEN are triggered by drugs and some by infections (3)(4). There were case reports of TEN associated with Covid 19 infection in adults with probable association with drugs such as hydroxychloroquine (3), Allopurinol (5), Lamotrigine (6), one case with no history of drug exposure (7). In a report of more than 5000 pediatrics patients with Covid-19 infection only one patient had SJS (8). Another case of 8-year-old boy with Covid-19 infection who developed SJS rash was reported (9). Both pediatrics cases had history of Amoxicillin- Clavulanate use. In our case the relationship between Covid-19 infection and TEN is not clear as the child had a history of Ibuprofen use that could be the culprit trigger. However, Covid-19 could still be the trigger in this case. It is worth reporting this case to keep in mind the wide spectrum of dermatological presentation in Covid-19 patients. Conclusion: Whether Covid 19 infection can trigger TEN in pediatrics patient is an important question that needs larger studies, yet it is worth reporting this case of possible correlation between Covid 19 and TEN in pediatrics.
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Purpose We investigated the prevalence of smell and/or taste loss and the clinical characteristics and recovery in a cohort of consecutive patients treated by two COVID-19 reference hospitals and evaluated the late persistence of hyposmia. Material and Methods 53 consecutive RT-PCR diagnosed patients (23 males, 30 females, 42,54 ± 10, 95 years) who had been hospitalized between January- June 2021 in the COVID-19 care wards were contacted, excluding patients with cognitive disorders and severe deconditioning. These patients (Group A) have been examined twice, once direct after leaving the hospital, and once again 4-6 weeks later. The patients- nasal and oral mucosa (Fungiform Papillae on tongue-s tip-fPap) were examined with a contact endoscope. Their olfaction was also examined with Sniffin' Sticks. As control-group we have examined 53 healthy subjects (Group B). Results Significant alterations in form and vascularization of fPap have been detect, specially by the first examination. Patients EGM-Thresholds of both measurements are higher than those of healthy subjects, although those of the second one are clearly lower. The same results have been found using Schniffin- Sticks. Discussion Our findings suggest that COVID-19 can produce a mild to profound neuropathy of multiple cranial nerves, which are responsible for the regeneration of fPap and the transmission of the chemical stimuli.
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COVID-19 has created a series of clinical conundrums since its emergence. We report a case of severe immune thrombocytopenic purpura (ITP) in a 67-year-old gentleman in April 2020. He presented to hospital with a rapidly evolving rash, 3 weeks following infection with COVID-19. Clinically he had a widespread non palpable petechial rash, haemorrhagic blisters across his oral mucosa and severe epistaxis. His platelet count was 2 × 109 L-1 (150-450 × 109 L-1). Full blood count and clotting studies were otherwise normal. With ITP not yet well reported as a complication of COVID-19, there was a treatment dilemma. ITP is an acquired autoimmune-mediated disorder (often with a viral or vaccine precipitant) and first-line treatment is immunosuppression. However, due to concurrent infection with the novel COVID-19 virus, a thrombopoietin receptor agonist (TPO-RA) (eltrombopag 50 mg once daily) was instead commenced. Persistent epistaxis, oral bleeding and a platelet count < × 109 L-1 required intravenous immunoglobulin (1 g kg-1) to be administered on day 7 of TPO-RA treatment. By day 12 of TPO-RA treatment the platelet count had successfully normalized. The patient remains in remission 18 months on. Since this case, ITP has become a recognized phenomenon of both COVID-19 infection and COVID-19 vaccination (Pishko AM, Bussel JB, Cines DB. COVID-19 vaccination and immune thrombocytopenia. Nat Med 2021;27: 1145-6). Moreover, corticosteroid therapy has become the first evidence-based therapy for severe COVID-19 infection (Horby P, Lim WS, Emberson J et al. Dexamethasone in hospitalized patients with Covid-19. N Engl J Med 2021;384: 693-704), although their use in COVID-19- related ITP remains unclear. This case demonstrates an important cutaneous manifestation of the COVID-19-provoked disrupted haemostasis pathways, which results in significant morbidity and mortality. Additionally, this case describes practical real-life multidisciplinary team decision-making to emerging complications of a uniquely studied virus.
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In this case report, we detail the case of a young adult with a recurrent case of Reactive Infectious Mucocutaneous Eruption (RIME) in the setting of Sars-COV-2 infection, the second time this has been reported in the literature. We review the more common causes of RIME, including Chlamydophila pneumoniae, metapneumovirus, parainfluenza, rhinovirus, enterovirus, and influenza;and we discuss patient characteristics in other reported cases of RIME secondary to COVID-19 and the features of recurrent RIME seen in patients reported in the literature. Our patient had the characteristic severe mucosal involvement seen with RIME, and was treated with supportive care alone and experienced rapid improvement in symptoms. [ FROM AUTHOR] Copyright of Our Dermatology Online / Nasza Dermatologia Online is the property of Our Dermatology Online and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
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Objectives: We aimed to reveal the skin, mucous membrane, hair and nail findings of children who meet the multisystem inflammatory syndrome in children (MIS-C) criteria. Method: A prospective case series consisting of 43 children who applied to Karadeniz Technical University Faculty of Medicine Farabi Hospital between January 2020 and January 2022 and met the criteria for MIS-C according to the diagnostic criteria of the Centers for Disease Control and Prevention was conducted. Results: Of 43 patients diagnosed with MIS-C, 18 (%41,9) were female and 25 (%58,1) were male. The mean age of the patients is 7.63, the age range is between 7 months and 15 years. The results of polymerase chain reaction tests for SARS-CoV-2 were positive for 4 (%9,3) patients, and the results of SARS-CoV-2 immunoglobulin G tests were positive for 39 (%90,7) patients. No mucocutaneous involvement was observed in 3 (%6,9) of the patients. Nonpurulent conjunctivitis was observed in 25 (%58,1) patients, and periorbital edema was observed in 4 (%9,3) patients. 4 (%9,3) patients had symmetrical edema of the hands and feet, and 2 (%4,6) patients had periungual desquamation. While no oral mucosal findings were observed in 15 (%34,9) patients;12 (%27,9) patients had fissured lips, 10 (% 23,3) had cheilitis, 8 (%18,6) had diffuse hyperemia of the oral mucosa, 6 (%13,9) had strawberry tongue, and 3 (%6,9) had herpes labialis. 21 (%48,8) of the patients had urticarial, 12 (%27,9) of them maculopapular, 5 (%11,6) patients livedoid and 1 (%2,3) patient had a skin rash compatible with pseudopernio. No hair or nail changes were observed in the patients while they were hospitalized. Discussion: In this case series of hospitalized children with definitive MIS-C during the COVID-19 pandemic, a wide spectrum of mucocutaneous findings was identified.
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INTRODUCTION: Based on the premise that every patient is a potential virus carrier and applying the concept of universality, which implies treating all patients equally, safe practice in front-line dentistry in the face of the SARS-CoV-2 pandemic, due to direct contact with oral mucosa and the generation of aerosols during clinical practice, has had to adapt new measures. However, in terms of biosafety, there has been a turning point. OBJECTIVE: To ascertain the changes, repercussions and updates in prevention and risk reduction measures in dental care practice. MATERIAL AND METHODS: To compare the protocols in place before the pandemic with the new procedures, in many cases intensified, focused on the care and safety of the patient, work and health personnel, equipment and dental treatments. RESULTS: The need to reinforce prevention and increase crossinfection control measures has led to the application of more rigorous conduct aimed at reducing aerosol transmission. The drawing up of checklists is useful to compile an organisational plan for quality of care and biosafety. CONCLUSIONS: This comparative assessment has established an improvement in safety for patients and health care staff;telephone consultation as a preliminary step to face-to-face consultation (teledentistry), thereby establishing the order of treatment principles. These measures have been set in place for current and future practice. Dental services have adapted to the new protocols, which are here to stay.
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Introduction: The clinical presentation of SARS-CoV-2 ranges greatly from asymptomatic disease to critical illness. The multisystemic effect of COVID-19 is becoming increasingly apparent, but its impact on the endocrine system, in particular, the hypothalamic adrenal axis has yet to be defined. Case Description: A 64-year-old woman with hypothyroidism and type 2 diabetes mellitus presented to the emergency room with a 1-week history of abdominal pain, nausea, and vomiting. The patient experienced an asymptomatic COVID-19 infection 5 months prior and reported an unintentional 30-lb weight loss since. She had been admitted several times at an outside hospital for hyponatremia where she never received exogenous steroids. Physical exam was notable for hypotension, epigastric tenderness, and hyperpigmentation of oral mucosa. Chemistry was significant for hyponatremia 117 mmol/L (135-145). Hyponatremia workup revealed a TSH of 0.33 mcIU/ml (0.35-4.00), free T4 1.4 ng/dl (0.6-1.7), serum osmoles 253 mOsm/kg (279-300), urine osmoles 324 mOsm/kg (300-900) and urine sodium 104 mmol/l consistent with hypotonic hyponatremia. Fluid restriction and salt tablets were initiated. Morning 8 AM cortisol returned low (2.6 μg/dl (ref: >18). A high-dose 250 mcg ACTH stimulation test followed;cortisol levels returned 2.3, 2.9, and 2.6 μg/dl (ref: >18) at baseline, 30, and 60 minutes, respectively. ACTH level was elevated to 1944 pg/ml (7.2-63.3), aldosterone was undetectable < 3.0 ng/dl (upright: 4.0-31.0), anti-21-hydroxylase antibody were positive (ref: neg). CT scan of the abdomen returned unremarkable for any adrenal pathologies. Fluid restriction and salt tablets were discontinued. Hypotension and hyponatremia resolved after initiation of Hydrocortisone IV 25 mg q8h. She was discharged on Hydrocortisone 30 mg daily and Fludrocortisone 0.05 mg daily. Discussion: This patient presented with hyponatremia and biochemical evidence of adrenal insufficiency confirmed by an abnormal stress cortisol response to a high-dose ACTH stimulation test. The markedly elevated ACTH level, inappropriately low aldosterone level, and the presence of anti-21-hydroxylase antibodies support the diagnosis of Addison's disease. Primary adrenal insufficiency (AI) after COVID-19 due to adrenal infarcts and hemorrhage have been documented, but the normal CT suggested that the etiology of AI, in this case, was not due to the aforementioned. This case is the first to suggest the onset of Addison’s disease in the COVID-19 sequelae.
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Purpose of The Study Awareness of Covid-19 virus infection can precipitate decompensation of chronic diseases such as type 2 diabetes Mellitus. Euglycemic diabetic ketoacidosis (eu- DKA) has been seen in patients using sodium-glucose co-transporter 2 inhibitor (SGLT2i) and with COVID-19 infection. Methodology Authors identified the case while providing clinical care of a 61-year-old man with medical history of Diabetes Mellitus Type II using SGLT2i and hypertension presented to the Emergency Room with chief complaint of fever, chills, dry cough, watery diarrhea and general malaise 5 days prior arrival to the hospital. Summary of Results A 61-year-old man Puerto Rican male with medical history of Diabetes Mellitus Type II using sodium-glucose co-transporter 2 inhibitor (SGLT2i), and hypertension, already vaccinated against COVID-19, who presented to the Emergency Room with chief complaint of fever, chills, dry cough, watery diarrhea and general malaise 5 days prior arrival to the hospital after returning from a recent family trip to Florida. Home medications include Empagliflozin. Patient referred he had a recent travel to Florida (United States) and was in contact with a family member infected with COVID-19 infection. Physical examination was remarkable for dry oral mucosa and laboratories showed a metabolic acidosis with a high anion gap of 20 mEq/L with a marked increase in plasma b-hydroxybutyrate of 57.8 mg/dL and a central glucose <300 g/dL. Patient tested positive for COVID- 19 infection. Chest X-ray showed bilateral scattered peripheral hazy groundglass opacities. Considering mentioned findings patient placed on airborne isolation precautions and was admitted to Medical Intensive Care Unit where he was started on DKA protocol with continuous intravenous regular, D5W and aggressive hydration. Medical therapy also included Remdesivir and Dexamethasone. Patient improved after 2 days with resolved eu-DKA. Patient transferred to Internal Medicine Ward. Conclusion Eu-DKA has been seen in patients using SGLT2i and with COVID-19 infection;several cases described in literature are suggestive of a specific association between these factors. Our case also highlights the importance of early recognition and management of euglycemic DKA in patients using SGLT2i infected with COVID-19, both increase the risk of dehydration. Physicians must be aware and identify this patients earlier in outpatient setting and be more aggressive in hydration, maintaining euvolemic status to avoid admission to Intensive Care Unit.
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The rapid spread of the COVID-19virus and related pneumonia has posed a major challenge for healthcare systems worldwide. The infection was discovered in the city of Wuhan, Central of China and swept across the world.Theincubation period of the viruscan range from 1-14 days, and the virus spread can happen in the absence of clinical symptoms as well.The most frequently reported symptoms are fever, cough, dyspnea, and myalgia or fatigue. Modes for transmission of virus include direct transmission through coughing,sneezing, and inhalation of droplets and contact transmission through contact with nasal, oral, and ocular mucosa. Droplet and aerosol transmission of the virus are the most common causes of COVID-19 infection in dental clinics and hospitals.COVID-19 virus has lately been detected in saliva of infected patients, thus posing an alert to health professionals to be customarily vigilant in protecting against the infectious disease spread. Because of the presence of virus in saliva, it may be helpful as a non-invasive tool in the rapid detection of the virus.During this pandemic dissemination of COVID-19, dental treatment must be confined to the procedures that cannot be deferred. All the precautions must be taken in terms of triaging, personal protective equipment, hand hygiene, pre-procedural mouthrinse, use of rubber dam, disinfection of the surfaces. Dental professionals are at the highest risk of COVID-19 infection;hence, dental practicehas to be reorganized in order to ensure higher safety standards for both dentists and patients.