Fulminant varicella infection complicated by disseminated intravascular coagulation following influenza-A case report

Objectives: Varicella is common infectious disease mainly in childhood, usually is a mild, self-limited illness and complications are usually rare. The incubation period for this disease is generally 14- 16 days but may vary from 7 to 21 days. Varicella in the adults with comorbidities or immunosuppressed children may be severe and prolonged with complications. Method(s): A case report of a 6-year-old girl hospitalized for new-onset manifestations of disseminated vesicular exanthema, the manifestations of which occurred mainly on the chest, back, capillitium, oral cavity, and genital area. The child was suffering from abdominal, knee and lumbosacral pain at that time. The patient's history revealed that 10 days prior to the cutaneous manifestations, she had influenza with bronchopneumonia requiring oxygen therapy, steroids and antibiotics. Result(s): The condition progressed within 48 h, complicated by the development of multi-organ failure, coagulopathy with the development of disseminated intravascular coagulopathy over the course of antiviral, antibiotic and antifungal therapy. Laboratory parameters included high elevation of C-reactive protein, il-6, leukocytosis, neutrophilia and highly elevated liver enzymes. Varicella infection was confirmed by detection of herpes zoster virus - polymerase chain reaction (PCR) from vesicles. The patient received intravenous immunoglobulin therapy at a dose of 2 g/L and fresh frozen plasma, thrombocyte concentrate. The girl was intubated with analogization. Laboratory parameters subsequently revealed high anti CoV-2 positivity, high CoV-2 IgG positivity and negative CoV-2 IgM. The patient's condition did not preclude the course of multisystem inflammatory syndrome in children (MIS-C) corticosteroids were added to the treatment at a dose of 1 mg/kg weight. Patient's condition stabilized after 1 month. Discussion(s): Our case report presents an example of fulminant complicated life-threatening course of varicella. Even in common respiratory infections, we must think about the risk and consequences of coinfections and post-infectious complications such as in our case especially influenza and COVID-19.

A Review on the Effect of COVID-19 in Pregnant Women

Coronavirus Disease 2019 (COVID-19) is an emerging disease with a rapid increase in cases and deaths since its first discovery in December 2019, in Wuhan, China. Limited data are available on COVID-19 effects during pregnancy;however, information on diseases associated with other highly pathogenic coronaviruses (i.e. Severe Acute Respiratory Syndrome [SARS] and the Middle East respiratory syndrome [MERS]) may provide insight into the effects of COVID-19 during pregnancy. Coronaviruses cause illnesses ranging from the common cold to severe respiratory disease and death. The data indicate an average of 5 days incubation period (range: 2-14 days). The average age range of the hospitalized patients was 49-56 years, and a third to half of them have an underlying illness. Children were rarely mentioned. Within hospitalized cases, men were more frequent (54%-73%). Fever, cough, myalgia, vomiting, and diarrhea are common symptoms. This review aims at giving an in-depth understanding of COVID-19 by comparing its effects with SARS and MERS to evaluate its severity in pregnant women1. The results of varied studies show that COVID-19 affects pregnant women seriously and there is an alarming need to look into this aspect to prevent its harmful effects on the fetus.Copyright © 2020

Managing Severe Acute Asthma Exacerbation in Pregnancy during the COVID-19 Pandemic: A Case Report from a Resource-limited Setting

BACKGROUND: One-third of pregnant women will experience worsening asthma requiring emergency hospitalization. However, no report comprehensively discussed the management of asthma attacks in pregnant women in impoverished settings. We attempt to illuminate what general practitioners can do to stabilize and improve the outcome of severe acute asthma exacerbations in primary care with resource limitations. CASE REPORT: A nulliparous 29-year-old woman in her 21st week of pregnancy presented severe acute asthma exacerbation in moderate persistent asthma with uncontrolled asthma status along with gestational hypertension, uncompensated metabolic acidosis with a high anion gap, anemia, respiratory infection, and asymptomatic bacteriuria, all of which influenced her exacerbations. This patient was admitted to our resource-limited subdistrict hospital in Indonesia during the COVID-19 pandemic for optimal stabilization. Crystalloid infusions, oxygen supplementation, nebulized beta-agonist with anticholinergic agents, inhaled corticosteroids, intravenous methylprednisolone, broad-spectrum antibiotics, subcutaneous terbutaline, mucolytics, magnesium sulphate, oral antihypertensives, and continuous positive airway pressure were used to treat her life-threatening asthma. After she was stabilized, we referred the patient to a higher-level hospital with more advanced pulmonary management under the supervision of a multidisciplinary team to anticipate the worst scenario of pregnancy termination. CONCLUSION(S): Limitations in primary care, including the lack of sophisticated intensive care units and laboratory panels, may complicate challenges in managing severe acute asthma exacerbation during pregnancy. To enhance maternal-fetal outcomes, all multidisciplinary team members should be well-informed about key asthma management strategies during pregnancy using evidence-based guidelines regarding the drug, rationale, and safety profile.Copyright © 2023 Muhammad Habiburrahman, Triya Damayanti, Mohammad Adya Firmansha Dilmy, Hariyono Winarto.

LABORATORY PARAMETERS ASSOCIATED WITH CODIV-19 CYTOKINE STORM DEVELOPMENT

BackgroundSince the end of 2019, physicians became more and more familiar with SARS-CoV-2 infection and the variety of forms in which it may present and evolve. There have been a lot of studies trying to understand and predict why some patients develop a dysregulation of the immune response, with an exaggerated release of pro-inflammatory cytokines, called cytokine storm (1–4). There is scarce evidence in Romania regarding this aspect.ObjectivesThis study aims to verify the correlation between some laboratory parameters and the development of cytokine storm in SARS-CoV-2 infection in a cohort of over 200 patients admitted in a tertiary hospital from Romania, hoping that early identification of these risk factors of progression to a severe form of the disease can bring considerable benefit to patient care.MethodsThis is an analytical, observational, case-control study which includes 219 patients (all COVID-19 hospitalized patients on the Internal Medicine 3 department of Colentina Clinical Hospital, Bucharest, from 01 March 2020 to 1 April 2021). A series of data were collected, the laboratory parameters being the most important, including: albumin, lymphocyte (percentage), neutrophil (absolute value), aspartate aminotransferase, alanine aminotransferase, D-dimers, lactate dehydrogenase (LDH), anionic gap, chloremia, potassium and the BUN:creatinine ratio (BUN - blood urea nitrogen). The laboratory parameters used for the statistical analysis represent the average values of the first 7 days of hospitalization for those who did not develop cytokine storm, respectively until the day of its development, for the others. Patients were classified into these groups, those who developed cytokine storm, respectively those who did not have this complication taking into account the clinical and paraclinical criteria (impairment of respiratory function, elevations of certain markers 2-3 times above the upper limit of normal, those who died as a result of SARS-CoV-2 infection). Then Binary Univariate Logistic Regression was applied in order to verify the individual impact of every laboratory parameter on cytokine storm development. Furthermore, all laboratory parameters were subsequently included in the multivariate analysis, using the backward selection technique to achieve a model as predictive as possible.ResultsWe mention that the analysis of demographic data was previously performed, showing no statistically significant relationship between patient gender, age or comorbidities (history of neoplasm, lung diseases, cardiac pathology, obesity, type II diabetes and hypertension) and their evolution to cytokine storm. After performing binary univariate logistic regression we concluded that 8 of the 13 laboratory analyzes have had a significant change between groups (ferritin, PCR, albumin, Lymphocyte, Neutrophils, TGO, LDH, BUN:creatinine ratio). Only 150 patients were then included in the multivariate analysis. After the analysis, some of the variables lost their statistical significance, the final model including C-reactive protein, neutrophilia, LDH, ferritin and the BUN:creatinine ratio. This model correctly predicts the development of cytokine storm in 88% of cases.ConclusionHigh C-reactive protein, neutrophilia, LDH, ferritin and the BUN:creatinine ratio are risk factors for cytokine storm development and should be monitored in all COVID-19 patients in order to predict their evolution.References[1]Pedersen SF et all. SARS-CoV-2: A storm is raging[2]Mehta P et al. COVID-19: consider cytokine storm syndromes and immunosuppression[3]Hu B et al. The cytokine storm and COVID-19.[4]Caricchio R et al. Preliminary predictive criteria for COVID-19 cytokine stormAcknowledgements:NIL.Disclosure of InterestsNone Declared.

Orthopedic surgical scoring in asymptomatic COVID-19 patients

Aim: The purpose of this study is to create a scoring system to decide which patient will take maximum precautions while the covid 19 disease continues. Taking maximum precautions is not always possible in all surgical procedures. Therefore, surgical scoring in asymptomatic patients, selecting patients who need maximum precautions, and taking the necessary precautions for these patients will prevent unnecessary use of the equipment. Material(s) and Method(s): A total of 347 who were surgically treated for emergency or elective procedures between March 11 and November 11, 2020 were included in the study. Of these patients, 277 patients whose data could be accessed were included in the study. A scoring system has been created. Patients were divided into 2 groups: bearing low and high risk. Patients with a score above 10 were identified as having a high surgical risk, and those with a score below 10 were identified as having a low surgical risk. Result(s): There were 132 patients in Group 1 and 145 patients in Group 2. It was observed that 29 of 277 patients became positive within the first month. Two of these patients were in Group 1 and 27 of them were in Group 2. It was observed that COVID-19 antibody or PCR tests gave more positive results in patients in Group 2 in the first month compared to two patients in Group 1. The highest positivity rate in Group 2 was observed in the arthroscopy group. Discussion(s): Advanced precautions should be taken in patients with high surgical risk scores. In patients with low surgical risk scores, less strict precautions can be taken.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Hematological Profile in COVID-19 Infection Among Patients in a Tertiary Care Hospital in Tamil Nadu, South India.

Introduction A wide range of hematological abnormalities has been observed in SARS-CoV-2 infection which is directly related to the disease progression, clinical severity, and mortality among affected individuals. The objective of this study was to evaluate the abnormalities in hematological parameters among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected patients in a tertiary care hospital in south India. Methods This was a cross-sectional study carried out in the pathology department of Karpaga Vinayaga Institute of Medical Sciences and Research Centre, Chengalpattu, Tamil Nadu, India from 1st May 2021 to 30th June 2021. The hematological reports including complete blood count (CBC), neutrophil-lymphocyte ratio (NLR), serum ferritin, serum C-reactive protein (CRP), serum lactate dehydrogenase (LDH), and D-dimer levels of all the blood samples from COVID-19 positive patients were retrieved from the laboratory records. The Leishman-stained peripheral smear findings were also tabulated and analyzed. Results Out of 65 patients, 38 (58.5 %) were males and 27 (41.5%) were females with a majority (78.4%) of them being more than 40 years of age. The salient hematological abnormalities were leukopenia (21.5%), elevated NLR (43%), and thrombocytopenia (6.2%). Peripheral smear showed schistocytes (15.4%), neutrophils with ring nuclei (84.6%), and toxic granules (81.5%). A statistically significant association between elevated NLR and serum CRP was seen among male patients. The association between the presence of schistocytes with serum LDH and D-dimer levels was statistically insignificant. Conclusions The significant hematological abnormalities in patients with COVID-19 infection were elevated NLR, lymphopenia, thrombocytopenia, and elevated D-dimer levels. Careful evaluation of the hematological parameters will help in categorizing the high-risk cases and thereby initiating early intervention and appropriate intensive care management. This will bring down the morbidity and mortality among COVID-19 patients.

Morphological Changes in Blood Cells as Indicators for Disease Progression in COVID-19

BACKGROUND: COVID-19 as a pandemic has caused an alarming increase in mortality and morbidity. Viral-induced morphologic changes in the peripheral blood cells are well characterized in certain infections and can direct diagnostic workup to ensure timely therapeutic intervention. This study describes the morphological changes of blood cells in various stages of COVID disease. MATERIALS AND METHODS: A total of thousand COVID-positive patients admitted in the tertiary care center were taken for the study. They were classified as mild, moderate, and severe based on the clinical criteria suggested by World Health Organization. Peripheral smears of the patients were analyzed, and the morphological changes in various blood cells were correlated with the disease stage and coagulation parameters. RESULT(S): The study demonstrated significant morphological changes in the blood cells of COVID patients during the course of disease progression and during the onset of COVID-associated coagulopathy. Leukocytosis, neutrophilia, and toxic changes in neutrophils were seen in the severe stage of the disease and in COVID coagulopathy suggesting these are important indicators of disease severity. Activated lymphocyte was found to be the most common morphological presentation seen in all patients irrespective of the disease stage, whereas plasmacytoid lymphocytes were an important finding in severe-stage disease. Schistocytes an important finding in any other coagulopathy was present only in 1% of cases of COVID coagulopathy. CONCLUSION(S): The study demonstrated significant morphological changes in the blood cells of COVID-positive patients during the course of disease progression. Comprehensive daily complete blood count and peripheral smear examination should be undertaken in patients hospitalized with COVID-19 to predict potential clinical deterioration and signs of disease progression. These morphological changes in peripheral smear can be used as one of the factors indicating disease progression which can formulate for further evaluation. Since follow-up and post-COVID morphological examination were not done, additional research in this aspect can shed light on the clinical categorization of COVID patients based on the morphological findings.Copyright © 2023 Journal of Applied Hematology Published by Wolters Kluwer - Medknow.

Opportunities for predicting adverse pregnancy outcomes in severe COVID-19.

Aim: to asses an opportunity for predicting an unfavorable perinatal and maternal pregnancy outcome in severe novel coronavirus infection (NCI) COVID-19. Materials and Methods. A retrospective comparative study of the course and outcomes of pregnancies was performed in 40 patients with a gestational age of 22-42 weeks who had severe and extremely severe COVID-19 in 2021. The main group included 21 cases with an extremely severe course of the disease resulting in maternal mortality;the comparison group consisted of 19 patients with severe COVID-19 who successfully completed pregnancy. The diagnosis of NCI COVID-19 was confirmed in all cases by identifying SARS-CoV-2 RNA by polymerase chain reaction in a nasopharyngeal swab. During the study, all patients (during hospitalization, at the peak of the disease and before death/discharge from the hospital) underwent a comprehensive anamnestic, clinical and laboratory-instrumental examination. There were analyzed clinical blood test, biochemical parameters - lactate dehydrogenase (LDH), alanine aminotransferase, aspartate aminotransferase, creatinine, glucose, total bilirubin, total protein;coagulation parameters - prothrombin level according to Quick and fibrinogen, activated partial thromboplastin time, international normalized ratio;the level of C-reactive protein, procalcitonin, D-dimer, interleukin-6 (IL-6);ultrasound examination was performed during pregnancy (fetometry, placentometry), dopplerometry of uteroplacental blood flow and ultrasound of the pelvic organs, as well as pathomorphological placenta examination. Results. In patients who died from extremely severe NCI COVID-19 (main group), the course of the infection was accompanied by developing of respiratory distress (RD) degree III (chi2 = 12.84;p <= 0.05), and a progressive deterioration in mother's condition and/or fetal distress was an indication for emergency delivery by caesarean section (CS). The course of severe NCI COVID-19 in patients with a favorable outcome (comparison group), as a rule, was accompanied by the development of RD grade I and/or II;most of them were also delivered by CS on an emergency/urgent basis. Predictors of rapid progression of severe NCI COVID-19 in the main group were identified: subfebrile body temperature at the initial stages skewing to high fever during treatment instead of rapid temperature normalization (chi2 = 5.41;p <= 0.05;odds ratio (OR) = 5.0;95 % confidence interval (CI) = 1.23-20.3);lack of leukocytosis at the initial stages (chi2 = 4.91;p <= 0.05;OR = 50;95 % CI = 5.43-460.54) with rapidly increased leukocyte count with persistent stagnation in dynamics until death (chi2 = 19.79, p <= 0.05, OR = 50;95 % CI = 5.43-460.54);severe lymphopenia (chi2 = 8.09;p <= 0.05;OR = 7.29;95 % CI = 1.74-30.56), neutrophilia (chi2 = 10.17;p <= 0.05;OR = 10.29;95 % CI = 2.21-47.84);high LDH values (chi2 = 17.99;p <= 0.05;OR = 31.88;95 % CI = 5.09-199.49);increased IL-6 level at the peak of the disease (chi2 = 9.66;p <= 0.05;OR = 18;95 % CI = 1.99-162.62) and in dynamics, as well as stably high D-dimer values (chi2 = 9.53, p <= 0.05;OR = 11.33;95 % CI = 2.07-62.11). Conclusion. Significant changes observed in clinical and laboratory examination were identified, which reliably reflect the degree of patients' state, to be interpreted as predictors of adverse pregnancy outcomes during NCI COVID-19 and as a potentially justified serious reason for making a decision in the light of timely delivery aimed at a favorable outcome for mother and child. Timely delivery, carried out within the time limits for enabling adequate compensatory capabilities of the pregnant woman's body, demonstrates a rapid normalization of the main laboratory parameters.Copyright © 2023 IRBIS LLC. Pravo. All rights reserved.

Immune dysregulation in hospitalized COVID-19 patients is associated with worse clinical outcome

Background: COVID-19 is a viral disease affecting mostly respiratory system with variable severity of the clinical course. Several clinical and laboratory parameters are associated with poor outcome. Progression of the clinical stage is associated with the exaggerated immune response and the cytokine storm. Method(s): We focused on the search of potential prognostic markers of fatal outcome among immune parameters. To this end, we examined the immune profile in 823 COVID-19 patients hospitalized in University Teaching Hospital in Martin (Slovakia) on admission and its changes over time during the first week of hospitalization. The examined immune profile consisted of the differential blood cell counts, serum concentration of immunoglobulins and basic complement compounds C4 and C3, flow cytometric lymphocyte subsets phenotyping and the measurement of selected activation and inhibition markers. Result(s): Although none of examined parameters alone had sufficient AUC value to be considered as a marker of (un)favourable outcome, we found several significant differences among different severity groups of patients, as well as between survivors and non-survivors. Severity of COVID-19 correlated with the severity of neutrophilia, thrombocytopenia, depletion of leukocyte (except for neutrophils) and lymphocyte subsets. In comparison to the fatal outcome, survival was associated with higher concentration of C3 and IgM, lower proportion of CD8+CD38+ cells, higher proportion of CD8+NKG2A+ and NK NKG2A+ cells on admission and with the significant increase in the expression on HLA-DR on both CD3+ and CD8+ cells over the first week. Conclusion(s): Our results point out to the dysregulated functional status of depleted CD8+ cells with their over-activation and possibly insufficient compensatory inhibition in COVID-19 non-survivors. Based on our results, the increase in HLA-DR expression on CD3+ and CD8+ cells is necessary for recovery.

Clinical Characteristics of Deceased with COVID-19 Infection: Data from the Largest COVID-19 Dedicated Hospital in Bangladesh

The death t toll of the coronavirus disease 2019 (COVID-19) has been considerable. Several risk factors have been linked to mortality due to COVID-19 in hospitals. This study aimed to describe the clinical characteristics of patients who either died from COVID-19 at Dhaka Medical College Hospital in Bangladesh. In this retrospective study, we reviewed the hospital records of patients who died or recovered and tested positive for COVID-19 from May 3 to August 31, 2020. All patients who died during the study period were included in the analysis. A comparison group of patients who survived COVID-19 at the same hospital during the same period was systematically sampled. All available information was retrieved from the records, including demographic, clinical, and laboratory variables. Of the 3115 patients with confirmed COVID-19 during the study period, 282 died.The mean age of patients who died was higher than that of those who survived (56.7 vs 52.6 years). Approximately three-fourths of deceased patients were male. History of smoking (risk ratio 2.3;95% confidence interval: 1.6-3.4), comorbidities (risk ratio: 1.5;95% confidence interal:1.1-2.1), chronic kidney disease (risk ratio: 3.2;95% confidence interval: 1.7-6.25), and ischemic heart disease (risk ratio:1.8;95% confidence interval: 1.1-2.9) were higher among the deceased than among those who survived. Mean C-reactive protein and D-dimer levels [mean (interquartile range), 34 (21-56) vs. 24 (12-48);and D-dimer [1.43 (1-2.4) vs. 0.8 (0.44-1.55)] were higher among those who died than among those who recovered. Older age, male sex, rural residence, history of smoking, and chronic kidney disease were found to be important predictors of mortality. Early hospitalization should be considered for patients with COVID-19 who are older, male, and have chronic kidney disease. Rapid referral to tertiary care facilities is necessary for high-risk patients in rural settings.Copyright © 2023 Hoque MM.

Massive polyuria associated with severe COVID-19-related pneumonia complicated by pulmonary embolism

Coronavirus disease 2019 (COVID-19) predominantly manifests with signs of respiratory system injury;however, multi-systemic manifestations may occur. Renal pathology develops in up to 80% of patients with COVID-19. The aim of the study was to describe the case of isolated massive polyuria of unknown etiology in the patient with severe COVID-19-related pneumonia complicated by pulmonary embolism (PE). A 54-year-old male with bilateral pneumonia, related to COVID-19, developed PE. The next day after successful thrombolysis with alteplase (90 mg) the diuresis of the patient began to increase and fluctuated between 5000 mL and 8000 mL. The diuresis returned to normal ranges two weeks after PE episode. The rise of the diuresis was not accompanied by electrolyte disorders and elevation of serum creatinine. Changes in the urine tests were minimal, only once the urine protein was detected (0.25 g/L). The highest urine excretion was observed in evening hours (16.00-24.00). Chest CT on the day 14 after the patient's admission revealed 90% of lung tissue injury, cranial CT showed no brain abnormalities, including hypothalamus and pituitary gland. The patient's condition met neither diagnostic criteria of acute kidney injury, nor acute interstitial nephritis, nor pituitary gland damage. The course of the polyuria in the presented case was benign (self-limiting, no blood electrolyte abnormalities, compensated by oral rehydration only). Polyuria in patients with COVID-19 may not be a life-threatening condition that does not require active treatment.Copyright © 2021 EDIZIONI MINERVA MEDICA.

Pathophysiology of SARS-CoV-2 Infection and COVID-19

A detailed understanding of the pathophysiologic mechanisms of severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) infection and Coronavirus disease 2019 (COVID-19) is vital for improving patient management - to facilitate prompt recognition of progression to severe disease and effective therapeutic strategies. This chapter summarizes the underlyingpathophysiology in the lungs and other organs of COVID- 19 patients. The roles of the cytokine storm culminating in exaggerated inflammatory responses and formation of neutrophil extracellular traps (NETs) are discussed. Pathological features of the various stages from the onset of COVID-19 are outlined - progressing from early mild infection to severe clinical illness to the critically ill phase. © 2023 by World Scientific Publishing Co. Pte. Ltd.

Assessment and management of the SARS-CoV-2 infection: A secondary center experience: Approach to COVID-19 infection

Aim: The aim of the study was to evaluate the management and outcomes of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a secondary hospital. Material(s) and Method(s): This study included 699 hospitalized patients who had positive rRT-PCR for SARS-CoV-2 and/or typical findings of COVID-19 on chest computed tomography (CT). Demographics, comorbidities, initial laboratory tests on admission, treatment modalities, complications and outcomes were evaluated retrospectively. Result(s): The mean age was 57.0+/-15.6 (range:16-94 years), and male to female ratio was 1.24;58.7% of the patients had at least one underlying comorbidity, the most common was hypertension;18.1% of the patients had lymphopenia, 35.7% hyperferritinemia, 58.3% had increased lactate dehydrogenase, and 58.5% had increased D-dimer. Chest CT revealed moderate and severe stages in 57.9% of the patients. Hydroxychloroquine was given to 37.2% and favipiravir to 67.1% of the patients. No significant difference was observed between treatment groups in terms of mortality (P=0.487);5.8% of the patients were transferred to the ICU, 75.6% of whom needed non-invasive and 36.5% invasive mechanical ventilation. The overall case-fatality rate was 0.9. Discussion(s): Older age, male gender, low lymphocyte count, CT findings, including bilateral involvement and severe stage were significantly associated with poor prognosis and mortality.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Hematopathology of Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Coronavirus Disease-19.

Coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus 2 and is associated with pronounced hematopathologic findings. Peripheral blood features are heterogeneous and very often include neutrophilia, lymphopenia, myeloid left shift, abnormally segmented neutrophils, atypical lymphocytes/plasmacytoid lymphocytes, and atypical monocytes. Bone marrow biopsies and aspirates are often notable for histiocytosis and hemophagocytosis, whereas secondary lymphoid organs may exhibit lymphocyte depletion, pronounced plasmacytoid infiltrates, and hemophagocytosis. These changes are reflective of profound innate and adaptive immune dysregulation, and ongoing research efforts continue to identify clinically applicable biomarkers of disease severity and outcome.

Encephalitis as a post-COVID-19 complication: causation or association?

Case Report: Although the coronavirus disease 2019 (COVID-19) affects the respiratory system, neurological complications in children have been reported. Neurological manifestations in children with acute COVID-19 infection are rare and range from headaches, transverse myelitis, strokes, and encephalitis which presents as a part of Multisystem Inflammatory Syndrome in Children (MIS-C). However, encephalitis presenting post-COVID-19 in the absence of MIS-C in children has not been described. Case presentation: A 9-year-old Hispanic female with no past medical history presented with altered mental status and seizures. Associated symptoms prior to seizures included worsening headaches and vomiting. Initial labs were significant for an elevated erythrocyte sedimentation rate of 32 mm/hr, C-reactive protein of 2 mg/dL, and white blood cell (WBC) count of 28 000 cells/mcl with neutrophilia. Comprehensive metabolic panel was normal. Computed tomography of the head and urine drug screen were normal. Magnetic resonance imaging of the brain demonstrated diffusion restriction in the left frontal lobe as well as mild leptomeningeal enhancement concerning for meningoencephalitis. Lumbar puncture (LP) showed pleocytosis (WBC 169 cells/mcl, 76% neutrophils), elevated glucose 77 mg/dl, normal protein 56 mg/dl, and elevated myelin basic protein indicative of a demyelinating disease. Infectious workup was significant for a positive COVID-19 immunoglobulin (Ig) G (19.66), positive Mycoplasma pneumoniae (M. pneumoniae) IgM (0.87 units/L), with an equivocal IgG (0.11 units/L). Autoimmune workup was negative. She received dexamethasone 0.15 mg/kg/dose for 1 day, followed by methylprednisolone (10 mg/kg/dose) for 3 days and oral prednisone for 5 days resulting in significant improvement. Although CSF cultures returned negative, she received a 7-day course of doxycycline for a possible coexisting M. pneumoniae infection. Repeat LP showed improving pleocytosis, and lymphocytic predominance. Discussion: In this case report, rapid neurological recovery after administration of corticosteroids in the presence of positive COVID-19 IgG and demyelinating disease was suggestive of encephalitis presenting post- COVID-19 infection. Although M. pneumoniae can present with neurological symptoms (e.g., encephalitis), repeat titers at follow-up after recovery did not show the expected 4-fold increase in IgG, making it less likely the cause of this presentation. The proposed pathophysiology of COVID-19-mediated encephalitis includes direct invasion of the nervous system, immune-mediated cytokine response, and molecular mimicry between coronaviruses and neuronal proteins causing demyelination. The mainstay treatment includes immunomodulators such as corticosteroids, Intravenous Immunoglobulin, monoclonal antibodies (eg., rituximab), or plasma exchange. Conclusion: COVID-19 infection should be considered when evaluating a patient with meningoencephalitis or post-infectious encephalitis.

Thrombotic Thrombocytopenic Purpura (TTP) secondary to Covid-19 infection in a patient with Systemic Lupus Erythematosus (SLE)

Background: Covid-19 infection has caused a global pandemic in the recent years and although initially it was considered mainly a respiratory ailment it has proven over time to cause a constellation of complications across various systems such as hematological, immune, cardiovascular, gastrointestinal, and neurological. Method(s): We report a case of a lupus patient with Covid-19 infection who presented initially with fever and gum bleeding with a negative dengue serology and negative HIV serology. Result(s): A 45-year- old lady with a 30-year history of SLE was admitted to our hospital with Covid 19 infection. She had relatively stable disease over the past few years but was admitted to the hospital with complaints of fever, gum bleeding and shortness of breath with no chest x-ray changes. Her oxygen saturations were 95% under room air and her vital signs were stable. Laboratory examinations revealed raised white cell count (11.63) with neutrophilia and elevated C-reactive protein (2.84mg/dl). Her platelet count was low at 113 when compared to her baseline of 549. An urgent peripheral blood film showed an incidental finding of Stomato-ovalocytosis with mild anaemia however there was no features of haemolysis. She was initially treated as acquired Immune thrombocytopenia provoked by Covid-19 infection and was started on IV hydrocortisone. She had a lack of response as evident of a further decline in her platelet counts and the following day, she developed rapid decline in her renal function wherein her creatinine increased from 83 to 207. An urgent ultrasound doppler of the kidneys to rule out acute renal vein thrombosis was organised however it showed normal patent renal vessels. Peripheral blood films were repeated which showed minimal schistocytes and the diagnosis was clinched with the Adamst13 activity levels being less than 0.2%. She was started on 20g IVIG per day with plasma exchange however succumbed to the illness. Conclusion(s): The diagnosis of TTP classically involves the recognition of the pentad of fever, microangiopathic hemolytic anemia, thrombocytopenia, acute renal failure, and neurological abnormalities however 60% of patients do not fulfil the pentad. It is essential to recognize that Covid-19 is an acquired cause of TTP, and a high index of suspicion must be maintained for early treatment institution.

Rare case of post-COVID transverse myelitis

Case Report: Acute transverse myelitis (TM) is a rare inflammatory disease that typically presents asweakness, sensory alterations, and bowel or bladder dysfunction. Among the causes of TM are infections, paraneoplastic syndromes, or autoimmune conditions of CNS. Postinfectious TM can develop secondary to a viral or bacterial infection. SARS-CoV-2 is a recently discovered viral illness, and sequelae due to COVID-19 infection are still being studied. There is scarce literature relating the two conditions, and it is imperative to raise awareness. A 72-year-old man with hypertension and GERD, completely independent in ADL, was brought to the ED with sudden onset of bilateral lower extremity weakness. He reported symptoms started with difficulty climbing stairs that rapidly progressed to inability to ambulate independently and were associated with bilateral thigh soreness. Nine days prior, he developed fever and generalized malaise, and two days later, SARS-CoV-2 PCR and Ag tests were positive. He received azithromycin, Paxlovid, and dexamethasone as treatment. Upon evaluation, the patient was afebrile and hemodynamically stable. Neurological examination was remarkable for spasticity and hyperreflexia at bilateral lower limbs, clonus, preserved motor strength with adequate sensation to soft touch, and intact vibration and proprioception in all extremities. Cranial nerves were intact. These findings were consistent with an upper motor neuron lesion. On imaging, the Head CT scan was unremarkable. Thoracic/Lumbar Spine MRI was significant for distal thoracic and conus areas with central homogeneous brightness compatible with nonspecific myelitis. Laboratories showed leukocytosis without neutrophilia or bandemia, thrombocytosis, and elevated CRP. HIV and RPR tests were negative. A lumbar puncture for CSF analysiswas remarkable for mild monocytic pleocytosis (7 cell/muL), an increased level of total proteins (56 mg/dL), and normal glucose (57 mg/dL). CSF culture and gram stain were negative. CSF cytology yielded few lymphocytes and few monocytes and was negative for malignant cells. The meningoencephalitis panel was negative. Based on these findings, a clinical diagnosis of postinfectious myelitis secondary to COVID-19was made. The patient was treated with intravenous Methylprednisolone 1 g daily for five days. On follow-up, lower extremity weakness resolved completely, and he resumed his daily physical activities. Patients with COVID-19 infection can present with neurologic manifestations such as headache, myalgias, dizziness, dysgeusia, and anosmia. This case hopes to raise awareness of less commonly known neurological manifestations of SARS-CoV-2 infection and how the early recognition of symptoms can help expedite the diagnosis and treatment of the condition to avoid long-term sequelae. [Figure presented] Copyright © 2023 Southern Society for Clinical Investigation.

Kawasaki-like multisystem inflammatory syndrome in an adult filipino with covid-19 infection: a case report

Objectives: Several case series have been identified describing adult patients with a secondary Multisystem Inflammatory Syndrome (MIS) after a recent COVID-19 infection, presenting with features similar to Kawasaki Disease (KD). This paper aims to describe the first case of Kawasaki-like presentation in an adult Filipino with COVID-19 infection. Method(s): A case of Kawasaki-like presentation in an adult Filipino with COVID-19 infection was reviewed in a tertiary hospital. Result(s): This is a case of a 38-year- old Filipino woman who presented with fever, malaise, dry cough, sore throat, diarrhea and rashes. On examination, she had classic features of KD: non-exudative conjunctivitis, cracked lips, edema of the hands and feet, palmar erythema, diffuse rash, and cervical lymphadenopathy. Laboratory results showed anemia, leukocytosis with neutrophilia, hyponatremia, hypokalemia, transaminitis, hypoalbuminemia, and elevated inflammatory markers. COVID-19 PCR test was negative but serologic studies showed positivity for IgM and IgG, suggesting a recent infection. Treatment included methylprednisolone pulse therapy, intravenous immunoglobulin (IVIG) and anticoagulation, which resulted in rapid clinical improvement. Conclusion(s): As the knowledge of COVID-19 and its associated clinical features continually evolves, it is imperative to be aware of the possibility of KD as a delayed post-viral multisystem inflammatory response in adults that may warrant prompt treatment.

Study of Haematological Profile in Covid-19 Patients

Introduction: Coronavirus disease 2019 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 recognized on 31st December 2019 in Wuhan, China which was declared a worldwide pandemic by the World Health Organization on 11 March 2020. Haematological and inflammatory test results are found to be peculiar in COVID-19 patients. Aim(s): This study was conducted to add to the knowledge database of haematological values in Covid patients and to correlate with clinical findings wherever possible to carry out timely intervention. Method(s): This was a prospective cohort study conducted from July 2020 to December 2021 in a tertiary care centre at Pune in Western Maharashtra region. The study included 603 RTPCR Covid positive patients. The patients were grouped clinically according to the severity score based on the CT/chest x-ray and SpO2 findings and their blood samples were analyzed at the Central Clinical Laboratory of our hospital for complete haematological profile. Result(s): The haematological parameters were tabulated and statistically analyzed. The mean Hb, PCV, Eosinophil, Basophil, Lymphocyte and Monocyte counts were significantly low in severe category. The mean MCV, MCH, NLR, PLR, ESR and D-dimer was high in severe category. Leucocytosis and Neutrophilia were seen in severe category patients. The mean PT was prolonged in severe category patients. Overall, there were 15% deaths. Significantly, more deaths were found in severe category. Conclusion(s): Hematological and coagulation parameters are closely related to the covid-19 disease severity. Among various parameters, some like ESR, D-Dimer, NLR/PLR Ratio can be used as a reliable predictor of severity. Copyright © 2022 Authors. All rights reserved.

Neutrophilia and its correlation with increased inflammatory response in COVID-19 in diabetic and pre-diabetic patients

Background: Hyperglycemic patients are at a high risk of COVID-19 severity. Neutrophils have been considered critical effector cells in COVID-19 development. Vitamin D deficiency is prevalent in hyperglycemic patients and was found to adversely associate with the neutrophil count. Aim: The goal of this work was to evaluate the characteristics of diabetic and pre-diabetic COVID-19 patients and discovered changes in neutrophils and their correlation, if any, with disease clinical presentation. Patients and Methods: The study included total of (514) Covid-19 positive patients confirmed by PCR and recruited from the Prince Mohammad Bin Abdulaziz Hospital in Riyadh, Saudi Arabia. Patient's clinical characteristics were collected for all patients. Laboratory tests include HbA1c, neutrophil count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), ferritin, D- dimer, 25 hydroxy vitamin D (25(OH)D), and folate. Results: The results found that 286 patients (55.6%) were diabetic, 77 patients (15%) were pre-diabetic and 151 (29.4%) were normoglycaemic. A significant difference was exhibited regarding the neutrophil count and inflammatory factors of COVID-19 severity. Furthermore, the neutrophil count was found to be directly correlated with the severity monitoring biochemical markers for Covid-19: CRP, ESR, ferritin, and D-dimer and inversely associated with vitamin D levels in diabetic and pre-diabetic patients. Conclusion: Our findings highlight the change of neutrophils in COVID-19 diabetic and pre-diabetic patients that was found to correlate positively with CRP, ESR, ferritin, and D-dimer, and negatively with 25(OH)D, but their correlation with the clinical presentation of the disease need further large investigations. [ FROM AUTHOR]