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Outcomes: 1. Utilizing CRISIS approach, participants can employ a unique strategy to holistically support patients with poor coping in an acute life-threatening situation. 2. Utilizing the CRISIS approach, participants will apply an ethical tool to mitigate the incongruence that sometimes happens between two ethical principles-autonomy versus beneficence. Autonomy is not always in harmony with beneficence. We present a patient with decisional capacity hospitalized with acute reversible neuromuscular paralysis who refused treatment despite expected recovery. Her decision created moral distress for the clinicians. An improvised palliative strategy resolved the above dilemma. Case presentation: 68-year-old female admitted with new-onset unsteady gait, diplopia, and speech impairment on waking up. She was healthy until 3 weeks before admission, when she developed upper extremity numbness progressing to both legs after a COVID-19 infection. She had bulbar and axial muscle weakness and right oculomotor nerve palsy with ptosis. Positive ice pack and pyridostigmine test indicated myasthenia gravis (MG). During hospitalization, she required mechanical ventilation secondary to acute respiratory failure from progressive paralysis. Serum-negative MG diagnosed, given the response to IVIG and pyridostigmine. The patient, amid acute crisis, refused therapies and wanted to transition to DNR-comfort care despite understanding the reversibility of her illness. Her family members supported comfort care option. Neurology was conflicted with the patient's choice because MG was treatable. Palliative care, ethics, and neuropsychology consulted to establish decision-making capacity, goals-of-care, and holistic support. Intervention(s): Palliative team utilized the CRISIS approach to address the impasse between the patient and the clinicians: 1. Continue care, collaborate with the teams 2. Respond empathetically 3. Integrate patient's autonomy 4. Support holistically 5. Improvise a care plan 6. Sustain quality of life We validated patient's autonomy. We recommended allowing time for the patient/family to process her illness. We continued holistic support and symptom management and created an improvised multidisciplinary plan to help her cope with the acute illness. The above approach enabled her to opt for therapies instead of comfort care only, and she gradually recovered. Respecting patients' autonomy and incorporating beneficence via our intervention led to positive outcomes. The CRISIS approach could help other clinicians in the situation when conflict arises between autonomy and beneficence.Copyright © 2023
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Background: Myasthenia gravis (MG) is an autoimmune disease of unknown etiology. Infections are known as a major cause of MG exacerbations. A few studies have shown an association between new onset MG and SARS-CoV-2 infection. Case presentation: We have reported a case of new onset myasthenia gravis in a 68-year-old man presented with bulbar symptoms a few days after receiving COVID-19 vaccine (Sinopharm vaccine). The disease was confirmed by high titer of antibody against acetylcholine receptor and electrophysiological examinations. Conclusion(s): Among the adverse effects reported with the COVID-19 vaccine, new onset myasthenia gravis is very rare. The underlying mechanism is unknown but the immune response after vaccination and molecular mimicry theory has been proposed.Copyright © 2022
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Introduction: COVID-19, a new coronavirus illness, swiftly spread throughout all continents. However, evidence on all of COVID-19's indications and symptoms is lacking. Patients who have COVID-19 may be more susceptible to fungal infections. Mucormycosis is an uncommon and frequently fatal fungal illness caused by hyphae invading the bloodstream and causing thrombosis and necrosis. Material(s) and Method(s): Patients diagnosed with mucormycosis following a recent COVID-19 infection were included in the case series analysis. Surgical therapy was limited to individuals who tested negative for COVID-19 on PCR. To remove the infection, endoscopic, open, and combination techniques were used. For the first month after surgery, survivors were followed up on on a regular basis. Result(s): About 30 people with a history of Covid-19 were given dexamethasone and remdesivir in this study. Following therapy, these individuals developed mucormycosis, which was treated by Functional Endoscopic Sinus Surgery (FESS). As a consequence, 16 patients (53.34 %) had numerous operations. The most prevalent related condition was diabetes mellitus (60 %). The majority of the patients were men (60 %). Our patients had an average age of 55.53+/-8.093. 43.34 % of the people died. Conclusion(s): In conclusion, mucormycosis is a rare but critical problem complicating the later part of the clinical course of COVID-1, possibly due to improper drug usage during Covid treatment. Copyright © 2023 Authors. All rights reserved.
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Purpose : To explore whether the COVID-19 lockdown increased the incidence of myopia among age-school children. Methods : Retrospective study recruiting children aged 5-12. Selection: random. Inclusion criteria: healthy children presenting for an eye exam since 2016. Exclusion criteria: presence of ocular comorbidities other than refractive error, spherical equivalent (SE) less than -4D or greater than +4D, BCVA less than 20/20, blepharoptosis, media opacities, corneal or retinal dystrophies, strabismus, amblyopia, nystagmus, or concurrent therapy with atropine 0.01%. Outcome measure: age measured in months, SE of the right eye (RE) measured in diopters (D) under cycloplegia (cyclopentolate 1%). Statistical analysis: ANOVA, Chi-square, Tukey's test. Significance: p < .05. Results : A total of 803 children. In the years prior to COVID-19, the mean SE ± SD diopters in the RE: 0.54 ± 1.49 D in 2016 (n = 160), 0.43 ± 1.84 D in 2017 (n = 145), 0.34 ± 1.41 D in 2018 (n = 152), 0.35 ± 1.75 D in 2019 (n = 166) (ANOVA, p = .659) (Fig. 1). In 2021 (n = 180), the mean SE was -0.08 ± 1.44 D (ANOVA, p = .005). Using the Tukey's test, the mean SE of 2021 changed by -0.619 D 95% CI [-1.091, -0.147] and -0.501 D 95% CI [-0.986, -0.016] as compared to the SE of 2016 and 2017, respectively (Fig. 2). Mean age was comparable in all groups (ANOVA, p = .307). The decrease of the mean SE of the 2021 group corresponds to an increase in the percentage of myopes (≤-0.5D) and a decrease in the percentage of hyperopes (≥ 2D). Myopes represent the 24.10% of children aged 60-96 months, and 63.86% of children aged 97-144 months. Hyperopes represent 9.64% of children aged 60-96 months, and 6.02% of children aged 97-144 months. This represents a statistically-significant increase in the number of myopes (Chi-square, p = .016) and decrease in the number of hyperopes (Chi-square, p = .001), as compared to the previous years (2016- 2019). Conclusions : This retrospective study shows a statistically-significant decrease in the mean SE in children aged 5-12 in the year following the COVID-19 lockdown (2021). The percentage of myopes has increased significantly, while the percentage of hyperopes has decreased. Children aged 8-12 years showed the greatest refractive change. The lifestyle changes imposed by the lockdown were likely responsible for the increased prevalence of myopia observed in 2021.
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Background: Mucormycosis is one such infection which has shown a sudden rise during the second wave in India. (Our present study has been designed to all the confirmed cases of rhino orbital mucormycosis. In our study we have included all the rhinorbital mucormycosis cases that have been confirmed by microscopy and or radiological evidence.Mucormycosis (also called zygomycosis) is a serious fungal infection caused by agroup of molds called mucoromycetes. Materials and Methods: All the patients that have directly attended the ophthalmology OPD. Chief complaint with duration (Look for redness, watering, discharge & pain in the eye, diplopia, eyelid/ periocular swelling) facial swelling, eyelid/perioculay facial discoloration, Worsening headache, sudden drooping of eyelid (or) restricted eye movements, sudden loss of vision, facial parasthesia / anaesthesia, nasal discharge (blakish/ bloody/foul smell nasal stuffiness, dental pain. Results: Out of all 60 cases, 79 there were 47 males and 13 females. In this study 48.33% cases belongs to age group of 50-60 years followed by 36.66% belongs to age group of 60-70 years. Among the 60 patients who presented to hospital within 1 week of onset of symptoms likee pain redness watering et 35 of them got good vision, whereas among the 15 members who presented beyond 2 weeks after the onset of their symptoms only 7 got good vision while 2 of them got poor vision below 6/60 indicating the importance of early diagnosis. 65% cases affected at right eye and 63.33% cases showing symotoms like Redness, treatment under goes with total Restriction 42 members and Painful oculr movement in 43.33% cases. Conclusion: The second wave of COVID-19 in India has led to more deaths than the first. In just a few weeks, the B.1.617.2 (Delta) variant became the dominant strain across India. It has since spread to about 40 nations, which include United Kingdom, Fiji and Singapore.18 the first case of Covid-19-related Mucormycosis has now been found in Chile. It is important to recognise at an early stage this infection, so as to potentially reduce soft and hard tissue necrosis and severe complications and alert colleagues of this mutilating and life threatening infection.
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CASE: Patient is a 60-year-old woman who works at a local hospital in billing department. She has a history of rheumatic fever, non ST elevation MI, osteoarthritis, Crohn's disease. Her husband was diagnosed with COVID-19 infection in November 2020. A Week later, patient developed myalgias, diarrhea and subsequent testing confirmed COVID-19 infection. Overall, her symptoms were mild and required no treatment or hospitalization. Six weeks following the infection she woke up one morning with diplopia and a large left pupil. She tried to manage this by covering one eye initially, but later visited with a neurologist, ophthalmologist, neuro-ophthalmologist. She was found to have fixed, dilated left pupil and horizontal diplopia with some diagonal component. There were no other neurological signs or meningismus. Laboratory tests showed hemoglobin of 12.5, White cell count 5.7, platelets 405. Electrolytes, kidney function, liver function tests were normal. ACH receptor antibodies were negative. Imaging studies included a negative CTA head, negative brain MRI, face, orbits and optic nerves. She was diagnosed with left third cranial nerve palsy possibly as a complication of COVID-19 infection. She was prescribed oral prednisone 60 mg with a slow taper. Her pupil size and vision gradually improved over the ensuing weeks and the recovery of the third cranial nerve was nearly complete. IMPACT/DISCUSSION: The third cranial nerve supplies the levator muscle of the eyelid, medial rectus, superior rectus, inferior rectus, and inferior oblique;constricts the pupil through its parasympathetic fibers. Patients with oculomotor cranial nerve palsy develop diplopia and droopy eyelid. Etiology for third cranial nerve palsy include many pathologies such as a structural lesion, infectious or inflammatory conditions, cerebrovascular disease and trauma. Our patient developed acute 3rd cranial nerve palsy 6 weeks following the COVID-19 infection. The workup was negative for any structural lesions, CVA or other known causes. This raised the possibility that her symptoms are possibly complications of COVID-19 infection. Neurological complications of COVID-19 infection have been well documented. These include encephalopathy, stroke, dysgeusia and anosmia. There were two case reports of oculomotor nerve palsy that occurred during the acute phase of COVID-19 infection. These were thought to be from direct invasion of the virus. Our patient however, had developed symptoms 6 weeks following the infection raising the possibility of immune mediated complication. She made near complete recovery with oral glucocorticoid treatment. However, it is not known whether the improvement is the result of the treatment. CONCLUSION: 1. Oculomotor cranial nerve palsy is potentially associated with COVID-19 infection. 2. Oculomotor cranial nerve palsy could present several weeks after the acute COVID-19 infection. 3. In patients presenting with 3rd cranial nerve palsy, it is important to obtain the history of past COVID-19 infection.
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Purpose. Theoretically substantiate and practically identify ocular manifestations after the transferred SARS-CoV-2 virus. Patients and methods. For the study we were invited patients who had recovered from SARS-CoV-2 at the hospital of V.M. Buyanova, the age from 20 to 65 years old in period from 2020 to 2021. The total number of patients was 68 people. The patients had with them the results of PCR tests or ELISA tests, or an extract from the hospital confirmed COVID-19 case and also a clinical blood test and CT scan of the chest organs for the period of illness. Before the start of the study, the patients were asked to fill out a questionnaire “Questionnaire for patients who have had a new coronavirus infection” (Appendix 1). For a detailed study of this group of people, each underwent visometry, pneumotonometry, B-scan, a slit lamp study and also a slit lamp study with a 60D lens using 0.5 % Mydriacyl eye drops in the absence of contraindications and pupillography. Results. As a result of the work carried out, we concluded that the virus is capable of causing inflammation of the choroid of the eyeball, uveitis. Moreover, in our study, we identified patients with acquired intermittent divergent strabismus, anisocoria, ptosis, and accommodation disorder. And, in this regard, we came to the conclusion that the coronavirus belongs to the group of neurotropic, as it is able to affect the nervous tissue and cause the above clinical picture. In other words, the virus negatively affects the somatic and autonomic innervation of the oculomotor nerve. As a result of these lesions, we get the corresponding tetrad of symptoms: heterotropy, mydriasis, ptosis, accommodation paralysis. Conclusions. One of the extraordinary complications of coronavirus infection is damage effect to the fibers of the oculomotor nerve, the signs include: strabismus, mydriasis, ptosis and accommodation paralysis. Thus, this clinical picture is associated with the affinity of the virus to the nervous tissue. And as a result, this ability of the virus can probably infect various areas of the brain, which will lead to corresponding complications, not only from the oculomotor nerve, but also from other cranial nerves with the manifestation of the corresponding symptoms, which in theory can aggravate the patient's condition, causing deep disturbances of motor and sensory innervation.
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Objective: To present a patient with acute-onset of multiple cranial neuropathies associated with recent COVID-19 vaccination. Background: Vaccine-associated neurologic adverse effects have been well-described over the decades;the influenza vaccine as well as others have been thought to precede Guillain-BarréSyndrome (GBS), Miller-Fisher Syndrome (MFS), and similar processes. Hyper-inflammatory responses have been frequently reported with SARS-CoV-2 infection and immunization, along with various neurologic pathologies. In this case report we describe a cranial polyneuropathy (3, 6, 7 and 12) associated with the COVID-19 vaccine. Design/Methods: Case Report with Video/Photos Results: A 52-year-old R-handed female presented with acute-onset, rapidly progressive deficits including left upper lid ptosis, left eye ophthalmoplegia, leftward tongue deviation, left facial paresis and dysarthria. History includes congenital left eye cataract s/p lens exchange, remote strabismus surgery and slight ptosis at baseline. She denied recent illness or injuries, though had completed single-dose vaccination for SARSCoV-2 11 days prior to symptom onset. Exam revealed new L eye esotropia with restriction in abduction and supraduction. Also noted was worsening of baseline ptosis, weak tongue protrusion with right-sided fasciculations and leftward deviation. Patient endorsed dysphagia and dysarthria. Workup consisted of three unexplanatory MRIs during week of symptom onset, lumbar puncture, evaluation by ENT and neuro-ophthalmology as well as other serum and CSF studies to investigate other autoimmune causes. Consent-obtained videos and photographs were taken for documentation/educational purposes. Follow-up visits revealed slow improvement starting three months after symptom onset. Conclusions: We outline a case of a female patient who presented with progressive, multiple cranial neuropathies with onset 11 days after single-dose SARS-CoV-2 vaccination. This constellation of symptoms in the setting of COVID-19 vaccination suggests propensity towards autoimmune neurologic processes. Further investigation is needed to determine the true incidence of similar polyneuropathies with the COVID-19 vaccine and to guide providers and patients to make informed decisions.
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Objective: NA Background: A 32 year-old man with no medical history and no prior documented SARS-CoV2 infection developed malaise, dyspnea, and exercise intolerance in the days following first dose SARS-CoV2 vaccine administration (Pzifer-BioNTECH mRNA). Dysarthria and dysphagia manifested within hours of the second vaccine dose administration, and progressed to severe bifacial weakness with reduced eyelid and mouth closures within one week's time. Design/Methods: NA Results: Severe dysphagia prompted hospitalization and neurology consultation. At an outside hospital, IVIG (2 gm/kg) and pyridostigmine were initiated for empiric treatment of suspected myasthenia gravis. The patient's facial strength, dysphagia and dysarthria improved. Anti-AChR and anti-MuSK serologic studies were non-reactive. A thymoma was not identified. MR brain, cerebrospinal fluid, and ganglioside antibody serologic studies were without explanatory pathological findings. A nerve conduction study, obtained in the outpatient setting, demonstrated decrement in facial nerve-nasalis CMAPs with low frequency repetitive stimulation, consistent with a post-synaptic neuromuscular disorder. Monthly IVIG infusions and pyridostigmine were prescribed. The patient's symptoms worsened and he was rehospitalized. A repeat nerve conduction study revealed post-exercise and repetitive stimulation-induced decrements in median-abductor policus brevis and spinal accessorytrapezius CMAPs, confirming a systemic post-synaptic neuromuscular disorder. AChR binding and blocking antibodies were ultimately detected through repeat serologic testing, consistent with autoimmune myasthenia gravis. Plasma exchange and prednisone therapies engendered near full symptom resolution. Conclusions: While myasthenia gravis symptom exacerbation and crisis in the setting of vaccination are well described, no cases of new-onset myasthenia gravis following vaccination are reported to date. Further, the patient's bifacial weakness with impaired eyelid closure was atypical in contrast to ptosis and diploia typically observed in oculo-bulbar forms of myasthenia gravis. The immune-mediated mechanism and clinical phenotype of SARS-CoV2 vaccinationassociated myasthenia gravis require further investigation.
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Herpes zoster Ophthalmicus accounts for a minority of all patients with zoster infections. It leads to varied clinical presentations, but total unilateral ophthalmoplegia has rarely been reported in the literature. We hereby present a 50-year-old male patient presenting with the above combination for aiding the clinical diagnosis by dermatologists and ophthalmologists. Early initiation of treatment leads to a near total recovery of ophthalmoplegia in the majority of treated patients.
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Introduction: The novel coronavirus 2019 (COVID-19) pandemic started in Wuhan city, China in December 2019 and now the infection has a high prevalence worldwide and the pandemic is still ongoing. Symptomatic patients with COVID-19 typically complain of fever and respiratory, as well as gastrointestinal symptoms. It is known that human coronaviruses and particularly severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are neuroinvasive and neurotropic. There is growing evidence of various neurological complications and manifestations of COVID-19 infection. Neurological symptoms may range from mild, non-specific pre-sentations such as headache to severe complications both in the central or peripheral nervous system. Even rare neurological disorders can occur during or after this infection. Case presentation: We report a case of a 65-year-old female with COVID-19 infection, who also developed left ophthalmoparesis with two cranial nerve palsies, which further was concluded to be a probable Tolosa-Hunt syndrome, an association not yet been described in the literature. The decision was made to treat with glucocorticosteroids, followed by dramatic relief of pain (which also speaks in favor of the diagnosis). Conclusion This report describes an interesting case of probable Tolosa-Hunt syndrome, a rare peripheral nervous system involvement syndrome, co-occurred with COVID-19 infection. Whether this was just a co-occurrence or the inflammation was triggered by a SARS-CoV-2 in-fection, is still a question to be discussed. The possible causal link between these two conditions may help to understand both conditions better.