Septic cavernous sinus thrombosis in a patient with COVID-19.

The cavernous sinus is one of the dural venous sinuses which plays an important role in venous outflow from the brain and eye sockets and in the regulation of intracranial circulation. We report a case of septic cavernous sinus thrombosis in a female patient with COVID-19. The disease often results in alterations of blood rheology, thrombosis in different organs, and septic complications. This article aims to raise awareness of healthcare professionals about the characteristics of COVID-19 that might cause septic cavernous sinus thrombosis in patients with severe comorbidities. Laboratory testing revealed severe comorbidities, including diabetes mellitus and liver cirrhosis caused by hepatitis C. They manifested with an impaired protein production in the liver and coagulation disorders. Systemic effects of SARS-CoV-2 on the vascular endothelium aggravated preexisting coagulation disorders and led to hemorrhage into retrobulbar tissue and clinical signs of septic cavernous sinus thrombosis, including swelling of the eyelids, bilateral exophthalmos, and ophthalmoplegia, followed by necrosis of the facial skin.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Risk factors affecting outcome of rhino-orbital-cerebral mucormycosis in COVID-19 patients

Background: Mucormycosis is a serious life-threatening fungal infection that recently made severe sudden and devastating surge during the second wave of the COVID-19 epidemic with a mortality rate of up to 50%. Although the causality link between COVID-19 and rhino-orbito-cerebral mucormycosis (ROCM) remains unclear, many factors including poor diabetes control, high doses of steroids, viral-induced lymphopenia, and cytokine storm have been attributed to ROCM in patients with COVID-19. Orienting to risk factors and early recognition of this potentially fatal opportunistic infection is the key to optimal management and improved outcomes. In these contexts, we conducted a prospective study for 33 patients admitted to our tertiary hospital to determine the risk factors for ROCM in patients with COVID-19 and the cumulative mortality rates. Result(s): This study found a statistically significant relation between the fate of death in COVID-MUCOR patients who had presented fever, ophthalmoplegia, facial skin necrosis, and visual loss with those who received dose of steroid to control their respiratory symptoms P < 0.001. Death from COVID-MUCOR was statistically significant related to the prolonged interval from the onset of the symptoms to start of treatment and intervention. Also, it was found that there was a significant decrease in duration between COVID-19 infection and the start of mucormycosis (days) with incidence of DKA on admission. Nineteen (57.6%) of the patients had uncontrolled diabetes mellitus (hemoglobin A1C (HbA1c) of > 7.0%). Conclusion(s): Mucormycosis epidemic was precipitated by a unique confluence of risk factors: diabetes mellitus, widespread use of steroids, and perhaps SARS-CoV-2 infection itself. Restricting steroid use in patients with severe COVID-19 requiring oxygen therapy, and screening for and optimally controlling hyperglycemia, can prevent COVID-MUCOR in a large majority.Copyright © 2023, The Author(s).

Possible immune reaction to COVID-19 vaccination - a case report

Introduction Side effects may occur after vaccination against COVID-19. Temporary reactions such as redness, swelling and pain at the injection site, high temperature, fever, tiredness, etc. may be signs of the body's response to the vaccine. Such reactions usually develop within two days after vaccination and last for a few days. With the growing number of vaccinations against SARSCoV- 2 a rising number of reports also showed serious side effects. In some of the most severe cases, life-threatening thrombotic events may develop. We present a case that shows further symptoms that may be due to an immune reaction to the vaccine. Method In this case report a 67 male smoker presented to our outpatient clinic in April 2022. A few days after vaccination against SARS-CoV-2 with an mRNA vaccine the patient developed pain at all finger tips. The clinical examination showed cool and livid discoloration of all fingers to different degrees;toes were not involved. The symptoms developed progressively over the following weeks into a severe form with progressive fingertip skin necrosis. Results The blood test showed a CRP of 9.18 mg/l (reference range: 0-3 mg/l) as well as an increased fibrinogen and factor VIII activity. D-dimers were only slightly increased to 290 ng/ml (reference range: < 230 ng/ml) during initial examination. Cold agglutinins, cryoglobulin and cryofibrinogen were tested negative. Angiologic examination revealed small multiple thrombi in the ulnar and digital arteries. Furthermore, the resting ECG showed no dilated ventricles and no indication of a hemodynamically relevant defect. The assessment revealed a good cardiac function overall with no evidence of embolism. Therapy was started with Nifidipine (gold standard in Raynaud's disease), Eliquis 5 mg 1-0-1, and diclofenac following hospital admission. In the further course, the therapy regimen was changed to Ilomedin IV for 4 days once a month. After two weeks, symptoms significantly improved and the signs of necrosis at the fingers disappeared. Conclusion In summary, a circulatory perfusion disorder associated with microthrombotic events may be a possible side effect of SARS CoV-2 vaccination. A combination of Nifidipine, DOAC and pain therapy has been shown to be an effective treatment of "COVID-fingers" in this case report.

A novel approach to low-energy calcaneal tuberosity avulsion fractures in patients with fragile bone quality: A report of two cases

Maintaining reduction of a calcaneal tuberosity avulsion fracture is challenged by the powerful force exerted upon the bone fragment by the Achilles tendon. Low-demand, elderly patients with osteoporotic bone usually undergo a low-energy mechanism when this fracture pattern occurs. Likely attributable to poor bone quality, the rate of early fixation failure has been documented to be as high as 40%. We present the cases of two 65-year-old female patients who each sustained a calcaneal tuberosity avulsion fracture. Both patients underwent a low-energy mechanism of injury and had a medical history of many comorbidities. The first patient underwent a partial calcaneal ostectomy and tenotomy after failing open reduction internal fixation (ORIF). The second patient primarily underwent a partial calcaneal ostectomy and tenotomy. Postoperatively, after the incision site was fairly healed, both patients could bear weight as tolerated. This method of excision and release may allow for decreased risk of skin compromise and return trips to the operating room for failed ORIF. In low-demand patients with low-energy calcaneal avulsion type fractures and osteoporotic bone, this technique may be the preferred surgical option.Copyright © 2022 The Author(s)

Drug repurposing against SARS-CoV-2: A review based on principal reports

Despite the measures taken and the molecular advances for the development of new agents for the control of SARS-CoV-2 infection, there is still insufficient development of an effective treatment. The objective of the review was to de-scribe the clinical studies and reported articles on drugs used as possible therapeutic agents for COVID-19 and the main conclusions on their reuse. A non-systematic review through PubMed, ScienceDirect, and clinical trials at ClinicalTrials. gov on original articles and case report in English and Span-ish that will report information on COVID-19 treatment and its main conclusions. Articles that were not relevant or that did not mention updated information to that reported in other articles were excluded. A total of 99 bibliographic references were included. COVID-19 appears as a multisystemic disease with variable clinical symptoms. Since no specific treatment is yet known, multiple drugs have been proposed that attack the different pathways of SARS-CoV-2. For severe disease in patients who require hospitalization and oxygen support, the use of remdesivir, dexamethasone, or tocilizumab is recommended if there are patient conditions that apply to use them. The use of ivermectin, colchicine, lopinavir/ritonavir, hydroxy-chloroquine, and chloroquine have not reported benefits that surpass adverse effects.

Abstracts Criticare - IJCCM2022

The proceedings contain 246 papers. The topics discussed include: nasotracheal vs orotracheal intubation and post-extubation airway obstruction in critically ill children: an open-label randomized controlled trial;prognostication of the outcomes in patients on mechanical ventilation due to severe ARDS in COVID-19 using neutrophil to lymphocyte ratio (NLR) at admission;prognostic role of different severity indexes in COVID-19 pneumonia: a retrospective study;monoclonal antibody for COVID treatment;fluid management 100% non-invasive for COVID patient in ICU by sterling stroke volume guided resuscitation;post-COVID double valve and bypass surgery one of 1st in world;terlipressin-induced skin necrosis;safety, feasibility, and outcome of percutaneous dilatational tracheostomy in critically ill COVID-19 Patients;Cisatracurium for Orgen failure patient in ICU;and is there association between trends of inflammatory marker to clinical course of critically ill COVID-19 patient require prolong hospitalization?.

Cutaneous thrombosis associated with skin necrosis following Oxford/AstraZeneca COVID-19 vaccination: a case report

A 73-year-old man presented with left shin ulceration two weeks after receiving his first dose of the Oxford-AstraZeneca vaccine. Within 24 h of vaccination, the patient became generally unwell with fever and headache. On the third day after vaccination, he developed left shin erythema and blistering, which rapidly ulcerated. This formed two superficial ulcers with a necrotic base and a violaceous edge on the lateral aspect of his left shin, measuring approximately 2 cm × 3 cm. He had a background of atrial fibrillation and ischemic cardiomyopathy, and had been on several longstanding medications including apixaban. Blood tests revealed normal clotting, full blood count, liver and renal function. The differential diagnosis included pyoderma gangrenosum, vasculitic ulceration, and a cutaneous adverse drug reaction to vaccination. A punch biopsy was obtained from the edge of an ulcer, which revealed microthrombi within blood vessels, an ischemic epidermis, and fat necrosis of subcutaneous tissue. The patient experienced slow healing of ulceration with topical clobetasol propionate 0.05%, neomycin sulphate and nystatin ointment, and compression bandaging treatment. To our knowledge, this is the first reported case of cutaneous thrombosis associated with skin necrosis following Oxford/AstraZeneca vaccination. Recently there have been concerns related to reports of thrombotic events at atypical sites (including cerebral and splanchnic vascular beds) associated with thrombocytopenia following Oxford/ AstraZeneca vaccination (Greinacher A, Thiele T, Warkentin TE et al. Thrombotic thrombocytopenia after ChAdOx1 nCov-19 vaccination. N Engl J Med 2021;384: 2092-101). These findings extend the range of atypically located thromboses associated with COVID-19 vaccination and reinforce the necessity for physicians to be vigilant for signs and symptoms related to thromboses at atypical sites in recently vaccinated patients.

17th Medical Dermatology Meeting

The proceedings contain 42 papers. The topics discussed include: a pediatric case series of COVID-19-associated chilblain-like acral lesions;genital dermatology: a window to the gut. Three cases of genital cutaneous Crohn disease;Influence of biologics on COVID-19-positive patients: a case series;cutaneous thrombosis associated with skin necrosis following Oxford/AstraZeneca COVID-19 vaccination: a case report;reactive infectious mucocutaneous eruption (RIME) secondary to COVID-19 infection;adverse events following immunization (AEFI) with COVID-19 vaccines: case series and literature review;challenges in the management of toxic epidermal necrolysis and COVID-19: a case report;and a rare case of epidermolysis bullosa acquisita in one of identical twins.

Cutaneous Manifestations of Coronavirus Disease 2019: Skin Narratives and Dialogues

BACKGROUND: Although the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is primarily responsible for respiratory symptoms, an increasing number of cutaneous manifestations have been reported. Cutaneous manifestations are reported by patients following disease recovery. OBJECTIVE: We sought to document various skin lesions relating to COVID-19 symptoms either before, during, or after infection with severe acute respiratory syndrome coronavirus 2. METHODS: This was a descriptive study with 273 patients who had cutaneous manifestations after recovering from COVID-19. Each patient provided a thorough medical history and underwent a general physical examination. Following polymerase chain reaction analysis, all participants were confirmed to be COVID-19 patients. RESULTS: Acral lesions were the most common, accounting for 39% of all cases. An erythematous maculopapular rash was found in 21% of cases and was the second most common after urticaria, with fewer cases of erythema multiform, vesicular rash (9%), vascular livedo reticularis, figurate erythema, and flexural rash documented. CONCLUSION: The most common cutaneous changes seen in patients with COVID-19 were pseudo-chilblain acral lesions, which had a good prognosis. Vascular rashes within the spectrum of livedo/purpura/necrosis were seen with severe forms of COVID-19.

Peripheral vascular lesions with the development of hand and foot skin necrosis in a patient with COVID-19: a case report

In the presented case report, 36-year-old female patient, who was hospi talized in the rheumatology department, developed thrombotic microangiopathy and sepsis-related coronavirus disease 2019 (COVID-19). In the department, hereditary thrombophilia was revealed: heterozygous polymorphism in the coagulation factor 5 gene (Factor V Leiden). Livedo reticularis. It is known that in October 2020, the patient had COVID-19 with bilateral pneumonitis on chest computed tomography. On examination, dry gangrene of 1, 2, 4, 5 fingers of the right hand, 2 finger of the left hand, as well as 2, 3, 4, 5 fingers of the right and left feet were diagnosed. Necrosis of the nasal tip. Surgery was performed with amputation of the affected fingers and distal feet with autodermoplasty.

Acro-ischemic lesions in COVID-19 patients: A case series.

COVID-19 is a systemic disease characterized by vascular damage, increased inflammation, and hypercoagulability. Acral ischemic lesions occur as a result of increased inflammation and cutaneous thrombosis. Skin lesions can sometimes be the only symptom of COVID-19. In this respect, recognizing acro-ischemic lesions, which are skin lesions, may help in the early diagnosis of the disease and in predicting the prognosis. In patients with skin lesions without typical symptoms, the diagnosis of COVID-19 should be kept in mind. Herein, we describe five patients affected by COVID-19 which developed acro-ischemic lesions.

A case report: Necrotising leukocytoclastic vasculitis (NLV) of the breast mimicking necrotising fasciitis (NF)

Leukocytoclastic vasculitis (LV) is an inflammation of the small vessels in the dermis characterised by the deposition of immunocomplexes in the involved vessel walls. It commonly manifests as palpable purpura, limited to the skin and predominantly of the lower limb. We report a rare case of necrotising LV (NLV) affecting bilateral breast, manifesting clinical features of necrotising fasciitis (NF), and emphasizes the potential diagnostic challenges that markedly influence the treatment and survival of patients. A 48-year-old female presented with an acute onset left breast skin necrosis and discolouration that rapidly progressed to the contralateral breast with surrounding erythema and oedema of the chest wall yet spared the intermammary cleft. Some non-blanching purpuric rash were also noted on upper abdomen and left lower limb. COVID-19 test was negative. CT scan showed extensive bilateral breast fat stranding and oedema. Patient became clinically septic with a moderately raised CRP and mild acute kidney injury. Radical mastectomies and chest wall excision were performed with intra-operative findings of cloudy fluid and easily peeled away subcutaneous tissue from fascia. Urgent gram stain and culture showed no organisms. Tissue biopsies subsequently showed the diagnosis of NLV. Chest wall defect was then reconstructed with split skin grafts, NLV treated with corticosteroids and patient made an uneventful recovery. This case highlights the incidence of a rare and aggressive manifestation of NLV on the breast that mimics NF, emphasizing the clinical differentiation that may lead to catastrophic results and significant cosmetic defect, if a differential diagnosis cannot be determined at the time.

Warfarin-Induced Calciphylaxis in a COVID-19 Patient.

Calciphylaxis is a rare but highly fatal vascular calcification disorder with a predilection for patients with end stage renal disease (ESRD). The pathogenesis of calciphylaxis is unknown, however, several risk factors have been identified such as hypercalcemia, hyperphosphatemia, hyperparathyroidism, low serum albumin, and history of warfarin therapy. This article presents a case of calciphylaxis induced by warfarin in a COVID-19 patient.