Clinical identification and severity in patients with COVID-19

The clinical evaluation of the patient with COVID-19 allows better care, application of safety criteria and preventive measures. The disease progresses from mild to severe and critical. In this work, is evaluated in patients with COVID-19 clinical format to identify moderate to severe stages of the disease. Following a cohort of male and female patients over 18 years of age admitted to the Infectology Service of the General Hospital of Mexico. Each patient is studied using the"COVID-19 Infectology"clinical format and in the first 24 hours of admission, a real-time RT-PCR molecular test is performed for SARS-CoV-2 infection. 65 patients classified as severe COVID-19 were studied, the RT-PCR was positive in 60 patients and negative in 5, clinical data did not differ from the positive ones and the 5 negative were considered false negative cases of the molecular test. There were no differences between positives and negatives with Fisher's test, and no difference in age, comorbidities, or prognostic evaluation with Student's t test. The conclusion is that the clinical format"COVID-19 Infectology"allows to recognize the cases and identify those that are in a severe evolution.Copyright /© 2021 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.

Esophageal Mucosal Calcinosis: A Rare Site of Calcium Deposition in End-Stage Renal Disease

Introduction: Calciphylaxis, otherwise known as calcium uremic arteriolopathy, is defined as calcium deposition around blood vessels in skin and fat tissue which occurs in 1-4% of patients with end-stage renal disease (ESRD). Calcium deposition in the esophagus is extremely rare;to date, there have been only 4 cases reported worldwide. We report the fifth case of esophageal mucosal calcinosis occurring in a young male with ESRD. Case Description/Methods: A 37-year-old Thai man with ESRD on peritoneal dialysis since 2005 presented with generalized weakness and odynophagia due to oral ulcers, resulting in poor PO intake. He denied drinking alcohol, illicit drug use, or smoking. On exam his abdomen was soft, non-distended, non-tender, without any guarding. Past medical history included hypertension and COVID-19 in January 2022. Laboratory tests revealed neutropenia and pancytopenia, hyperphosphatemia, and hypocalcemia. EGD revealed distal esophageal esophagitis and hemorrhagic erosive gastropathy. Biopsy showed ulcerative esophagitis with dystrophic calcification, consistent with esophageal mucosal calcinosis .No intestinal metaplasia was noted. Immunohistochemistry was negative for CMV, HSV1, and HSV2. The patient was treated with pantoprazole 40mg IV every 12 hours, Magic Mouthwash 5ml qid, and Carafate 10mg qid. He was transferred to a cancer center where he had a bone marrow biopsy formed which was negative. His symptoms resolved and the patient was discharged to home (Figure). Discussion(s): Esophageal mucosal calcinosis is extremely rare. It is due to a combination of factors involving acidosis and the phenotypic differentiation (and apoptosis) of vascular smooth muscle cells (VSMC) into chondrocytes or osteoblast-like cells. These changes, along with the passive accumulation of calcium and phosphate, induce calcification. Acidosis is well-known to promote inflammation of the arterial walls, releasing cytokines that induce vascular calcification. The benefits of treatment with sodium thiosulfate remain unclear. An ample collection of cases should help devise standardized treatment options and establish management guidelines for this condition.

Post-Covid mucormycosis presenting as retropharyngeal abscess: a rare case report

Background: Post-Covid retropharyngeal mucormycosis is a rare presentation, and no case has been reported in literature until date. Case presentation: A-32-year-old female post Covid presented to our OPD with history of dysphagia and with a history of steroid intake. Radiology confirmed it as retropharyngeal abscess. Endoscopic-guided aspiration was done. HPE (histopathological examination) revealed classic broad aseptate hyphae of mucormycosis. Patient was managed conservatively with broad-spectrum antifungal. Conclusion(s): Retropharyngeal mucormycosis is a rare entity in Covid era. Rapid diagnosis and management are needed to save life of an individual, or results could be fatal.Copyright © 2022, The Author(s).

A Clinical and Demographic Profile of Tonsillitis Patients during the COVID-19 Pandemic

Background: Tonsillitis is a common public health problem seen by otorhinolaryngology surgeons. It has socio-occupational and economic impact. Most of the tonsillitis is treated by antibiotic but some can lead to life threatening complication if not treated on time and not diagnosed the impending complication. Aim and Objectives: The objective of this work was to study the epidemiological and complications profile of acute and chronic tonsillitis and their distribution, followed by final outcome of the treatment adopted in the ANIIMS Portblair, ENT Department. Material(s) and Method(s): This is a retrospective study over a 12-month period from September 2020 to Aug 2021 including 225 patients who presented with tonsillitis and/or their complications were analysed. Their demography, clinical findings, types of tonsillitis, month wise distribution of types of disease and final outcome after medical treatment was analyzed. Result(s): Two hundred and twenty five (225) patients were studied. The mean +/- SD of cases studied was 23.32 +/- 12.98 years with minimum - maximum age range was 02 - 60 years. In this study there were 92/225 (40.9%) males and 133/225 (59.1%) females with a male to female ratio of 1:1.44. 76.88% of the patients showed a good outcome, 14.22% showed a moderate outcome, 07.55% showed an average outcome and 00.88% showed poor outcome. 19/ 225 (08.44%) of the patients who showed poor and average response were advised tonsillectomy after the COVID-19 pandemic in this study. Conclusion(s): Chronic Tonsillitis was a common throat disorder observed during COVID-19 pandemic. Males were more commonly affected. The increased attendance of patient's throat complaints was high due to awareness and similarity of symptoms of tonsillitis and COVID-19 disease. Low socio economic groups were more affected. The common types of tonsillitis were parenchymatous type, follicular type. Complications due to acute infection frequently observed were peritonsillar abscess, neck abscess. Medical treatment with Amoxycillin and clavulinic acid combination was highly responsive with 76.88% responding well.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Predictive factors for hospitalization in a cohort of primary healthcare patients with suspected COVID-19

Background: The objective of the study was to identify clinical and demographic factors predictive of hospitalization in primary healthcare patients diagnosed with suspected COVID-19 at the beginning of the pandemic. Method(s): A retrospective cohort study design was used. Patients attended in Casanova primary healthcare centre (CAP) (Barcelona, Spain) for symptoms compatible with possible or confirmed SARS-CoV-2 infection between February 24 and May 30, 2020, were included. Data was collected through the electronic medical record and by telephone interview. Result(s): 518 patients were included, of whom 283 (54.6%) were female. The median age was 50.2 years and 19.3% were aged >= 65 years: 79% were followed on an outpatient basis while the rest were hospitalized. Predictive factors for hospital admission were male sex, older age, a history of ischemic heart disease and the presence of dyspnoea, haemoptysis, nausea and vomiting, with a sensitivity of 48% and a specificity of 95.4%. Odynophagia and nasal congestion were predictors of a good prognosis. Mortality was 2.3% and 25% of deaths did not occur in hospital. Conclusion(s): Nearly 80% of primary healthcare patients received only outpatient care. Male sex, older age, a history of ischemic heart disease and symptoms like dyspnoea, haemoptysis, nausea and vomiting could lead to a greater risk of an unfavorable evolution during COVID-19. Patients with at least one of the above factors, which correlate with a higher hospital admission rate, should receive a closer follow-up to early detect when they can benefit from a hospital evaluation based on their clinical evolution.Copyright © 2023 The Authors

Clinical and Cytopathological Traits of Herpes Zoster: A Report of Two Cases

Introduction: Varicella zoster virus is a highly infectious alpha-herpesvirus, pathogenic only to humans. The primary infection of varicella zoster virus causes chickenpox, which is contagious and primarily infects children and adolescents in India. Following the primary infection, the virus remains dormant in sensory root ganglia. Activation of the dormant virus in later stages of life causes herpes zoster infection which may vary from subclinical infection to typical zoster, scattered vesicles, zoster sine herpete or disseminated zoster, which depends on the individual's immune status. Case report: In this case series, we present two patients with herpes zoster involving the mandibular branch of the trigeminal nerve. Cytology revealed characteristic features of the infection including nuclear moulding, multinucleated giant cells and ballooning degeneration. Conclusion(s): More recently, patients presenting with herpes zoster have been reported to have sub-clinical Covid-19 infection, suggesting a possibility that herpes zoster might be an indicator for latent Covid-19. Timely detection and treatment of this infection can reduce the risk of post herpetic neuralgia.Copyright © 2022 Sciendo. All rights reserved.

Acquired hemophilia in a patient with SARS-CoV-2 infection, a case report

Acquired hemophilia (AH) is a potentially life-threatening hemorrhagic disorder. We report the second confirmed case of COVID-19-associated AH in a 45-year-old female which, unfortunately, expired as her treatment failed. She presented to the emergency department with abnormal bleeding and spontaneous hemoptysis about ten days after a removal surgery of her epiglottis tumor. Aggregation tests, such as partial thromboplastin time (PTT), are recommended in patients with COVID-19 infection that have bleeding episodes.Copyright © 2022 The Author(s);Published by Society of Diabetic Nephropathy Prevention.

Guillain-Barre syndrome associated with SARS-CoV-2 infection: A case series from 4 Colombian cities during the pandemic

SARS-CoV-2 infection has been associated with multiple neurological manifestations. One such manifestation, which has been described since the early stages of the COVID-19 pandemic and is relevant for current neurological practice, is Guillain-Barre syndrome (GBS). The literature describes neurotoxic mechanisms of the virus itself and the possible pathways by which it may affect the peripheral nerves in experimental studies;however, we still lack information on the mechanisms causing the immune response that gives rise to GBS in the context of SARS-CoV-2 infection. Colombia is one of the Latin American countries worst affected by the pandemic, with the third-highest number of cases in the region;thus, it is essential to recognise GBS, as this potential postinfectious complication may severely compromise the patient's functional status in the absence of timely diagnosis and treatment. We present a series of 12 cases of GBS associated with SARS-CoV-2 infection from hospitals in 4 different Colombian cities and describe the clinical presentation, laboratory and electrophysiological study findings, and treatment.Copyright © 2022 Sociedad Espanola de Neurologia

Incidence and Outcomes of Covid-19 in Dialysis Patients. Data from the Argentine Registry of Chronic Dialysis

Introduction: To describe the incidence and outcomes of SARS-CoV-2 infection, to evaluate its impact (mortality), and the factors associated with infection and mortality in dialysis patients in Argentina. Method(s): All prevalent dialysis patients were included from the period from April 2020 to February 2022. The positive COVID diagnosis was always made with swab and PCR. Signs and symptoms at disease onset were included, as well as the evolution of the patient that included the requirement of hospitalization, hospitalization in a care unit (ICU) and the need for invasive respiratory assistance. Continuous variables are expressed as mean +/- standard deviation or median and range, whether or not they are parametric, continuous variables are expressed as frequency and prevalence. According to the pandemic in the general population, 3 periods were considered: period 1 (Jan2020-Feb2021), period 2 (Mar2021-Nov2021), period 3 (Dec2021-Feb2022). Univariate analysis was performed for infection and mortality as dependent variables, using the T Test, Wilcoxon or Chi2 as appropriate. Multivariate analysis was performed for the dependent variable mortality. A p<0.05 was considered significant. The analysis was performed with the software MedCalc 20113. Result(s): 27,548 cases were recorded (12,221, 10,241, and 5,086 in periods 1, 2, and 3, respectively). The median age was 60.8 years (52% > 60 years) and 58% were male. The most frequent antecedents were community transmission and close contact with a suspected or confirmed case. The most frequent symptoms were malaise (16%), headaches (13%), odynophagia (10%) and myalgia (11%). The most frequent clinical signs were: cough (28%9, Tdegree >= 38degreeC (20%), dyspnoea (12%) and tachypnoea (6%). Mean time between the onset of symptoms and the PCR result of 3.8 days. Of the positive cases, 31% required hospitalization, and of these 26% were in the ICU. Of those admitted to the ICU, 50% required MV. Overall mortality was 23.4%. Mortality was higher during the first period and consequently reduced during 2nd and 3rd period (27, 2%;19, 8%;2, 9% respectively).The most frequent CKD aetiologies were DBT, unknown and nephroangiosclerosis. Most of the patients had less than 3 years on dialysis, but the highest mortality was seen in the group with more than 3 years of dialysis. COVID-19 cases were more prevalent in HD patients compared to PD patients, however the type of modality did not show differences in terms of mortality. Table 1 shows those variables associated with mortality. [Formula presented] Conclusion(s): Throughout the three periods of the COVID pandemic, a decrease in hospitalization and mortality was observed. These variables as well as the infection rate were higher than in the general population. Vaccination, a priority in this population, was associated with lower mortality. Joint actions between Public Health entities and Scientific Societies in pandemic situations ensure an adequate diagnosis of the situation and the bases for timely actions. No conflict of interestCopyright © 2023

Antibiotic Use in Acute Upper Respiratory Tract Infections

Upper respiratory tract infections are responsible for millions of physician visits in the United States annually. Although viruses cause most acute upper respiratory tract infections, studies show that many infections are unnecessarily treated with antibiotics. Because inappropriate antibiotic use results in adverse events, contributes to antibiotic resistance, and adds unnecessary costs, family physicians must take an evidence-based, judicious approach to the use of antibiotics in patients with upper respiratory tract infections. Antibiotics should not be used for the common cold, influenza, COVID-19, or laryngitis. Evidence supports antibiotic use in most cases of acute otitis media, group A beta-hemolytic streptococcal pharyngitis, and epiglottitis and in a limited percentage of acute rhinosinusitis cases. Several evidence-based strategies have been identified to improve the appropriateness of antibiotic prescribing for acute upper respiratory tract infections.Copyright © 2022 American Academy of Family Physicians.

SEVERE HYPONATREMIA AS A MANIFESTATION OF A NEUROLOGIC DISORDER ASSOCIATED WITH THE COVID-19 VACCINE

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: More reports are indicating a temporal association between Bell's palsy and the mRNA vaccine for coronavirus disease 2019 (COVID-19). Therefore, collecting vaccine history is becoming important in post-marketing surveillance to monitor the safety of vaccines in real-world settings. We report the case of concomitant occurrence of Bell's palsy and glossopharyngeal neuralgia leading to severe symptomatic hyponatremia in a previously healthy patient. CASE PRESENTATION: A 60 year-old-female without significant medical history presented to the hospital with odynophagia, and generalized weakness for two weeks. She decreased her oral intake due to stabbing pain in the back of her throat triggered by swallowing. She reported hyperacusis and frequent shooting pain in the left cheek managed with non-steroidal anti-inflammatory drugs. The symptoms occurred several days after the first dose of the mRNA vaccine for COVID-19. She denied previous COVID-19 infection and herpes zoster. Examination revealed dry mucosa, left facial muscle weakness, inability to raise the left eyebrow or lift the labial commissure, effacement of the nasolabial fold, and left-sided frontal wrinkles. Laboratory investigation revealed sodium of 110. Computerized Tomography of the brain revealed negative findings for intracranial abnormalities. Severe symptomatic hyponatremia was managed with hypertonic saline. The neurologist made the diagnosis of Bell's palsy and glossopharyngeal trigeminal neuralgia leading to poor oral intake. We initiated acyclovir, prednisone, and gabapentin. The patient recovered from hyponatremia and experienced improvement of neurological symptoms with initiated medications. DISCUSSION: High morbidity and mortality of patients with COVID-19 accelerated the development and production of the vaccines. During the pandemic, mRNA COVID-19 vaccines reduced asymptomatic and prevented severe symptomatic COVID-19 infection and its complications. Although the benefits and protective effects of the COVID-19 vaccines outweighed the risks associated with them, we have reports of associations between vaccines and certain disorders such as Bell's palsy. Glossopharyngeal neuralgia is defined as sudden severe brief pain in the distribution of the glossopharyngeal nerve. It can be described as transient stabbing pain experienced in the ear, tonsillar fossa, and base of the tongue. Unusual presentation is fear to eat as this can be a precipitating cause of the pain. It overlaps with trigeminal neuralgia and can create a diagnostic dilemma. CONCLUSIONS: In summary, it is unknown what causal relationship exists between the mRNA COVID-19 vaccine and neurological diseases such as Bell's palsy and glossopharyngeal neuralgia. Glossopharyngeal neuralgia is frequently overlooked as a diagnosis. This is a unique case of concomitant glossopharyngeal neuralgia and Bell's palsy that is coincidental with a history of COVID-19 vaccine. Reference #1: El Sahly HM, Baden LR, Essink B, et al. Efficacy of the mRNA-1273 SARS-CoV-2 Vaccine at Completion of Blinded Phase. New England Journal of Medicine. 2021;385(19):1774-1785. doi:10.1056/NEJMoa2113017 Reference #2: Singh PM, Kaur M, Trikha A. An uncommonly common: Is glossopharyngeal neuralgia. Ann Indian Acad Neurol. 2013;16(1):1-8. doi:10.4103/0972-2327.107662 Reference #3: Cellina M, D'Arrigo A, Floridi C, Oliva G, Carrafiello G. Left Bell's palsy following the first dose of mRNA-1273 SARS-CoV-2 vaccine: A case report. Clin Imaging. 2022;82:1-4. doi:10.1016/j.clinimag.2021.10.010 DISCLOSURES: No relevant relationships by Nemanja Draguljevic No relevant relationships by Katherine Hodgin No relevant relationships by Kristina Menchaca No relevant relationships by Catherine Ostos Perez

POSTER: SARS-COV 2 INFECTION and ANTI TNF THERAPY in RHEUMATOID ARTHRITIS PATIENTS

Background: High levels of tumor necrosis factor (TNF), a key proinfamma-tory cytokine, is associated with SARS-CoV-2 infection. In rheumatoid arthritis patients with SARS-CoV-2 infection, anti TNF therapy reduces not only TNF but other cytokines responsible for high morbidity and mortality. The severe systemic infammation in COVID-19 causes respiratory symptoms, fever, fatigue, neurological and gastrointestinal manifestations. Objectives: We followed the evolution of SARS-CoV-2 infection in rheumatoid arthritis patients who received anti TNF blockers. Methods: Our study included 95 rheumatoid arthritis patients who were diagnosed with SARS CoV-2 infection through a positive RT-PCR-SARS-CoV2 test. 21 patients were men and 74 were women. Mean age was 58 ±11,5. 24 patients received monotheraphy with anti TNF blockers (Adalimumab/Infiximab), 48 received TNF blockers in combination with Methotrexate (10 mg per week) and 23 received TNF blockers in combination with Lefunomide (20 mg per day). We followed serum ferritin, C reactive protein and D-dimer in all patients. 59 patients were vaccinated with two doses of Pfzer-BioNtech (64.1 %). The study group was analyzed from 30th December 2021 to 1st of January 2022. From 95 patients, 35 (36,8%) were hospitalized and 60 received ambulatory care. Results: Our patients with COVID-19 presented with asimptomatic forms, forms with mild symptoms and complicated forms that required hospitaliza-tion. No patients had died. Milder forms were associated with the use of TNF blockers and Methotrexate and patients with monotherapy-TNF blockers. They presented with mild symptoms (fever, arthralgia, odynophagia, dysgeu-sia/ageusia, anosmia). Hospitalization rate in patients who received mono-theraphy with TNF blockers was 29,1%, 31,2% in patients who received TNF blockers and Methotrexate and 56,5% in patients with TNF blockers and Lefunomide (69,3%). Factors associated with higher odds of hospitalization included older age (p=0,001), active disease (p=0,02), obesity (p=0,005), pulmonary chronic disease (p=0,02), diabetes (p=0,001) and concomitent dose of Lefunomide (p=0,0006). Female sex was associated with milder forms of the disease. Patients with high levels of D-dimer had a higher odd of hospital-ization (p<0,001). Strong positive correlation was observed between elevated D-dimers and hospitalization odds. Conclusion: TNF blockers in monotheraphy or associated with Methotrexate were correlated with lower odds of hospitalization and milder forms of COVID-19. No signifcant difference of hospitalization odd was observed between vaccinated and unvaccinated patients.

COVID 19 INFECTION in PATIENTS with RHEUMATIC IMMUNE-MEDIATED DISEASES in A SINGLE UNIVERSITY HOSPITAL. MATCHED CASE-CONTROL STUDY

Background: COVID19 may present different degrees of severity. It is generally thought that viral infections in patients with rheumatic infammatory diseases (R-IMID) or receiving immunosuppressive treatment tend to present more severe disease. However, data comparing the severity of the disease between R-IMID and the general population are scarce. Objectives: To assess the predisposing factors, clinical-analytical features and severity of COVID-19 infection in R-IMID compare to patients without R-IMID. Methods: Case-control study in a single University Hospital. We included all consecutive patients with a diagnosis of a R-IMID and a positive test for COVID-19 up to March 31st, 2021. A total of 274 controls were selected for each case, and matched by sex, age (± 5 years), and without previous diagnosis of R-IMID or use of immunosuppresive therapy. Confrmed infection was defned if the patient had a positive nasopharyngeal swab for SARS-CoV-2. COVID-19 case severity was divided into mild, moderate, severe and critical according to the United States National Institute of Health (NIH) COVID-19 guidelines (1). Mild/moderate COVID19 was compared with critical. Results: We included 274 patients (185 women/89 men), mean age 59.1 18 years. More frequent R-IMID were: Rheumatoid arthritis (RA) (n=87, 31.8%), Axial spondylarthritis/Psoriatic arthritis (SpA/PsA) (n=90, 32.8%), Polymyalgia Rheumatica (PMR) (n=22, 8%) and Systemic Lupus Erythematosus (SLE) (n=22, 8%) We also included 274 age and matched controls. Main characteristics of patients with R-IMID and controls are shown in Table 1. Concerning comorbidities, hypertension and dyslipidemia were more frequent in patients with R-IMID (p< 0.05). COVID-19 symptoms' distribution is shown in Figure 1. Cough and dyspnoea were more frequent and headache, odynophagia and diarrhea were less frequent in the R-IMID group. The only analytical difference was D-Dimer that was signifcantly higher in patients with R-IMID. Although most of the cases were mild, critical cases and deaths were more frequent in R-IMID (p <0.05). Conclusion: Most of the patients present a mild COVID-19. However, a more severe syndrome was observed in R-IMID.

Prevalence and epidemiological characterization of SARS-COV-2 in children of the Chaco, Argentina

sars-cov-2 infections appear to affect children less frequently and severely than adults. Children are frequently asymptomatic or have less severe symptoms and, therefore, less tested. objective. To determine prevalence and epidemiological characterization of sars-cov-2 in children from Chaco, Argentina. material and method. Descriptive, observational study. Once authorized by the Ethics Committee, the Chaco Epidemiology Computerized Database was reviewed, laboratory confirmed pediatric patients with sars-cov-2 infection of both sexes were included, aged between 30 days of life and under 13 years and 11 months of age, from March to September 2020. results. 320 pediatric patients (170 men and 150 women) were admitted. The ages between one and 13 years;average of seven years. The provenance mostly from Resistencia. Regarding morbidities, 86.8% did not present any type and 13.1% did. The most frequent comorbidity was asthma. Regarding the signs and symptoms of presentation: 285 (89%) presented signs-symptoms and 35 (10.9%) asymptomatic. The most frequent signs and symptoms were: fever 106 (37.1%);cough 61 (21.4%);odynophagia 47 (16.4%). conclusions. In the studied population, a higher prevalence of symptomatic was found;being fever and cough, the most prevalent symptoms, however they cannot be considered characteristic of sars-cov-2 in children, requiring further studies.

Oral manifestations in patients with COVID- 19 disease

The aim is to determine oral manifestations in patients with COVID-19 disease and in the postcovid period. Methods: A special survey (questionnaire) was made in 424 people who had COVID-19 confirmed by RT-PCR, ELISA for specific IgM and IgG antibodies and Chest CT scan (168 people). 123 people had complaints and clinical symptoms in the oral cavity 2-6 months after the illness and they came to the University dental clinic. Laboratory tests have been performed (clinical blood test, blood immunogram, virus and fungal identification). Results: Survey results showed that 16,0% participants had asymptomatic COVID-19, 23,6% - mild and 48,1% moderate disease. 12,3% with severe COVID-19 were treated in a hospital with oxygen support. In the first 2 weeks 44,3% indicated xerostomia, dysgeusia (21,7%), muscle pain during chewing (11,3%), pain during swallowing (30,2%), burning and painful tongue (1,9%), tongue swelling (30,2%), catharal stomatitis (16,0%), gingival bleeding (22,6%), painful ulcers (aphthae) (8,5%) and signs of candidiasis - white plaque in the tongue (12,3%). After illness (3-6 months), patients indicated dry mouth (12,3%), progressing of gingivitis (20,7%) and periodontitis (11,3%). In patients who applied to the clinic we identified such diagnoses: desquamative glossitis - 16 cases, glossodynia (11), herpes labialis and recurrent herpetic gingivostomatitis (27), hairy leukoplakia (1), recurrent aphthous stomatitis (22), aphthosis Sutton (4), necrotising ulcerative gingivitis (13), oral candidiasis (14), erythema multiforme (8), Stevens-Johnson syndrome (2), oral squamous cell papillomas on the gingiva (4) and the lower lip (1). According to laboratory studies, virus reactivation (HSV, VZV, EBV, CMV, Papilloma viruces) was noted in 52 patients (42,3%), immunodeficiency in 96 people (78,0%), immunoregulation disorders (allergic and autoimmune reactions) in 24 people (19,5%). Conclusions: Lack of oral hygiene, hyposalivation, vascular compromise, stress, immunodeficiency and reactivation of persistent viral and fungal infections in patients with COVID-19 disease are risk factors for progression of periodontal and oral mucosal diseases.

A Rare Cause of Angioedema - A Novel Case Report

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is well described as an etiology to severe acute respiratory distress syndrome (ARDS). However, rare immunologic and allergic manifestations may also occur from this infection. We report a novel case of angioedema occurring in the setting of COVID-19 infection in a fully vaccinated patient. Case Report: A 61-yearold COVID-19 vaccinated female with hypertension presented to the emergency department with tongue and lip swelling, odynophagia, dysphonia, and difficulty breathing. She denied personal or family history of allergies, anaphylaxis, or angioedema. Her home medications included Aspirin, methadone, Seroquel, and Klonopin, with no recent changes reported. Physical exam was notable for significant lip and tongue edema, audible dysphonia, and bilateral end-inspiratory wheezing. She was hypoxemic and placed on nasal cannula. Laboratory findings revealed lymphopenia, elevated inflammatory proteins, including C-reactive protein (57), Lactate dehydrogenase (LDH) (238), and D-dimer (11.52). Functional C1 esterase inhibitor levels (>91) were normal. Nasal PCR swab returned positive for SARS-CoV-2. Ear, nose, and throat specialist was consulted given concern for angioedema, and flexible nasolaryngoscopy was performed revealing uvular, epiglottic, and bilateral arytenoid edema concerning for impending airway compromise. The patient was initiated on intravenous methylprednisolone, epinephrine, antihistamines, tranexamic acid and admitted to the medical intensive care unit (ICU). She was monitored closely in the ICU with subsequent improvement of the angioedema and resolution of the hypoxemia. She was discharged with an oral steroid regimen and scheduled for a follow-up appointment with an allergist. Discussion: There exists only a handful of case reports describing angioedema in patients with COVID-19 infection. In those reports, patients also had normal C1 esterase inhibitor levels and no personal or family history of inherited angioedema. Interestingly, our patient was vaccinated six months prior to her presentation. The association between SARS-CoV-2 and angiotensinconverting enzyme 2 (ACE-2), the primary receptor for viral entry into the epithelial cells of the lungs, could be a potential explanation for the occurrence of angioedema. ACE-2 plays a pivotal role in inhibiting a potent ligand of bradykinin receptor 1, Arginine bradykinin. It has been postulated that SARS-CoV-2 downregulation of ACE-2 leads to elevated angiotensin II levels and subsequent activation of the bradykinin pathway. Excessive bradykinin production generates high levels of nitric oxide and prostaglandins, resulting in vasodilation, increased vascular permeability, and angioedema. This case highlights the importance of recognizing atypical and rare presentations of COVID-19 infection, especially angioedema, given its sudden onset and life-threatening complications.

COVID-19 associated myositis with severe proximal and bulbar weakness

Objective: NA Background: Here we report a patient with COVID-19 associated inflammatory myopathy, presenting with facial, bulbar and proximal limb weakness. A 58-year-old woman presented with cough, dyspnea, and myalgia. Vital signs and her physical exam was unremarkable. Initial PCR testing for SARS-CoV-2 was negative and the patient was discharged home. She returned three weeks later with more severe dyspnea, cough, dysarthria, dysphagia, odynophagia and severe generalized weakness with inability to ambulate. She had no sensory symptoms or bowel or bladder dysfunction. Physical examination was significant for tachycardia and oxygen saturation of 88% on room air. She had bilateral ptosis, facial weakness, hypernasal dysarthria and profound symmetric proximal limb weakness. Reflexes were symmetrically diminished. Repeated SARS-CoV-2 PCR was positive. MRI of the entire neuroaxis showed no central or peripheral nervous system involvement, but demonstrated diffuse muscle edema and enhancement, with a region of myonecrosis Motor nerve conduction studies were unremarkable, needle electromyography revealed sparse fibrillation potentials;On admission, CK was elevated to 700 U/L. Anti-Sjögren's-syndrome-related antigen and anti-small ubiquitinlike modifier-1 activating enzyme antibodies were both strongly positive and Ku antibody was weakly positive. Muscle biopsy showed perivascular inflammatory infiltration with endomysial extension, regenerating fibers and upregulation of HLA Class ABC expression on non-necrotic fibers. Our presumptive diagnosis was COVID-19 associated myositis and a five-day course of 1000 mg intravenous methylprednisolone was administered. Over two weeks, her CK levels normalized and she recovered the ability to raise her arms and legs from the bed and showed slow improvement in bulbar function. Design/Methods: NA Results: Viral infection is a well-known cause of myositis. The severe immune activation known to occur in COVID-19 patients likely plays a major pathophysiologic role. The finding of multiple serologic autoimmune antibodies is intriguing suggesting an epiphenomenon rather than activation or unmasking of a specific immune response directed to the muscles. Conclusions: NA.