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Background: Severe acute respiratory syndrome coronavirus 2 (SARSCoV2) has been associated with several neuro-ophthalmic manifestations. We report a case of bilateral longitudinally extensive optic perineuritis suspected due to SARSCoV2. Case Presentation: A 32-year-old woman developed headaches, photophobia, pulsatile tinnitus, and blurred vision 8 d after having a positive SARS-CoV-2 qualitative polymerase chain reaction (PCR) testing for coronavirus disease 2019 (COVID-19). She was diagnosed with and treated for idiopathic intracranial hypertension (IIH) elsewhere. Repeat evaluation at our institution showed a poor visual acuity in both eyes with Frisen grade II papilledema and cotton wool spots on fundoscopic examination. Orbital magnetic resonance imaging (MRI) showed bilateral longitudinally extensive optic nerve sheath enhancement. Repeat lumbar puncture revealed an elevated cerebrospinal fluid (CSF) opening pressure and protein, a finding that is incompatible with the diagnosis of IIH. Myelin oligodendrocyte glycoprotein, aquaporin-4 (AQP4)-IgG antibodies, and other serological tests for optic neuritis were unremarkable. Her visual acuity partially improved after corticosteroids. With the growing association of demyelinating disorders and COVID-19, unremarkable serological workup, and temporal relation of the patient's symptoms to the infection, we believe that her diagnosis is SARS-CoV-2 associated bilateral optic neuritis. Conclusion(s): There is a growing association between demyelinating disorders and COVID-19 and COVID-19 vaccination, and it is essential to recognize CSF abnormalities that are incompatible with a diagnosis of IIH, such as increased protein in our case, and may lead to an incorrect diagnosis.Copyright © 2023 The Authors. Clinical and Experimental Neuroimmunology published by John Wiley & Sons Australia, Ltd on behalf of Japanese Society for Neuroimmunology.
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Arterial dissection is an uncommon complication of reversible cerebral vasocon-striction syndrome (RCVS). We describe the case of a 35-year-old woman with a migraine history who presented with recurrent thunderclap headache and focal neurological signs, including right hemiataxia. She had been diagnosed with COVID-19 disease two weeks earlier. Neuroimaging revealed multifocal stenosis of the posterior circulation arteries and dissection of the right superior cerebellar artery. She improved significantly throughout her one-week hospitalization and maintained only mild ataxia. The interplay between COVID-19 disease, RCVS, and arterial dissection requires further investigation.Copyright © Author(s) (or their employer(s)) and Sinapse 2022.
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SARS-CoV-2 causes Coronavirus Disease 2019 (COVID-19), an infectious condition that can present none or one or more of these symptoms: fever, cough, headache, sore throat, loss of taste and smell, aches, fatigue and musculoskeletal pain. For the prevention of COVID-19, there are vaccines available including those developed by Pfizer, Moderna, Sinovac, Janssen, and AstraZeneca. Recent evidence has shown that some COVID-19-vaccinated individuals can occasionally develop as a potential side effect Guillain-Barre syndrome (GBS), a severe neurological autoimmune condition in which the immune response against the peripheral nerve system (PNS) can result in significant morbidity. GBS had been linked previously to several viral or bacterial infections, and the finding of GBS after vaccination with certain COVID-19, while rare, should alert medical practitioners for an early diagnosis and targeted treatment. Here we review five cases of GBS that developed in different countries after COVID-19 vaccination.Copyright © 2021
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Purpose. The study of epidemiological and clinical and laboratory features and outcomes of multisystem inflammatory syndrome in children who were hospitalized against the backdrop of the current COVID-19 pandemic. Materials and methods. In 19 months (May 2020 - December 2021) 63 patients with a diagnosis of "Multisystem inflammatory syndrome in children" (MIS-C) associated with COVID-19 were observed in Anesthesiology and Intensive Care departments of the Healthcare Institution "City Children's Infectious Clinical Hospital" in Minsk, Republic of Belarus. MIS-C was diagnosed according to CDC/WHO criteria, 2020. All calculations were carried using the R Statistical Package, version 4.1. The results of the analysis were considered statistically significant with p<0.05. Results. Focusing on the periods of circulation of dominant coronaviruses, we generated 3 groups of patients. The 1st group included 40 patients (63.5%) received treatment from 05.25.2020 to 02.21.2021 ("wuhan" strains);the 2nd group comprised 9 children (14.3%) from 02.23.2021 to 06.13.2021 ("alpha");and the 3rd group consists of 14 children (22.2%) from 07.01.2021 to 11.19.2021 ("delta"). 47 (74.6%) patients had complete and incomplete Kawasaki Disease phenotype of MIS-C;nonspecific phenotype was observed in 16 (25.4%) children. The mean age didn`t differ in study groups. It was 7+/-2.5;9.4+/-4.2;7.9+/-5 years respectively. All children presented hyperthermic syndrome with febrile fever 3-4 times a day of an average duration of 3.2 (1-15) days. Clinically, the course of MIS-C in children was not dependent on the circulating strain of the virus, and gastrointestinal dysfunction was observed with equal frequency in all three groups (73%, 78% and 57%, respectively). The only statistically significant increase in number of children with cheilitis was observed in the 2 group - 8 (89%) and the 3 group - 13 (93%), p=0.002. Neurological disorders such as headache, hyperesthesia, hallucinations, photophobia were more frequently observed in the 1st group of children - 19 (48%) cases, and less frequently in the 2nd and 3rd group (in 11% and 14% of cases), p=0.022. Pathological blood flow regurgitation was the most common disorder (68-71%). Several biochemical markers of inflammation levels, such as C-reactive protein (CRP) and procalcitonin (PCT) were high. CRP levels were 162 mg/l (130;245);130 mg/l (90;160);130 mg/l (106;149) in 1-2-3 study groups, respectively. In children of the 1st group CRP level was significantly higher, p=0.052. PCT level was higher in patients of the 3rd group (4.2 ng/ml (2.4;8.8);3.9 ng/ml (3.2;11.9);8.7 ng/ml (3.4;14.1), respectively, p=0.625). Conclusion. The study revealed no appreciable association between clinical or laboratory features of MIS-C and the dominant circulating strain of SARS-CoV-2 within given time periods. During "alpha" and "delta" strains circulation, only a decrease in the number of patients with neurological disorders and an increase in the frequency of cheilitis were of significant differences, p=0.002. The remaining indicators of organ dysfunction were similar in all three groups of children. There was 1 (1.6%) fatal outcome in our study.Copyright © 2022, Professionalnye Izdaniya. All rights reserved.
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Purpose. The study of epidemiological and clinical and laboratory features and outcomes of multisystem inflammatory syndrome in children who were hospitalized against the backdrop of the current COVID-19 pandemic. Materials and methods. In 19 months (May 2020 - December 2021) 63 patients with a diagnosis of "Multisystem inflammatory syndrome in children" (MIS-C) associated with COVID-19 were observed in Anesthesiology and Intensive Care departments of the Healthcare Institution "City Children's Infectious Clinical Hospital" in Minsk, Republic of Belarus. MIS-C was diagnosed according to CDC/WHO criteria, 2020. All calculations were carried using the R Statistical Package, version 4.1. The results of the analysis were considered statistically significant with p<0.05. Results. Focusing on the periods of circulation of dominant coronaviruses, we generated 3 groups of patients. The 1st group included 40 patients (63.5%) received treatment from 05.25.2020 to 02.21.2021 ("wuhan" strains);the 2nd group comprised 9 children (14.3%) from 02.23.2021 to 06.13.2021 ("alpha");and the 3rd group consists of 14 children (22.2%) from 07.01.2021 to 11.19.2021 ("delta"). 47 (74.6%) patients had complete and incomplete Kawasaki Disease phenotype of MIS-C;nonspecific phenotype was observed in 16 (25.4%) children. The mean age didn`t differ in study groups. It was 7+/-2.5;9.4+/-4.2;7.9+/-5 years respectively. All children presented hyperthermic syndrome with febrile fever 3-4 times a day of an average duration of 3.2 (1-15) days. Clinically, the course of MIS-C in children was not dependent on the circulating strain of the virus, and gastrointestinal dysfunction was observed with equal frequency in all three groups (73%, 78% and 57%, respectively). The only statistically significant increase in number of children with cheilitis was observed in the 2 group - 8 (89%) and the 3 group - 13 (93%), p=0.002. Neurological disorders such as headache, hyperesthesia, hallucinations, photophobia were more frequently observed in the 1st group of children - 19 (48%) cases, and less frequently in the 2nd and 3rd group (in 11% and 14% of cases), p=0.022. Pathological blood flow regurgitation was the most common disorder (68-71%). Several biochemical markers of inflammation levels, such as C-reactive protein (CRP) and procalcitonin (PCT) were high. CRP levels were 162 mg/l (130;245);130 mg/l (90;160);130 mg/l (106;149) in 1-2-3 study groups, respectively. In children of the 1st group CRP level was significantly higher, p=0.052. PCT level was higher in patients of the 3rd group (4.2 ng/ml (2.4;8.8);3.9 ng/ml (3.2;11.9);8.7 ng/ml (3.4;14.1), respectively, p=0.625). Conclusion. The study revealed no appreciable association between clinical or laboratory features of MIS-C and the dominant circulating strain of SARS-CoV-2 within given time periods. During "alpha" and "delta" strains circulation, only a decrease in the number of patients with neurological disorders and an increase in the frequency of cheilitis were of significant differences, p=0.002. The remaining indicators of organ dysfunction were similar in all three groups of children. There was 1 (1.6%) fatal outcome in our study.Copyright © 2022, Professionalnye Izdaniya. All rights reserved.
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The disease pattern of acute cerebellitis has been increasingly noticed in recent years. Two different courses had been observed. A mild form with slight ataxic disorders (as a postinfectious self-limiting disease) and a fulminant course of cerebellitis with cerebellar swelling, which compresses Sylvius' aqueduct, leading to an increased intracranial pressure with an obstructive hydrocephalus, and downward herniation of the cerebellar tonsils in the foramen magnum. In this case the course can be fatal if neurosurgical emergency treatment comes too late. Cerebellitis has been observed as a sequela to a virus infection and by autoimmune-mediated inflammation. Numerous publications were concerned with childhood cerebellitis but less commonly in adults. Neuro-ophthalmological findings were frequently described as nystagmus (horizontal gaze-evoked nystagmus, vertical nystagmus, downbeat nystagmus, periodic alternating nystagmus), papilledema, more rarely paresis of the abducens or facial nerve, photophobia and very rarely an opsoclonous-myoclonous syndrome. Cerebellitis with neuro-ophthalmological findings has repeatedly been described in adults during the coronavirus disease 2019 (COVID-19) pandemic.
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SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Due to a wide range of clinical presentations, central venous thrombosis (CVT) is a rare neurologic condition that can be difficult to diagnose. Since the COVID-19 pandemic, more cases of venous thromboembolic events have emerged and been found associated with COVID-19. We detail a potential case of COVID-19 associated CVT. CASE PRESENTATION: A 28-year-old female with past medical history of obesity, polycystic ovary syndrome, recurrent sinusitis, and presumed history of COVID-19 infection with anosmia, ageusia, and sinusitis symptoms three- months prior presented to the hospital with 1-month history of worsening, right-sided pain behind her ear, eye, head, posterior neck and shoulder, nausea, and photophobia, which had worsened in the last 5 days. She initially tried over-the-counter medications with no improvement. Vital signs were unremarkable. Examination was notable for frontal sinus and right postauricular tenderness to palpation. C- reactive protein was elevated at 26.2 mg/L. Non- contrasted brain computed tomography (CT) was concerning for right transverse sinus and superior sagittal sinus thrombosis. Brain magnetic resonance imaging (MRI) showed early signs of cortical edema and venous infarction and findings concerning for right mastoiditis. Intracranial venous MRI showed complete thrombosis of the right transverse and sigmoid sinus, superior sagittal sinus, and most of the superior draining cortical veins. Heparin drip was started. Initial empiric antibiotics for mastoiditis were stopped. Hyper-coagulopathy work-up with beta- 2 glycoprotein 1 antibodies and phospholipid antibodies were negative. As there were no other inciting factors for CVT found and no history of positive COVID-19 test, a COVID-19 antibody immunoassay was obtained and returned positive. The patient did not have a history of COVID vaccination. She was discharged on warfarin and enoxaparin. Anticoagulation was stopped after 6 months with repeat imaging showing resolution of clot burden. DISCUSSION: Usual risk factors associated with CVT are morbid obesity, hormone replacement therapy, oral contraceptive use, hereditary thrombophilia, and pregnancy. Literature on CVT related to COVID-19 is limited. In 41 documented cases, the average age of incidence is 50 years old and median onset of neurological symptoms from initial COVID-19 diagnosis is 7 days [0 to 21 days]. Our patient's neurological symptoms began about 3 months after her initial diagnosis, potentially making it the first known case of COVID-19 associated CVT with symptom onset past 21 days. Anticoagulation is the mainstay treatment for CVT, and duration depends on the presence of provoking factor. CONCLUSIONS: In patients with new neurologic symptoms and recent diagnosis of COVID-19, CVT should be considered in the differential diagnosis as it can initially present in a subtle manner. Early recognition could improve patient morbidity and mortality. Reference #1: Abdalkader, M., Shaikh, S. P., Siegler, J. E., Cervantes-Arslanian, A. M., Tiu, C., Radu, R. A., Tiu, V. E., Jillella, D. v., Mansour, O. Y., Vera, V., Chamorro, Á., Blasco, J., López, A., Farooqui, M., Thau, L., Smith, A., Gutierrez, S. O., Nguyen, T. N., Jovin, T. G. (2021). Cerebral Venous Sinus Thrombosis in COVID-19 Patients: A Multicenter Study and Review of Literature. Journal of Stroke and Cerebrovascular Diseases. https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105733 Reference #2: Idiculla, P. S., Gurala, D., Palanisamy, M., Vijayakumar, R., Dhandapani, S., Nagarajan, E. (2020). Cerebral Venous Thrombosis: A Comprehensive Review. European Neurology (Vol. 83, Issue 4). https://doi.org/10.1159/000509802 Reference #3: Ostovan VR, Foroughi R, Rostami M, et al. Cerebral venous sinus thrombosis associated with COVID-19: a case series and literature review. Journal of Neurology. 2021 Oct;268(10):3549-3560. DOI: 10.1007/s00415-021-10450-8. PMID: 33616740;PMCID: PMC7897893. DI CLOSURES: No relevant relationships by Shu Xian Lee No relevant relationships by Arif Sarwari No relevant relationships by Benita Wu
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Purpose : R-shiny apps can be useful in maintaining and analyzing data collected in clinical trials of rare diseases, where a suite of measures is used to characterize retinal and visual function, functional vision, and safety courses over time following the treatment. In a phase 3 trial, participants with biallelic RPE65 mutation-associated inherited retinal dystrophy (IRD), an ultra-rare genetic disorder, received bilateral, subretinal injections of gene augmentation therapy, voretigene neparvovec and followed-up annually. We explored the development of a novel data visualization tool, VNEAN (R-shiny application), to help in maintenance and analyses of complex trial data into a visual storytelling form that is easier to understand for healthcare audience. Methods : We developed an interactive and dynamic application using Shiny package for R programming language. This app improves the ability to explore the longitudinal trajectory of main efficacy outcomes (mobility testing and full-field light sensitivity) in concert with other data, including visual function and safety that can be visualized overall and in subsets. Results : This app has 11 modules of data analyses (Figure 1), including longitudinal visualization, analyses of correlation between changes, and timeline of adverse events. It presents the durability in improvement of functional vision, retinal and visual function, and the safety data at the group, subset and participant levels. The dynamic interface allows the user to define a subset based on the measures at baseline and/or their changes and select measures and/or timepoints. Conclusions : COVID-19 demonstrated digital engagement at its peak. The R shiny app has the potential to provide alternative data visualization and interpretations of analyses that offer a comprehensive representation of the data generated in rare diseases, not easily achievable via traditional didactic lectures and static data methods. This patient-centric and enduring visualization approach enables health care professionals to learn and retain information for the management and engagement of IRD patients in their clinical practice. Additionally, this application can progress the knowledge and understanding of treatment effects of rare diseases and help inform the design of future small- or largescale trials.
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Objective: Stroke has been reported to be a potential neurological complication of COVID-19 infection in adults, however, only a few reports have been made in the pediatric population. We describe a case of a 12-year-old female with post-COVID-19 syndrome who was found to have an ischemic stroke on MRI as well as positive for lupus anticoagulant. Background: COVID-19 has been documented to potentiate a prothrombotic and proinflammatory state. It is postulated this occurs via endothelial cell disruption and clotting cascade activation. However, cases have reported the presence of prothrombotic antibodies in patients with COVID-19 infections. The persistent presence of these antibodies has important clinical implications, including an increased thrombotic risk. Design/Methods: Chart review Results: A 12-year-old female with history of migraines presented to the neurology clinic for increased frequency and severity of headaches. Patient reported to have COVID-19 infection one year prior with symptoms of fatigue, arthralgias, sore throat, and headaches. Following infection, patient had resolution of most symptoms but continued having increased headaches and difficulty concentrating. Headaches have been occurring multiple times per week, lasting hours to days, and are associated with nausea, vomiting, and photophobia. Patient has no focal neurological deficits. Brain MRI showed small focal encephalomalacia with surrounding gliosis and volume loss in the anterior right basal ganglia and adjacent external capsule consistent with a small chronic infarct. On thrombophilia work-up patient was positive for lupus anticoagulant and had a heterozygous MTHFR variant. Patient was started on baby aspirin and her headaches have been controlled with prophylactic co-enzyme Q-10 and naproxen. Conclusions: Due to the known prothrombotic risk of COVID-19 infections, there should be a high index of suspicion for stroke symptoms among pediatric patients with COVID-19. Improved clinical surveillance and increased screening for prothrombotic antibodies could ensure better outcomes, including timely treatment and prevention of complications.
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Background: The ocular symptoms are common manifestations in coronavirus infectious disease 2019 (COVID-19), which faces secondary complications and therapeutic challenges. Underlying diseases actuate the body to infectious diseases and their related manifestations through the aberration of metabolism and suppressing the immune system. This study aimed to investigate the correlation of underlying diseases and ocular manifestations in COVID-19 patients. Methods: This cross-sectional study was held on 108 hospitalized COVID-19 patients (confirmed by molecular detection) admitted to Rouhani hospital, Babol, Iran. Upon hospitalization, all clinical symptoms and underlying diseases were registered. Detailed clinical examinations regarding ophthalmological protocols were used to investigate the ocular symptoms. All analyses were performed by SPSS, version 25. Results: Our results showed that 26.67% of patients with at least one ocular symptom had hyperlipidemia, while 10.42% of patients without any ocular symptoms had hyperlipidemia (P=0.049). In this study, 97.81% of COVID-19 patients without epiphora had no thyroid disorders (hyper-/hypo-thyroidism), while 82.35% of COVID-19 patients with epiphora had not any thyroid disorders (P=0.012). Also, 75.00% of patients with blurred vision had diabetes mellitus, while 35.00% of patients without blurred vision suffered from diabetes mellitus. This difference was borderline significant (P=0.051). Other results showed that 13.04% of COVID-19 patients with eye redness suffer from myalgia, while 35.29% of patients without eye redness had myalgia (P=0.044). Also, 35.11% of COVID-19 patients without photophobia had myalgia, while none of the patients with photophobia had myalgia (P=0.005). Finally, 70.00% of patients with respiratory distress had at least one ocular symptom, while 43.10% of patients without respiratory distress had at least one ocular symptom (P=0.007). Conclusion: Some underlying diseases, e.g., hyperlipidemia, diabetes mellitus, and thyroid disorders, and some clinical symptoms in hospitalized patients, e.g., myalgia and respiratory distress, are correlated with ocular manifestations in COVID-19 patients.
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Objectives: (1) Present a case of visual decompensation related to a Rathke's cleft cyst (RCC) in setting of acute COVID-19 infection. (2) Review the literature on the presentation and management of RCCs. Study Design: Case report and review of the literature. Results: We report a case of a 32-year-old female diagnosed with a sellar mass who was transferred from an outside hospital for acute visual field decompensation. Upon arrival, the patient reported a decline in vision over the past 3 days, photophobia, and diplopia with physical exam confirming these findings. Of note, patient was unvaccinated and laboratory testing revealed that she was COVID-19 positive with mild symptoms of congestion. Imaging revealed a large intrasellar and suprasellar T1 hyperintense mass with displacement of the optic chiasm superiorly ([Fig. 1]). An endoscopic transsphenoidal approach was performed and the cyst was marsupialized into the sphenoid sinus decompressing the optic chiasm. Cultures demonstrated many white blood cells, but no organisms. Pathology confirmed a diagnosis of RCC. There was no intraoperative cerebrospinal fluid leak noted. To prevent reaccumulation of cyst contents, a free mucosal graft harvested from the posterior septectomy and was used to line the sellar defect to facilitate marsupialization into the sphenoid sinus. Postoperatively, physical exam revealed normalization of her vision and extraocular movements, and the patient subjectively confirmed these findings. She was discharged home on postoperative day 3 without complications. Review of the literature demonstrates that visual field deficits are a common presenting finding in RCC patients and acute inflammation of RCCs can present similarly to pituitary apoplexy. Transsphenoidal approaches are safe and effective in surgical decompression of RCCs. Lining the exposed cyst cavity with a free mucosal graft or nasoseptal flap may facilitate promotion of an epithelialized track to prevent cyst reaccumulation. Conclusion: A case of acute visual decompensation related to a RCC in setting of acute COVID-19 infection is presented. Inflammation of the RCC, presumably related to COVID-19 infection, contributed to the acute presentation. Endoscopic transsphenoidal approaches are effective at decompression of RCCs and free mucosal grafts or nasoseptal flaps may promote epithelialization of a tract to decrease recurrences.
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Background: The coronavirus disease 2019 (COVID-19) pandemic has been the most challenging health problem in the last 2 years. Post-COVID-19 multisystem inflammatory syndrome of children (MIS-C) is a severe post-COVID-19 complication in pediatric patients. Ocular manifestations may be the first presentation of MIS-C, wherein prompt treatment may improve outcomes. In this systematic review, we aimed to summarize the acute and sub-acute ocular manifestations in pediatric patients with laboratory-confirmed COVID-19. Methods: We included all online primary studies, with no language restriction and published between January 1, 2019 and November 18, 2020, reporting any acute or sub-acute ocular manifestations in children with laboratory-confirmed COVID-19. PubMed/MEDLINE was searched using the following MeSH and Emtree terms: “eye,” “ophthalmologic,” “ocular,” “vision,” “conjunctivitis,” “severe acute respiratory syndrome coronavirus 2,” “SARS-CoV-2,” “corona,” “2019-nCoV,” “COVID19,” and “COVID.” The eligibility and quality of the selected records were assessed by two independent reviewers as per the Cochrane Handbook for Systematic Review. Results: A total of 1,192 records were identified electronically. Seven papers were extracted from the reference lists of the eligible records. Thirty-six papers met the inclusion criteria and were categorized into two subgroups according to acute or sub-acute presentation of ocular manifestations. Among 463 pediatric patients with COVID-19, 72 (15.5%) had acute ocular manifestations. There was one patient with central retinal vein occlusion and another with photophobia and diplopia associated with meningoencephalitis. Among 895 pediatric patients with post-COVID-19 MIS-C, 469 (52.4%) had ocular manifestations, which only included non-purulent conjunctivitis. Conclusions: Ocular manifestations have been reported in less than one-fifth of pediatric patients with acute COVID-19. Furthermore, conjunctivitis was the only ocular manifestation reported in half of the patients with MIS-C, and it may be missed easily due to its non-purulent nature. During the COVID-19 pandemic, pediatricians and health workers must remain vigilant for early detection of signs of this potentially fatal post-COVID-19 inflammatory syndrome.
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Case Report A 45-year-old man with a history of end-stage renal disease s/p kidney transplant 14 months prior presented with severe headaches, neck pain, nausea, and vomiting for the past week. He takes tacrolimus, mycophenolate mofetil, and prednisone. Exam was notable for fever of 38.1°C, photophobia, and neck pain induced with forward flexion. Noncontrasted CT head found no intracranial processes. Lumbar puncture demonstrated an opening pressure of 45 cm H20 with CSF showing 108 WBCs with 67% neutrophils, normal glucose, and protein elevated to 112 mg/dL. Due to our high suspicion for cryptococcal meningitis, he was started on induction therapy with amphotericin B and flucytosine. CSF and serum cryptococcal antigens later returned positive at 1:320 and 1:2560, respectively. CSF culture also grew Cryptococcus neoformans/gattii complex. He underwent serial lumbar punctures and completed 14 days of induction therapy. He was transitioned to fluconazole consolidation after CSF cultures cleared and opening pressures on lumbar puncture had normalized. After induction, he acutely developed a severe leukopenia to 100 cells/mm3 along with profuse diarrhea. Over the next 1-2 days, he had progressive cough and dyspnea followed by hypotension, tachycardia, and hypoxemia, at which point he was diagnosed with SARS-CoV-2. He had completed his SARS-CoV-2 vaccinations 4 months prior to hospitalization. He was started on broad spectrum antibiotics and dexamethasone, placed on high-flow oxygen, and transferred to the intensive care unit. He was diagnosed with Klebsiella pneumoniae bacteremia. He developed progressive multi-organ failure and suffered a cardiac arrest. After discussion with family, the patient was transitioned to comfort care and passed away. Patients on immunosuppressive therapy are high risk for severe outcomes from both opportunistic infections and common infections that may affect the immunocompetent. It was critical to maintain a broad differential on this patient's presentation, as while cryptococcal meningitis is classically a disease of advanced HIV/AIDS, it may also occur in patients with alternative causes of immunosuppression. These patients often have other features that complicate therapy, such as an inability to reduce immunosuppression to control the disease, or drug interactions between antifungals and their immunosuppressive medications. This patient also suffered other complications from his chronic immunosuppression;a poor response to his initial SARS-CoV-2 vaccination and predisposition to more severe COVID-19 disease. Both leukopenia and diarrhea are common findings in COVID-19, which provoked the Klebsiella pneumoniae bacteremia. This unfortunate case demonstrates the need to always remain vigilant for both opportunistic and routine infections in an immunocompromised patient, especially in the setting of an ongoing viral pandemic.
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Objective: To identify the perceived causes for chronic ocular pain (COP) (≥3 months pain duration), its impact on quality of life (QoL) and understand the patient journey from social media posts. Methods: In this retrospective study, publicly available social media conversations were identified from searches triaged by a combination of automated relevancy keyword algorithm and manual review, and subsequently analyzed post anonymizing for COP content. Twitter, forums, and other (Facebook, Blogs, etc.) platforms were leveraged for the time period February 2020 to February 2021. Results: A total of 464 (UK=208, US=175, Canada=65 and Australia=16) patient/caregiver conversations on COP were identified. Top discussion points were symptoms (62%) and causes of COP (58%). Ocular factors (including dry eye disease, thyroid/Graves’ disease, and ocular surgeries) contributed to ∼46% of causes identified, while non-ocular factors (including migraine, COVID, and side-effects/withdrawal of medications) contributed to ∼54%. The most commonly mentioned symptoms (555) were headache/head pressures (96), dry/gritty eyes (67), light sensitivity (34), insomnia (29), and redness/pink eyes (28). Symptoms impacted all aspects of patients’ QoL: physical day-to-day activities such as reading, driving, and sleeping;emotional wellbeing such as depression/hopelessness, frustration/anger, fear, and suicidal thoughts;functional wellbeing such as difficulty at work/study place, reduced productivity or having to quit their job;social impacts such as being irritated around people, and having a less active social life. Eye drops (58/140 mentions) are the most commonly mentioned treatment option. Common coping strategies mentioned were blue-light filter glasses/eyeglasses (17), and hot compresses (11). Key unmet needs mentioned by patients were failed, improper, delayed diagnosis (62), and lack of effective treatments or appropriate management (30). Conclusion: Insights from this study reported patients’ experiences, concerns, and the adverse impact on overall QoL. The results can help in better understanding the patients’ perspective, which can be considered during drug development.
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Case report-IntroductionBy June 2020, 175,000 cases of COVID-19 had been identified in London alone. The most common symptoms include fever, headache, loss of smell, cough, myalgia, and sore throat. The major complication is acute respiratory distress syndrome (ARDS) but systemic complications such as cardiomyopathy, acute kidney injury, encephalopathy and coagulopathy are being identified. A delayed multi-system inflammatory syndrome in children has also been recognised and further complications are likely to be identified as our experience increases. Here, we report the case of a patient with large vessel vasculitis who initially presented with symptoms highly likely to be due to COVID-19 infection.Case report-Case descriptionA 36-year-old black African nurse presented in May 2020, with acute onset 7 days prior of high-grade fevers, rigors, nights sweats, generalised myalgia, sore throat, headache with photophobia, anosmia, dysgeusia and a widespread rash. She was a smoker with no other relevant medical, travel nor sexual history, and no drug use. A COVID-19 swab on day 2 had been negative and she had taken a course of Doxycycline.Examination revealed firm palpable subcutaneous nodules on lower limbs, upper back and forehead and cervical lymphadenopathy. She was photophobic with no meningism. The rest of her physical examination was normal. BP was 116/97 mmHg, heart rate 109 bpm and satO2 100%. Investigations demonstrated C-reactive protein 330mg/L, erythrocyte sedimentation rate 140, Ferritin 479, lymphopaenia 0.7x109, eGFR 54 with no haematoproteinuria, D-dimer 3.05 mg/L with INR 1.1, aPTT 1.3, fibrinogen 8.8 g/L. Hb, WCC, liver function, CK, serum ACE and triglycerides were normal. Infectious screen revealed negative blood cultures, HIV, Hepatitis B and C, EBV, CMV and Treponema pallidum serology. CT brain and CSF analysis were normal including bacterial culture and viral PCR. ANA, ENA, dsDNA, ANCA and aPL antibodies were negative with normal complement levels. Throat swab grew group A streptococcus and she was treated with broad spectrum antibiotics for 7 days maintaining fevers up to 39oC. Skin biopsy was non-specific with negative direct immunofluorescence but showed microvascular thrombi in the papillary dermis. COVID-19 PCR tests (three naso-pharyngeal swabs and one stool PCR) and IgG test (day 38) were negative. CT showed no pneumonitis but non-specific retroperitoneal stranding with medium/large vessel vasculitis involving both proximal renal arteries and a 6 cm segment of mid abdominal aorta on PET-CT. We started oral prednisolone 40mg with immediate resolution of her fevers, myalgia, and inflammatory markers, remaining well a month later.Case report-DiscussionTakayasu's arteritis is the most common autoimmune large vessel vasculitis (LVV) affecting young females and involves inflammation of the arterial wall ultimately resulting in stenosis and obstruction of the vessel. However, it is rare in patients with African heritage and usually presents with a prolonged prodromal phase. Given the atypical presentation and symptoms consistent with COVID-19 infection we feel that this patients' LVV may have been a complication of COVID-19 infection. The relationship between infections and vasculitis is complex. TB and syphilis cause aortitis and a relationship between infection and vasculitis has been proven in HBV associated PAN and HCV associated cryoglobulinemia.Experimental data supports a possible association between CMV and herpes virus and Takayasu arteritis. It could, therefore, be hypothesised that COVID-19 infection can trigger LVV. Our patient had a throat swab positive for Streptococcus pyogenes which is an uncommon cause of infective endocarditis and mycotic aneurism, but this patient had no evidence of either endocarditis or aneurism formation and so it was felt the throat swab finding was incidental. Our patient had repeated negative COVID-19 nasopharyngeal swabs and a negative antibody test at day 38.Although this argues against a diagnosis of COVID-19 related illness, the relative lack of inform tion we currently have regarding sensitivities of the tests, at what point COVID-19 PCR becomes negative in the illness and when/if patients develop antibodies, means these negative tests in the presence of typical symptoms cannot exclude the diagnosis. We believe this case is extremely important to highlight a possible novel inflammatory complication of COVID-19 infection. We decided to treat this patient in line with guidance for the management of LVV, including the introduction of methotrexate, but it will be interesting to observe her long-term outcome.Case report-Key learning points Increasing numbers of COVID-19 related systemic inflammatory conditions are likely to be recognised over the coming months. We present the case of patient with large vessel vasculitis who initially presented atypically with symptoms consistent with COVID-19 infectionTo identify these complications, COVID-19 symptoms questioning should be part of any routine medical historyMore information is required regarding the sensitivity of COVID-19 PCR and antibody tests to aid the diagnosis of these conditionsThe long-term management of inflammatory conditions associated with COVID-19 infection is not clear and a discussion is warranted as to whether DMARDs should be initiated.