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The respiratory pump that provides pulmonary ventilation includes the respiratory center, peripheral nervous system, chest and respiratory muscles. The aim of this study was to evaluate the activity of the respiratory center and the respiratory muscles strength after COVID-19 (COronaVIrus Disease 2019). Methods. The observational retrospective cross-sectional study included 74 post-COVID-19 patients (56 (76%) men, median age - 48 years). Spirometry, body plethysmography, measurement of lung diffusing capacity (DLCO), maximal inspiratory and expiratory pressures (MIP and MEP), and airway occlusion pressure after 0.1 sec (P0.1) were performed. In addition, dyspnea was assessed in 31 patients using the mMRC scale and muscle strength was assessed in 27 of those patients using MRC Weakness scale. Results. The median time from the COVID-19 onset to pulmonary function tests (PFTs) was 120 days. The total sample was divided into 2 subgroups: 1 - P0.1 <= 0.15 kPa (norm), 2 - > 0.15 kPa. The lung volumes, airway resistance, MIP, and MEP were within normal values in most patients, whereas DLCO was reduced in 59% of cases in both the total sample and the subgroups. Mild dyspnea and a slight decrease in muscle strength were also detected. Statistically significant differences between the subgroups were found in the lung volumes (lower) and airway resistance (higher) in subgroup 2. Correlation analysis revealed moderate negative correlations between P0.1 and ventilation parameters. Conclusion. Measurement of P0.1 is a simple and non-invasive method for assessing pulmonary function. In our study, an increase in P0.1 was detected in 45% of post-COVID-19 cases, possibly due to impaired pulmonary mechanics despite the preserved pulmonary ventilation as well as normal MIP and MEP values.Copyright © Savushkina O.I. et al., 2023.
ABSTRACT
The respiratory pump that provides pulmonary ventilation includes the respiratory center, peripheral nervous system, chest and respiratory muscles. The aim of this study was to evaluate the activity of the respiratory center and the respiratory muscles strength after COVID-19 (COronaVIrus Disease 2019). Methods. The observational retrospective cross-sectional study included 74 post-COVID-19 patients (56 (76%) men, median age - 48 years). Spirometry, body plethysmography, measurement of lung diffusing capacity (DLCO), maximal inspiratory and expiratory pressures (MIP and MEP), and airway occlusion pressure after 0.1 sec (P0.1) were performed. In addition, dyspnea was assessed in 31 patients using the mMRC scale and muscle strength was assessed in 27 of those patients using MRC Weakness scale. Results. The median time from the COVID-19 onset to pulmonary function tests (PFTs) was 120 days. The total sample was divided into 2 subgroups: 1 - P0.1 <= 0.15 kPa (norm), 2 - > 0.15 kPa. The lung volumes, airway resistance, MIP, and MEP were within normal values in most patients, whereas DLCO was reduced in 59% of cases in both the total sample and the subgroups. Mild dyspnea and a slight decrease in muscle strength were also detected. Statistically significant differences between the subgroups were found in the lung volumes (lower) and airway resistance (higher) in subgroup 2. Correlation analysis revealed moderate negative correlations between P0.1 and ventilation parameters. Conclusion. Measurement of P0.1 is a simple and non-invasive method for assessing pulmonary function. In our study, an increase in P0.1 was detected in 45% of post-COVID-19 cases, possibly due to impaired pulmonary mechanics despite the preserved pulmonary ventilation as well as normal MIP and MEP values.Copyright © Savushkina O.I. et al., 2023.
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Background: Cystic fibrosis (CF) is a chronic, multi-system disease that can greatly affect quality of life, so it is important for people with CF to be closely evaluated. Routine care includes measurement of basic vital signs, which allows providers to assess respiratory, cardiovascular, and nutritional status, all of which are aspects people with CF at high risk of decompensation because of the disease's pathophysiology [1]. Providing patients with home devices can improve access to vital sign monitoring, which in turn can expand the scope of telehealth and bring attention to daily changes in a patient's overall health [2]. We predict that providing patients with medical devices to monitor vitals will benefit their overall health and wellbeing. Method(s): Medical device kits were offered to patients coming for their routine in-person visits at VCU Health Mayland Medical Center. Each kit contained a tape measure, pulse oximeter, thermometer, blood pressure apparatus, and weight scale. Before receiving the kit, patients who agreed to participate in the study filled out a pre-distribution survey that was modeled after the Centers for Disease Control and Prevention Health- Related Quality of Life-14. If patients did not know how to use a device, health care staff instructed them on its use. Twoweeks after they received the kit, patients were emailed a post-distribution survey that assessed the usefulness of each medical device. Result(s): Seventeen of 18 patients (94.4%) agreed to participate in the study. From the pre-distribution survey, 11.8% of patients frequently monitored their vitals;94.1% of those believed that using the devices would help improve the maintenance of their health, and 82.3% were aware of normal values for blood pressure, pulse, oxygen level, and body temperature and how to measure height and weight. All six of the 17 (35.3%) patients who responded to the post-distribution survey stated that the devices had worked as intended and that they did not find the devices too time consuming. Of the five devices that patients received, most patients found the pulse oximeter and blood pressure apparatus to be useful (100%), followed by the weight machine (75%), thermometer (50%), and tape measure (0%). Conclusion(s): Although most patients agreed that monitoring their vital signs at home would help maintain or enhance their health (94.1%), before this study, only two (11.8%) indicated that they regularly self-measured their vital signs. Overall, patients received being provided home devices was overall positively, with the pulse oximeter and blood pressure apparatus being the most popular. Reasons included ease of access and ability to self-triage and determine the urgency of seeing a health care provider if feeling unwell. The results of this study highlight not only patient desires to be more involved with their health, but also the importance of continuing to find ways to optimize remote monitoring during this COVID era.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved
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Background. Environmental factors such as infections and vaccines are known to trigger dermatomyositis (DM), and during the recent SARS-CoV-2 pandemic this has become even clearer. SARS-CoV-2 infection may share features with anti-MDA5 DM, such as rapidly progressive lung involvement, cutaneous lesions and cytokine release syndrome. A few case reports of DM following SARSCoV-2 vaccination have been published, suggesting the onset of an aberrant immune response leading to DM with specific autoantibody signatures and severe organ impairment. Methods. Clinical and laboratory data of the 2 case reports were obtained from electronic clinical charts in Humanitas Research Hospital (Rozzano, Milan, Italy). Autoantibody analysis was performed by protein-immunoprecipitation for anti-MDA5 and immunoblot for anti-Ro52 and TIF1gamma antibodies as per protocol. Results. Case report 1 is a 71-year-old woman who developed fever, cough, and anosmia, which resolved spontaneously in two weeks, but did not undergo a nasopharyngeal swab, while her relatives were diagnosed with SARS-CoV-2 infection. When symptoms improved, she developed arthralgia and skin lesions on her face, chest, and hands for which she started topical treatment, with negative SARSCoV-2 nasopharyngeal swab and positive serum test for IgG against SARS-CoV-2 spike protein. For the persistence of the skin rash and arthralgia, she was admitted to our Department in March 2021. Blood tests showed mild elevation of C reactive protein (2.1 mg/L -normal value NV<5), aspartate (84 UI/L) and alanine aminotransferase (133 UI/L -NV<35), ferritin (595 ng/ml -NV<306), troponin I (19 ng/L -NV<14), and BNP (251 pg/ml -NV<100) with normal complete blood cell count, creatine kinase, C3 and C4. IgG antibodies for SARS-CoV-2 spike protein were confirmed to be elevated (96 AU/ml -NV<15). Autoantibodies associated with connective tissue diseases were tested and only anti-MDA5 antibodies were positive at immunoprecipitation. A punch biopsy of a Gottron-like lesion on the left hand showed leukocytoclastic vasculitis. We observed reduced capillary density with neoangiogenesis and ectasic capillaries at the nailfold capillaroscopy. EKG and ecocardiography were normal, while cardiac magnetic resonance detected abnormalities in the parametric sequences, consistent with signs of previous myocarditis. A lung CT scan revealed pulmonary emphysema while respiratory function tests demonstrated reduced volumes (FVC 82%, FEV1 64%, inadequate compliance CO diffusion test). Based on the biochemical and clinical findings, a diagnosis of anti-MDA5-associated DM with skin and heart involvement was made and treatment with low-dose methylprednisolone (0.25 mg/kg daily) and azathioprine 100 mg was started, then switched to mycophenolate because not effective on skin lesions. Case report 2 is an 84-year-old woman with history of colon cancer (surgical treatment) and oral lichen treated with low doses steroids in the last 2 years. After the 2nd dose of SARS-CoV-2 mRNA vaccination, in March 2021 she developed skin rash with V-sign, Gottron's papules, periungueal ulcers, muscle weakness and fatigue, thus she performed a rheumatologic evaluation. Blood tests showed mild elevation of creatine kinase (484 UI/L, NV <167), CK-MB (9.6ng/ml, NV <3.4), BNP (215 pg/ml -NV<100) with normal values of complete blood cell count, C3 and C4. Anti-Ro52kDa and TIF1gamma were positive at immunoblot, thus we confirmed a diagnosis of DM. The clinical evaluation also showed active scleroderma pattern at nailfold capillaroscopy, normal echocardiography, bronchiectasia but not interstitial lung disease at lung CT, and normal respiratory function tests (FVC 99%, FEV1 99%, DLCO 63%, DLCO/VA 81%). A PET-CT scan was performed to exclude paraneoplastic DM, and treatment with steroids and mycophenolate was started. Conclusions. SARS-CoV-2 may induce mechanisms for escaping the innate immunity surveillance and causing autoimmune diseases, but more clinical and functional studies are needed to demonstrate this possible association.
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Introduction: Hospitalized COVID-19 patients commonly develop pulmonary complications and respiratory insufficiency. Prediction of respiratory deterioration in hospitalized COVID-19 patients is an unmet goal. Aim(s): To assess monitoring of lung fluid status of hospitalized COVID-19 patients to predict respiratory deterioration and prognosis. ClinicalTrials.gov Identifier: NCT04406493. Method(s): Study population comprised 51 patients hospitalized in Hillel Yaffe Medical Center with COVID-19 infection. Patient lung fluid status was monitored by repeat measurements of the lung impedance (LI), a technique found to be very effective for monitoring and guiding treatment of heart failure patients. Decreasing LI reflects lung fluid accumulation. Clinical and laboratory parameters, chest X-ray and LI level were recorded during hospitalization. Result(s): Of 51 patients hospitalized for COVID-19 infection (37- men and 14- women, 55.7+/-12.6 years-old), 46 were discharged alive after successful treatment and of these 27 returned for follow-up evaluation 3-6 months after discharge. In these patients' admission LI was 72.6+/-18.4 Ohms (Figure 1) and discharge LI was 83.8+/-20.7 Ohms, which is 15% higher than the admission value (p< 0.04). LI at the follow up visit was surprisingly low (63.7+/-15 Ohms), or 31.6% lower than discharge value (p<0.01, figure 1). At follow up, examination of the patients and the NT-proBNP tests were within normal limits. Using our previous experience we calculated the normal ("dry") LI based on the age, sex, weight, height and anthropology of the chest. The calculated values of the normal LI of patients in time of post-discharge visits were exactly same as measured. Therefore, the LI values of patients in time of hospitalization were higher than their normal values. This finding contrasts with our experience with heart failure patients, where decreasing LI reflects lung fluid accumulation. The possible explanation of this finding is that the lung fluid of COVID-19 patients, containing a high concentration of proteins, has different conductivity properties than the lung fluid of heart failure patients. Conclusion(s): Decreasing of LI level at post-discharge visits of COVID-19 patients 3-6 months after hospitalization differs significantly from the pattern in heart failure patients.Copyright © 2022
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Background: Long COVID emerged as a new condition, following the acute episode of coronavirus disease 2019 (COVID-19),exerting a significant impact on patients' quality of life [1]. Several studies involving COVID- 19 survivors emphasized the presence of cardiac abnormalities following the acute infection. However, data on possible mechanisms associated to long COVID remain limited. Clinical applications of myocardial work (MW) analysis, assessed by transthoracic echocardiography (TTE) have expended recently, showing an additional value in detecting cardiac dysfunction compared to standard parameters such as left ventricle ejection fraction (LVEF) or global longitudinal strain (GLS) in various pathologies, including COVID-19 [2]. Nevertheless, its potential role in detecting subclinical cardiac dysfunction in long COVID remained unexplored. Purpose(s): We assessed the association between subclinical cardiac dysfunction evaluated by global work index (GWI) and global constructive work (GCW) and long COVID. Method(s): We included 310 COVID-19 patients hospitalized between March and April 2020. All patients were invited to a systematic one-year follow-up, including clinical evaluation, TTE with MW assessment, chestcomputed tomography and spirometry. 140 patients completed the followup. Normal values for GWI and GCW were defined as 1926+/-247 mmHg% and 2224+/-229 mmHg% [3]. The primary endpoint was long COVID, characterized by a cluster of symptoms such as fatigue or dyspnea more than 3 months after the acute infection, without any other explanation. Result(s): 140 patients (57.1+/-13.9 years, 90 (64.3%) males) had a mean follow-up of 337.1+/-34.5 days.The mean values of LVEF, GWI and GCW were 55.2+/-3.2%, 2105.9+/-403.3 mmHg% and 2377.8+/-446.2 mmHg%. 83 (61%) patients had long COVID. No significant differences in terms of comorbidities, clinical evaluation and COVID-19 severity were found between patients with and without long COVID. GCW (2276.7+/-410.3 vs 2516.5+/-458.6, p=0.006) and GWI (2008.5+/-358.9 vs 2242.2+/-427.0, p=0.003) were the only TTE parameters different between patients with and without long COVID. Multivariable regression analysis showed that GWI <1926 mmHg% (OR 6.095;CI: 2.024-18.355, p=0.001) and GCW <2224 mmHg% (OR 3.205;CI: 1.181-8.694, p=0.022) were the only MW parameters independently associated with long COVID, irrespective of age or the severity of the acute infection, at one year. In a subgroup analysis of 77 patients without previous cardiovascular diseases, long COVID was diagnosed in 45 (58.4%)patients. GWI <1926 mmHg% (OR 8.015;CI: 2.149-29.887, p=0.002) remained independently associated with long COVID at 1 year follow-up. Conclusion(s): Long COVID, frequently observed in recovered COVID-19 patients may indicate the presence of subclinical cardiac dysfunction, reflected by a decrease of the left ventricle performance, assessed by GWI and GCW.Long-term follow-up including cardiac screening should be performed in order to identify patients at risk who would benefit from cardiac rehabilitation programs.
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Background/Introduction: Clinical applications of myocardial work(MW) analysis have expended recently, showing an additional value in detecting cardiac dysfunction compared to standard echocardiographic parameters such as left ventricle ejection fraction(LVEF) or global longitudinal strain(GLS). Nevertheless, its role in detecting subclinical cardiac dysfunction in long COVID remained unexplored. Purpose(s): We assessed the association between subclinical cardiac dysfunction evaluated by MW and long COVID. Method(s): All COVID-19 discharged patients were invited to a systematic one-year follow-up, including clinical evaluation, echocardiography, chest-computed tomography and spirometry. Normal values for global work index(GWI) and global constructive work(GCW) were defined as 1926 +/-247mmHg% and 2224+/-229mmHg%. The primary endpoint was long COVID, characterized by a cluster of symptoms (e.g. fatigue or dyspnea) more than 3 months after the acute infection, without any other explanation. Result(s): 140 patients(57.1 +/-13.9 years, 90(64.3%)males) had a mean follow-up of 337.1+/-34.5 days. The mean values of LVEF, GWI and GCW were 55.2+/-3.2%,2105.9+/-403.3mmHg% and 2377.8 +/-446.2mmHg%. 83(61%)patients had long COVID. No significant differences in terms of comorbidities or COVID-19 severity were found between groups.GCW(2276.7 +/-410.3 vs 2516.5+/-458.6, p=0.006) and GWI(2008.5+/-358.9 vs 2242.2+/-427.0, p=0.003) were significantly different between patients with and without long COVID. Additionally, GWI <1926mmHg%(OR 6.095 CI2.024-18.355, p=0.001) and GCW <2224mmHg%(OR 3.205, CI 1.181-8.694, p=0.022) were the only MW parameters associated with long COVID, irrespective of age or the disease severity, at one-year. In a subgroup analysis of 77 patients without cardiovascular diseases, long COVID was diagnosed in 45(58.4%)patients. GWI <1926mmHg%(OR 8.015, CI 2.149-29.887, p=0.002)remained independently associated with the primary endpoint. Conclusion(s): Long COVID may indicate the presence of subclinical cardiac dysfunction, reflected by a decrease of the cardiac performance, assessed by MW. Long-term follow-up including cardiac screening should be performed in order to identify patients at risk who would benefit from cardiac rehabilitation programs.
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Background: Impairment of lung function is one of the main complications observed with the coronavirus disease 2019 (COVID-19), but risk factors and outcomes associated with lung function are yet to be fully elucidated, partly due to limited pre-COVID-19 clinical data on lung health. Method(s): Spirometry data were retrieved from a population-representative adult cohort in Sweden. These were linked to national registers of COVID-19 diagnosis by real-time polymerase chain reaction (RT-PCR) or recommended ICD10 codes set by clinicians. We compared pre-COVID-19 lung function in COVID-19 cases and non-cases using independent t-test, presenting measurements as a percentage of predicted normal values. Result(s): From the cohort of initially 24,534 adults aged 16-75 years, spirometry, measured 2017-2019, was performed to 951 subjects (n=633 with asthma, n=316 no asthma). Of these, 201 (21.1%) had COVID-19. Overall, there was no difference between those who had and those who had no COVID-19 in FEV1 (93.99 +/- 1.05 vs 91.77 +/- 0.62, p 0.09), FVC (99.66 +/- 0.94 vs 98.78 +/- 0.57, p 0.47), or FEV1/FVC (94.25 +/- 0.16 vs 95.31 +/- 2.72, p 0.84). Stratifying by gender, FEV1 was higher in women who had COVID-19 than in women who had no COVID-19 (96.35 +/- 1.27 vs 92.54 +/- 0.78, p 0.02), and FEV1/FVC was higher in subjects with BMI >=30 who had COVID-19 than those with BMI >= 30 and no COVID-19 (98.42 +/- 1.07 vs 94.21 +/- 0.93, p 0.03). Conclusion(s): Pre-COVID-19 lung function in those who had COVID-19 was similar to those who have never been diagnosed. There is need to compare these baseline data with post-COVID-19 lung function data in order to ascertain possible changes in respiratory health due to the disease.
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Coronavirus disease 19 (COVID-19) is the worst pandemic ever recorded in history, as of this day more than 545 million people infected and more than 6 million cumulative deaths. COVID 19 is primarily respiratory disease, however non-respiratory presentations that could be manifested are venous and arterial thromboembolic events. Both pulmonary embolism (PE) and deep vein thrombosis (DVT) are the most frequently thrombotic events in COVID-19. Knee arthroscopy surgery is the one of the most common orthopedic surgical procedures nowadays, with the most common procedures are meniscectomy, meniscal repair and cruciate ligament reconstruction. Although knee arthroscopy is known to be a safe procedure, several complications could be found with the 3 most common complications are DVT, effusion and synovitis, and PE. We reported a case series of four patients with DVT post knee arthroscopy anterior cruciate ligament reconstruction during 2021. The DVT diagnosis was retained on clinical presentation and elevated of D-dimer testing. The patient's mean age was 35,25 years, and all of the patients had no risk factors of DVT, although they had COVID-19 infection within 3 months before surgery. The most common clinical presentation was swelling on the lower leg (around the ankle) with slightly pain and numbness. Only one patient had severe pain around the thigh. All of the patients had elevated D-dimer testing result with mean of D-dimer 1250 (normal value < 500). Only one patient had sonography testing and found proximal DVT. One of the patients had DVT at post operative day (POD) 3, one at POD 4 and the other two at POD 5. Three of the patients improved with oral anticoagulant therapy using rivaroxaban (XARELTO). In one patient the symptom was not improved after two days oral anticoagulant therapy and underwent thrombectomy by vascular surgeon. DVT is the most common complication of knee arthroscopy and also the most common non-respiratory events of COVID-19 infection. Routinely administration of thromboprophylaxis agent was not recommended, pre-operative risk assessment of DVT should be used, especially in post-COVID 19 patients.
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Background: Peripheral muscle weakness has been observed in the post-acute phase of Covid-19 patients. However, it is unknown whether Covid-19 is associated with structural changes in skeletal muscles, like atrophy, inflammation or fibrosis. Aim(s): To examine whether peripheral muscle weakness in post-Covid-19 patients is associated with changes in muscle echogenicity and thickness. Method(s): Post-Covid-19 patients with objectified muscle weakness (isometric quadriceps maximal voluntary contraction (MVC) <lower limit of normal) at ~6 months after infection were cross-sectionally studied. Vastus lateralis (VL), rectus femoris (RF), tibialis anterior (TA) and gastrocnemius (GCM) were examined unilaterally using quantitative muscle ultrasound. Standardized scores (z-scores) of 2 were defined as limits of normal. Result(s): Fourteen post-Covid-19 patients were included (age 47+/-15y, 64% male, BMI 26+/-3 kg/m2). Median z-scores were determined for muscle thickness and echogenicity of VL (-1.0 [-1.3- -0.2], 0 [-0.2-1.1]), RF (-0.2 [-1.4-0.1], -0.2 [-1.3-0.6]), TA (0.1 [-0.8-0.6], 0.5 [-0.4-1.0]), and GCM (0.8 [0.1-1.0], -0.7 [-1.3- -0.1]), respectively. Thirteen patients had values within the limits of normal. One patient showed increased echogenicity of VL, but normal values for other muscles. There were significant moderate-to-strong correlations between MVC and muscle thickness of VL (r=0.670), RF (r=0.812), TA (r=0.593) and GCM (r=0.579), and between MVC and echogenicity of GCM (r=-0.588). Conclusion(s): In a cohort of post-Covid-19 patients with peripheral muscle weakness, standardized muscle ultrasound investigations did not show any evidence for structural abnormalities.
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Background and Aim: The Coronavirus disease 2019/COVID-19/exerts an unprecedented global impact on public health and health care delivery. The aim of this study was to evaluate the knowledge on SARS-CoV-2, epidemiology, clinical presentation including cardiovascular and immunological status in postCovid children. Method(s): A group of 70 children/previously healthy or with no pre-existing heart disease/from Sarajevo with positive postcovid history, formed this study. Patients were evaluated at the Polyclinic Eurofarm in Sarajevo, from October 2020 till April 2021. Following history and epidemiological data, a detailed cardio-vascular examination has been performed including oxygen satu-ration, pulse, blood pressure, electrocardiogram/ECG/, values of polymerase chain reaction (PCR), serological tests for corona, lab-oratory blood tests and echocardiography. Result(s): The group consisted of 70 children/40 boys/: infants: 10, 1-5 years: 20;6-10:12;11-15:21;16-18 years: 7;forming five groups. Symptoms differ depending on age group, younger chil-dren had no or mild symptoms in comparison to the older group of children. The values of immunoglobulin G were significantly higher in the older group of children with (p lt;0.05;p = 0.043) indicating that the immune system with age is more responsive to the virus. PCR test was negative in 9/70 children. The majority of children/64.3 %/were asymptomatic. Two boys aged 14 years, had palpitation on exertion, shortness of breath, ECG changes, lower oxygen saturation/91% and 94%/, elevated creatinine phosphokinase miofibrilae/CPKMB/: 38 and 45, in one patient the diameter of left coronary artery/LCA/was enlarged up do 3.8mm, no aneurysm, no skin changes, with normal ejection frac-tion of left ventricle. They were on short period/10-15days/of treatment with nonsteroids including low doses of Aspirin, vita-mins/C and D/, rest and no sport activities. After treatment and a regime of no activities, they were fully recovered, free of symptoms, with normal oxygen saturation, normal values of CPKMB, diameter of LCA was within a normal range according to age and body weight of the patient. Conclusion(s): Practitioners should consider the possibility of COVID-19 in children with atypical symptomatology and posi-tive or suspicious epidemiological survey, paying special attention to coronary and immunological status.
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Background: Coronavirus-19 disease (COVID-19) has been responsible, to date, for more than 5 million of deaths. Immunothrombosis may be a major factor contributing to mortality in COVID-19 and pulmonary arterial tree involvement that mimics multiple pulmonary embolism could be a major contributor to disease course. Immunomodulatory drugs are of some beneft but mechanism not completely clear. We investigated pulmonary arterial tree clots to better appreciate their immunothrombotic nature, in contrast to the pathological characteristics of non-infammatory thrombi (1). Objectives: The primary objective was to study in depth the arterial thrombosis in COVID-19, by characterizing the immunohistochemical nature of thrombi, performing macroscopic and microscopic analyses, and by comparing clinical, laboratory and anatomical-pathological data of these patients with other patients died for COVID-19 but without evidence of pulmonary arterial thrombosis. Methods: Autopsies were performed in patients (cases) who died for COVID-19 with evidence of pulmonary arterial thrombosis at autopsy fnding but without pathological signs of bronchopneumonia or peripheral venous thrombosis. COVID-19 positive patients without pulmonary arterial thrombosis were selected as control group. Hematoxylin and eosin stained slides were reviewed choosing those with visible pulmonary thrombi. Further histochemical and immunohisto-chemical staining were performed in selected paraffin blocks. Each component of the thrombus was evaluated with the software application QuPath in terms of fbrin, red blood cells, platelets and immune cells percentage after scanning the slides with Aperio System. Laboratory tests were recorded at 2 points: at hospital admission and at Intensive Care Unit transfer. Results: We included 13 patients (cases) and 14 controls, matched for age, gender and time from diagnosis to death. Twenty arterial thrombi were studied. By immuno-histochemistry, arterial thrombi were composed by white blood cells (WBC) [median, IQR range: 10% (5-12.25)], mainly neutrophils [58% (35.2-64.5)], red blood cells [12%, (6-34.25)], fbrin [19% (14.5-42.25)], platelets [39%, (31.75-48)] (Figure 1). Three cases had a history of previous thrombosis. All cases had received anticoagulant treatment during hospitalization, low molecular weight heparin in 12/13 (therapeutic regimen in 4/12, prophylactic in 8/12) while 1/13 continued oral anticoagulants for comorbidity. By comparing laboratory fndings between cases and controls, cases showed signifcantly higher levels of platelet count [median, IQR range: 195000/mmc (157750-274500) vs 143500 (113000-175250), p=0.011], LDH [854 U/l (731-1315) vs 539 (391.5-660), p=0.003)] at hospital admission, and D-dimer at ICU transfer [25072 FEU (6951-50531) vs 1024 (620-5501), p=0.003)]. Conclusion: Pulmonary arterial thrombosis in COVID-19 is a type of immune-mediated infammatory thrombosis, since the amount of WBC is 6-times more than normal value seen in non-infammatory thrombi. Some markers of infammation, necrosis and coagulation are much more increased in this subset of patients. Chest CT angiography rather than simple CT scan at hospital admission could be more useful in this setting, and treatments with antiplatelet agents or anticoagulants, eventually in combination with immunotherapy, might positively affect the outcome.
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Introduction: During the pediatric trials for Coronavirus disease 2019 (COVID-19) vaccine the patient population was limited, likely leading to an inappreciable amount of adverse events. As more of the healthy adolescent male population began receiving the COVID-19 vaccination, cases of myocarditis shortly after became more frequently seen. Case Description: A previously well 15-year-old obese male presented to a pediatric ER with 3 days of left arm pain and 1 day of acute left-sided chest pain three days after receiving his second Pfizer-BioNTech COVID-19 vaccine in his left anterior deltoid area. The patient felt unwell afterwards with myalgias, headache, numbness, tingling, emesis, and 1-day history of fever of 38.8°C. He denied feelings of dizziness, syncope, palpitations, change in pain with position or deep breaths. Motrin and Tums did not seem to provide any relief. He had no history of recent viral illness and no known COVID-19 exposure. Initial evaluation included a normal chest Xray and normal sinus rhythm on EKG. Laboratory work revealed elevated troponin-I at 3.18 ng/mL, elevated Total CK at 399 units/L, CK-MB at 19 ng/mL, and BNP <10 pg/mL. Cardiology was consulted and following a normal echocardiogram, the patient was sent for a stat cardiac MRI. The imaging revealed acute myopericarditis with a small pericardial effusion. Mild patchy delayed subepicardial enhancement was also noted in the mid cavity and basal posterolateral wall (suggestive of postinflammatory scarring related to localized myocarditis.) During this time, CK-MB and Troponin-I continued to trend upwards. The patient was then started on standard treatment with Ibuprofen 800 mg Q6H and pantoprazole for gastric protection. His CK-MB peaked at 174 and Troponin-I at 26 which both subsequently trended downwards and normalized prior to discharge. Discussion: Patients who present with chest pain require a broad differential to encompass other possible etiologies including Coxsackie virus, Echovirus, Mycoplasma, EBV, and even Syphilis. Infectious diseases also followed along with the patient throughout his hospital course. All work-up for other potential causes remained negative. 1 week after presentation, his cardiac markers returned to baseline normal values. Conclusion: The study included close to 3,000 adolescents with only 754 ranging in the 16-17 age group further emphasizing the limited power of the study. Myocarditis and pericarditis are known, however rare, side effect of vaccinations and is seen more commonly in males. As the time period between receiving the COVID-19 vaccination and presenting with cardiac symptoms is short it is crucial to provide rapid care and adequate treatment.
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Background: With the emergence of the COVID 19 pandemic, a new disease, Multisystem Inflammatory Syndrome in Children (MIS-C), has evolved. Increasing numbers of children are being reported to have MIS-C in the U.S. & worldwide. In the U.S., there are currently 2617 MISC cases reported. MIS-C & Kawasaki Disease (KD) have almost the same presentation, making clinical differentiation difficult. This study aims at differentiating KD & MIS-C, which could assist clinicians to determine which disease they could be dealing with in their practices. Methods: Clinical features & laboratory values were collected from published studies found by queries on PubMed & other websites. Reported values were selected from published systemic reviews, metaanalyses, & large retrospective chart studies. Results: In KD, the most prevalent clinical features are fever (100%) & the 5 KDdefining clinical features: oral mucosal changes (96.5%), rash (96%), non-purulent conjunctivitis (89%), extremity changes (75.6%), and cervical lymphadenopathy (62.7%). MIS-C also presents with fever (100%) but has lower prevalence of oral mucosal changes (23%), rash (38.2%), non-purulent conjunctivitis (44.0%), extremity changes (2.5%), & cervical lymphadenopathy (4%). MIS-C leads to higher rates of ventricular dysfunction (39.3%), myocarditis (23%), & shock. For cardiac biomarkers, MISC has elevated troponin I (x6 normal) & Beta Natriuretic Peptide (BNP) (x414 normal), while KD has elevations of troponin I (x1.9 normal) & BNP (x15 normal). MIS-C has higher elevations in ESR, CRP, and D-Dimer at x6, x30, and x40 from the normal values, respectively, while KD has elevations of x2.8, x2.1, x7.3 from the normal values, respectively. MIS-C is associated with neutrophilia, thrombocytopenia, & anemia in 22% of cases. KD is associated with mild neutrophilia & anemia. KD has thrombocytosis in the subacute phase (x1.46 normal). Conclusion: Our results demonstrated that there are overlaps & differences in clinical and laboratory features. Fever is present in both KD & MIS-C, however the 5 KD defining clinical features of KD are less frequent in MIS-C. MIS-C induces higher levels of troponin I & BNP, findings that could potentially explain for higher rates of ventricular dysfunction & myocarditis. MIS-C causes higher elevations in inflammatory markers & D-Dimers compared to KD. Uniquely, thrombocytopenia is commonly present in MISC rather than in KD. Differentiating KD & MIS-C can be challenging, but by focusing closely on the clinical & laboratory features, clinicians may be able to distinguish between the two &, therefore, deliver the most appropriate care to patients in their practices.
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COVID-19 (coronavirus disease 2019), cause severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) across all age groups, it’s a positive-sense single-stranded RNA virus, and a member of the Betacoronavirus genus taxonomically (Jiang et al, 2020). Given the importance roles of zinc in combating oxidative damage and viral infections, Zinc also has confirmed roles in both male and female reproduction. The possible depletion of zinc with the oxidative events of COVID-19 is especially relevant to the fertility of affected couples (Sethuram et al, 2021). The aim of study is to determine the relation between zinc value and oxidative stress level represented by ROS (Reactive Oxygen Species) and testosterone level among the recovered COVID-19 patients in reproductive age. 120 men chosen from Center of Medical City, Health Center of 9 Nisan, Poisoning Consultation Center and Kamal AL-Samarrai Hospital, 70 recovered males from COVID-19 within a period of 6 months after the last negative PCR nasopharyngeal swab and 50 as control group (uninfected COVID-19) from the Medical staff and the relatives, during the period from December/ 2020 to February / 2021. Testosterone hormone level were measured for each male, level of COVID-19 anti-nucleocapsid IgG was estimated and designed as selection criteria for recovery from COVID-19. Pearson’s correlation coefficient and A stepwise method in linear regression statistic test was applied to detect the association of testosterone hormone level with zinc and ROS. The mean and standard deviation level of studied parameters are differ between cases of current studying;recovering COVID-19 males and control group then compared with normal value of each test. The levels of COVID-19 anti-nucleocapsid IgG increase among recovering males compared with control group, statistically highly-significant (P-value = 0.00), as well oxidative stress among cases recovered from Covid-19 compared with level of control are statistically highly-significant (P-value= 0.00), while levels of zinc are decreased among cases studied compared with control group, this differences was highly-significant (P-value = 0.00). In conclusion, the most factors affecting Testosterone hormone level identified in the study are Zinc, ROS
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Objective: To identify the frequency of blood pressure (BP) control among patients with peripartum cardiomyopathy (PPCM), barriers for follow up, and causes for elevation of BP. Design and method: Data about BP values, control, follow up, and treatment were prospectively documented for patients with PPCM who were presented to the cardio-maternal unit between 2015 - 2020. Baseline BP values were compared with the second readings between six months to one year postpartum. Adherence to medication and identifying the causes of elevated BP were reported. Results: Among 64 patients with PPCM presented to the unit, loss of follow up reported in 59.4% of patients;60.5% for unknown cause, 21.1% due to COVID-19 pandemic, and 18.4 due to death. For 26 (40.6%) patients who adhered to follow up, the mean age was (32.5 ± 7), 61.5% patients had normal BP at baseline and during follow up, while 38.5% of them had elevated BP at baseline or during follow up (cutoff 140/90);30% showed reduced BP to normal values comparing to their baseline measurements, and 70% developed increased in BP values during follow up (Table 1). All patients with increased BP measurements during follow up had hypertension associated with pregnancy, however, only 28.6% of them had known history of hypertension before pregnancy. Most common anti-hypertensive drug used post delivery was angiotensin-converting enzyme inhibitors 77%. Causes for increased BP measurements during follow up were obesity 57.1%, stress 28.6%, and use of oral contraceptive pills 14.3%. Conclusions: Among patients with PPCM with elevated BP at baseline, control of BP was reported in less than one-third of the patients. However, data for more than half of the patients was missing due to loss of follow up which is related to COVID-19 pandemic or mortality, but for the majority of patients the cause was unknown. Factors associated with elevated BP were obesity, stress, and use of oral contraceptive pills. Therefore, future enhancement in patient education regarding the importance of follow up and life style modifications is essential for better BP control among patients with PPCM. (Figure Presented).
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BACKGROUND AND AIMS: A Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents with severe pneumonia and fatal systemic complications. Currently, SARS-CoV- 2 vaccines are effective in reducing the risk of onset and severity of the disease. However, autoimmune diseases, including anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), have been reported as rare complications of the COVID-19 vaccine. Although the mechanism of ANCA vasculitis remains unknown, the genetic background, environmental factors and infections are involved in the development of the disease. Genome-wide association studies have identified several AAV-related haplotypes, including the human leukocyte antigen (HLA)-DRB1∗09: 01 allele. Here, we report a case of AAV with a risk HLA allele after SARS-CoV-2 vaccination (Pfizer-BioNTech) and a literature review. METHOD: Case report: A 71-year-old woman visited a clinic complaining of fever (37.0-37.5°C) and malaise, 1 week after receiving second dose of COVID-19 vaccine (Pfizer-BioNTech). Two months after her first dose, her serum creatinine (Cr) level had increased from 0.86 mg/dL to 1.2 mg/dL with high titer of MPO-ANCA (280 IU/mL, normal value <3.5 IU/mL). Urinary microscopy revealed a red blood cell count of 30-49/high power field and a urinary protein-creatinine ratio of 1.06 g/gCr. We diagnosed MPO-AAV with manifestations of renal involvement, general symptoms and the presence of ANCA, as a cause of renal progressive glomerulonephritis. A course of corticosteroids and intravenous cyclophosphamide was initiated. After treatment, her general symptoms and urinary abnormalities disappeared, and renal insufficiency was improved as well. Three months later, the MPO-ANCA titer decreased to 27.4 IU/mL. We examined a human leukocyte antigen (HLA) haplotype and her allele was HLA-DRB1∗09:01, which is a known risk allele of MPO-ANCAassociated vasculitis. RESULTS: Review: Until November 30, 2021, we searched PubMed, including the case report study and seven cases have been reported as De novo AAV after SARS-CoV-2 vaccination. The mean age of patients was 72.5 years (three women and four men). The onset of symptomatic symptoms, such as fever, headache and malaise, ranged from the day after the first dose to 2 weeks after the second dose;consequently, renal dysfunction was detected. In six patients (except for our case), histological findings showed pauci-immune crescentic glomerulonephritis. Most patients received initial induction immunosuppressive therapy, including corticosteroids and cyclophosphamide, followed by maintenance therapy. The renal involvement of six patients improved, but one patient with severe renal dysfunction developed end-stage renal disease. Information on HLA allele was not available in any case. CONCLUSION: This is the first case report of De novo AAV after SARS-CoV-2 vaccination in a patient with AAV susceptible HLA-DRB1∗09:01 allele. (Table Presented).
ABSTRACT
Protective, sustainable and long-lasting immunity following COVID-19 infection is uncertain, and the potential mechanisms that mediate it are not yet fully understood. We reported a case of a COVID-19 positive 53-year-old female with a medical history of hypertension, vaccination for COVID-19 in July 2021 and paucisymptomatic COVID-19 infection two months later, presented to the ED for an acute uneasy sensation over the posterior left side of the chest with radiation to left arm and shoulder of short duration and a nonproductive worsening cough in the last days. The patient's vital signs were notable for an oxygen saturation of 94% in RT and oxygen therapy was started. An ECG demonstrated sinus tachycardia with diffuse ST elevations. TC pulmonary scan showed a normal parenchimal density and a pericardial effusion. A TTE confermed small pericardial effusion and normal systolic function. CRP, myoglobin, CK-MB and troponin were within the normal values. The anti-spike antibodies were positive and no monoclonal antibody therapy could be performed. She also developed a diarrhea with negative coprocolture and parasitological stool exam. For pericarditis management, high dose steroidal drugs were started. Her symptoms improved rapidily. She was discharged 7 days after the admission. Unfortunately genomic analysis was not available in both episodes and it remains unclear whether they were caused by different strains. Given increased symptom severity during reinfection, our case highlights the need to monitor these patients more closely on a short-term and long-term basis.
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Background: Autoimmune limbic encephalitis (ALE) is an inflammatory disease involving the medial temporal lobes. It is characterized by subacute onset of short-term memory deficits, seizures and psychiatric disorders. Few new cases of ALE associated both with SARS-CoV2 infection and COVID-19 vaccine have recently been described. Case presentation: A 56-year-old woman was admitted to emergency department for persistent fever and acute onset of confusion few days apart the first dose of BNT162b2 COVID-19 vaccine. Neurological examination revealed confusion and short-term memory loss. Blood test showed only leukopenia and mild increase of the PCR. The patient underwent brain CT-scan which excluded organic lesion for the cognitive deficit. During the hospitalization the patient presented tonic clonic seizures and postictal state therefore an EEG was performed and revealed epileptiform abnormalities in the temporal lobes. Since the hypothesis of encephalitis brain MRI and lombar puncture for cerebral spinal fluid (CSF) analysis were performed with evidence of T2 hyperintensity in temporal lobes and normal values of CSF. Despite steroid and antiepileptic therapy with Carbamazepine, Valproate and Perampanel, several epileptic relapses occurred and there was no improvement of neurological manifestation. The patient was finally discharged with need of home care Conclusions: New onset ALE following COVID-19 vaccine or infection has rarely been described. Clinicians should monitor neurological symptoms to ensure appropriate therapy to maximize the likelihood of good outcome.
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Background: Graves' disease is an autoimmune disorder which represents the most common cause of hyperthyroidism. It is often triggered by an acute event, such as infections. SARS-CoV-2 binds to angiotensin-converting enzyme 2 (ACE2), expressed mostly in the lungs but also in several endocrine organs like thyroid. Description of the Case: We report a case of a 49-years-old woman admitted to our Unit due to fever, tachycardia and worsening dyspnea. Nasopharyngeal swab test resulted positive for SARS-CoV-2 (PCR). Blood sample test for D-dimer resulted increased (1272 ug/l, normal value <500), and bilateral subsegmental embolism was found on CTAngiography. She reported palpitations, insomnia and weight loss in the past days. Past medical history included euthyroid nodular thyroid disease, hypertension and obesity. Laboratory tests revealed hyperthyroidism with positive thyroid antibodies with TSH<0.05 mU/l, FT4 32 ng/l and FT3 5.9 ng/l (normal value 8-17 and 2-4, respectively), and elevated AbTPO 137 KU/l (<34) and AbTSH-r 2.4 U/l (<2). Thyroid ultrasound showed an enlarged gland with heterogeneous echotexture and hyperechoic nodules;an hypervascular pattern with elevated peak systolic velocity in inferior thyroid artery (50-69 cm/s) was found at colorDoppler. A diagnosis of Graves' disease was established and treatment with thiamazole was started, achieving normal heart rate control and recovery of symptoms. Conclusions: In the absence of a clear trigger for our patient's thyroid storm, we suggest SARS-CoV-2 infection, in addition to CT iodinate contrast medium, might precipitate or worsen a latent Graves' disease.