Diagnostic and Therapeutic Challenges of Concurrent Intracranial Hemorrhage and Cerebral Venous Thrombosis in a Patient With Acute Lymphoblastic Leukemia: A Case Report and Literature Review.

Cerebral venous sinus thrombosis (CVST) is a cerebrovascular condition due to the thrombosis of cerebral venous sinuses, leading to intracranial hemorrhage, increased intracranial pressure, focal deficit, seizure, toxic edema, encephalopathy, and death. The diagnosis and therapeutic approach of CVST remain challenging because of its highly nonspecific clinical presentation including headaches, seizures, focal neurologic deficits, and altered mental status, etc. Anticoagulation is the mainstay of CVST treatment and should be started as soon as the diagnosis is confirmed. Here, we present the case of a 34-year-old male construction worker who presented to the emergency department with a complaint of right chest wall pain and swelling. He was admitted to the hospital following a diagnosis of anterior chest wall abscess and mediastinitis. During hospitalization, his complete blood count revealed pancytopenia with blast cells, and bone marrow biopsy revealed 78.5% lymphoid blasts by aspirate differential count and hypercellular marrow (100%) with decreased hematopoiesis. He developed concurrent CVST and intracranial hemorrhage while receiving CALGB10403 (vincristine, daunorubicin, pegaspargase, prednisone) with intrathecal cytarabine induction chemotherapy for acute lymphoblastic leukemia (ALL). The patient failed two standard chemotherapy for ALL and achieved remission while on third-line chemotherapy with an anti-CD19 monoclonal antibody, blinatumomab. Although this patient had an MRI scan of the brain with multiple follow-up non-contrast CT scans, it was CT angiography that revealed CVST. This showed the diagnostic challenge in CVST, with CT and MRI venography having excellent sensitivity in diagnosing CVST. Risk factors for CVST in our patient were ALL and its intensive induction chemotherapy with pegaspargase.

The Implications of SARS-CoV-2 Infection in a Series of Neuro-Ophthalmological Manifestations-Case Series and Literature Review.

The global pandemic impact of the COVID-19 infection included clinical manifestations that affected several organs and systems, with various neuro-ophthalmological manifestations associated with the infection. These are rare and occur either secondary to the presence of the virus or by an autoimmune mechanism secondary to viral antigens. The manifestations are atypical, being present even in the absence of the systemic symptoms typical of a SARS-CoV-2 infection. In this article, we introduce a series of three clinical cases with neuro-ophthalmological manifestations associated with COVID infection that were shown in Ophthalmology Clinic of St. Spiridon Emergency Hospital. Case 1 is that of a 45-year-old male patient with no personal history of general pathology or ophthalmology, with binocular diplopia, painful red eyes, and lacrimal hypersecretion with a sudden onset of about 4 days. Based on the evaluations, a positive diagnosis of orbital cellulitis in both eyes is made. Case 2 is that of a 52-year-old female patient with general PPA (personal pathological antecedents) of SARS-CoV-2 infection 1 month prior to presentation with decreased visual acuity in the right eye and a positive central scotoma, preceded by photopsia and vertigo with balance disorders. The diagnosis is made at the right eye for retrobulbar optic neuritis and post-SARS-CoV-2 infection status. The last clinical case is that of a 55-year-old male patient known to have high blood pressure (HBP) with a sudden, painless decrease in VARE approximately 3 weeks post-SARS-CoV-2 immunization (Pfizer vaccine first dose). The diagnosis is made after consulting all the RE results for central retinal vein thrombosis. Conclusions: Although the cases were quickly and efficiently investigated and the treatment was administered adequately by a multidisciplinary team (cases 1 and 3), the evolution was not favorable in all three situations. Atypical neuro-ophthalmological manifestations can also be present in the absence of systemic symptoms typical of SARS-CoV-2 infection.

Prevalence of Deep Vein Thrombosis among COVID-19 Patients using Colour Doppler Ultrasound in a Tertiary Care Centre of Central India: A Prospective Cohort Study

Introduction: Acute respiratory disease, Coronavirus Disease 2019 (COVID-19) is an infectious and potentially fatal respiratory disease. Increase in the inflammatory response, hypoxia, immobilisation are suggested mechanisms of procoagulant state. Deep Vein Thrombosis (DVT) and pulmonary emboli are common and often silent. Venous duplex ultrasound help in determination of the presence, extent, age of the thrombus and its attachment to venous wall. Aim: To evaluate the prevalence of DVT by colour doppler ultrasound in lower limbs of mild to severe clinical categories of COVID-19 patients. Materials and Methods: A time-bound, hospital-based prospective cohort study was conducted in the Department of Radiodiagnosis, MY Hospital, Indore, Madhya Pradesh, India, between March 2021 and February 2022. Study comprised 2200 cases of COVID-19 positive patients with elevated D-dimer levels i.e., >0.5 ng/mL and colour doppler imaging for lower limb. The clinical (co-morbidities, clinical severity) and radiological data (compressibility, colour flow) were studied and analysed using Statistical Package for the Social Sciences (SPSS) software version 25.0. Results: In the present study, there were 1144 (53%) males and 1056 (47%) females. Out of 2200 patients, 792 (36%) patients showed presence of DVT. The most prevalent age group was 36-55 years having 506 (63.9%) patients. Majority of DVT positive patients were suffering with hypertension and diabetes i.e., 261 (33%) and 372 (47%) patients, respectively. Most commonly affected vein in DVT was Common Femoral Vein (CFV) in 704 (88.9%) patients. Superficial veins thrombosis was also associated with DVT affecting Short Saphenous Vein (SSV) in 439 (55.4%) patients and Great Saphenous Vein (GSV) in 221 (27.9%) patients. Conclusion: There was a high prevalence of DVT among COVID-19 positive patients. Colour doppler ultrasound has provided an excellent aid in the diagnosis of DVT.

Thrombosis Occurrence in COVID-19 Compared With Other Infectious Causes of ARDS: A Contemporary Cohort.

Thrombosis occurrence in coronavirus disease 2019 (COVID-19) has been mostly compared to historical cohorts of patients with other respiratory infections. We retrospectively evaluated the thrombotic events that occurred in a contemporary cohort of patients hospitalized between March and July 2020 for acute respiratory distress syndrome (ARDS) according to the Berlin Definition and compared those with positive and negative real-time polymerase chain reaction results for wild-type severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) using descriptive analysis. The association between COVID-19 and thrombotic risk was evaluated using logistic regression. 264 COVID-19-positive (56.8% male, 59.0 years [IQR 48.6-69.7], Padua score on admission 3.0 [2.0-3.0]) and 88 COVID-19-negative patients (58.0% male, 63.7 years [51.2-73.5], Padua score 3.0 [2.0-5.0]) were included. 10.2% of non-COVID-19 and 8.7% of COVID-19 patients presented ≥ 1 clinically relevant thrombotic event confirmed by imaging exam. After adjustment for sex, Padua score, intensive care unit stay, thromboprophylaxis, and hospitalization length, the odds ratio for thrombosis in COVID-19 was 0.69 (95% CI, 0.30-1.64). We, therefore, conclude that infection-induced ARDS carries an inherent thrombotic risk, which was comparable between patients with COVID-19 and other respiratory infections in our contemporary cohort.

Life-threatening Coagulation Disorders

The article discusses the task of radiologic technologists to know clotting disorders and image them best. Topics covered include the various symptoms and blood clots of patients with thrombotic disorders, and medical imaging's beneficial indication of the severity and blood clots' location in the patient's circulatory system, and support for accurate diagnosis and appropriate treatment. Also noted is the boost for positive patient outcomes when the health care team works together.

Evaluation of stroke frequency in COVID-19 patients

Objective: Neurological symptoms occur due to central and peripheral nervous system involvement with different mechanisms in coronavirus disease 2019 (COVID-19). Microvascular thrombosis develops with prothrombotic activation along with the increase in cytokines in COVID-19 infection. We aimed to investigate the incidence of cerebrovascular disease and concomitant risk factors in COVID-19 positive patients. Materials and Methods: Acute and temporally related cerebrovascular diseases with a diagnosis of COVID-19 were evaluated. Cerebrovascular events were assessed in 4 groups as ischemic and hemorrhagic events, transient ischemic attacks, and cerebral venous thrombosis. Risk factors for cerebrovascular disease in these patients were also assessed, and which risk factors for cerebrovascular diseases in COVID-19 patients are high risk were examined. Results: Of the 1000 patients with COVID-19 disease were evaluated. Ischemic cerebrovascular disease and/or transient ischemic attack were found in 14 patients (1.4%). The most common symptoms related to COVID-19 were fever and respiratory distress in 14 patients with acute ischemic stroke diagnosed with COVID-19. Conclusion: COVID-19 increases the risk of stroke in patients with multiple risk factors. Close follow-up should be performed more carefully, especially in patients with pulmonary involvement and acute ischemic stroke, because mortality is likely to be higher.

Superior ophthalmic vein and cavernous sinus thrombosis associated with COVID-19: a case report / Trombose de veia oftálmica superior e seio cavernoso associada à COVID-19: relato de caso

ABSTRACT Cavernous sinus and superior ophthalmic vein thrombosis is a rare clinical condition, and little described in the literature. The clinical presentation is nonspecific and highly variable, and symptoms may include red eye, ophthalmoplegia, coma, and death. The main etiology results from infection of the paranasal sinuses. The final diagnosis must be made through imaging tests such as magnetic resonance imaging. We describe a case of cavernous sinus and superior ophthalmic vein thrombosis after COVID-19 infection in a 64-year-old patient with persistent ocular hyperemia and pain on eye movement. Ophthalmological examination showed preserved visual acuity, conjunctival hyperemia, dilation of episcleral vessels and retinal vascular tortuosity in the right eye. Magnetic resonance imaging confirmed the diagnosis. The association with the COVID-19 was raised, excluding other infectious causes. Enoxaparin and Warfarin were started with significant improvement in the ocular clinical presentation and maintenance of initial visual acuity after 12 months of follow-up.

RESUMO A trombose de seio cavernoso e veia oftálmica superior é uma condição clínica rara e pouco descrita na literatura. A apresentação clínica é inespecífica e altamente variável. Os sintomas podem incluir olho vermelho, oftalmoplegia, coma e morte. A etiologia principal resulta da infecção dos seios paranasais. O diagnóstico final deve ser efetuado por meio de exames de imagem, como ressonância magnética. Descrevemos um caso de trombose de seio cavernoso e veia oftálmica superior após COVID-19 em paciente de 64 anos e com quadro de hiperemia ocular persistente e dor à movimentação ocular. Ao exame oftalmológico, observou-se acuidade visual preservada, hiperemia conjuntival, dilatação de vasos episclerais e tortuosidade vascular retiniana em olho direito. A ressonância confirmou o diagnóstico. A associação com a COVID-19 foi levantada, excluindo-se demais causas infecciosas. Prescrevemos enoxaparina e varfarina, com melhora do quadro clínico ocular e manutenção da acuidade visual inicial após 12 meses de acompanhamento.

Orbital cellulitis and cavernous sinus thrombosis with contralateral sinus disease in a COVID-19 positive adolescent patient.

Patients with COVID-19 have been reported to have elevated coagulation factors, which is a well-documented cause of venous thromboembolism events such as deep vein thrombosis and pulmonary embolism. Other venous thrombotic events, however, such as cavernous sinus thrombosis (CST) have been less commonly observed, specifically in combination with primary orbital cellulitis. Due to its unique anatomic location, the cavernous sinus is susceptible to thrombophlebitis processes including septic thrombosis and thrombosis most commonly from sinusitis. Many studies have shown that in the antibiotic era thromboembolic events of the cavernous sinus are less common due to infection spread from the orbit or facial region. This case report describes a 17-year-old COVID-19 positive male who presented with a left-sided primary orbital cellulitis with CST without radiographic evidence of ipsilateral sinus disease.

Prophylactic Inferior Vena Cava Filters for Venous Thromboembolism in Adults With Trauma: An Updated Systematic Review and Meta-Analysis.

Background: Trauma is an independent risk factor for venous thromboembolism (VTE). Due to contraindications or delay in starting pharmacological prophylaxis among trauma patients with a high risk of bleeding, the inferior vena cava (IVC) filter has been utilized as alternative prevention for pulmonary embolism (PE). Albeit, its clinical efficacy has remained uncertain. Therefore, we performed an updated systematic review and meta-analysis on the effectiveness and safety of prophylactic IVC filters in severely injured patients. Methods: Three databases (MEDLINE, EMBASE, and Cochrane) were searched from August 1, 2012, to October 27, 2021. Independent reviewers performed data extraction and quality assessment. Relative risk (RR) at 95% confidence interval (CI) pooled in a randomized meta-analysis. A parallel clinical practice guideline committee assessed the certainty of evidence using the GRADE approach. The outcomes of interest included VTE, PE, deep venous thrombosis, mortality, and IVC filter complications. Results: We included 10 controlled studies (47 140 patients), of which 3 studies (310 patients) were randomized controlled trials (RCTs) and 7 were observational studies (46 830 patients). IVC filters demonstrated no significant reduction in PE and fatal PE (RR, 0.27; 95% CI, 0.06-1.28 and RR, 0.32; 95% CI, 0.01-7.84, respectively) by pooling RCTs with low certainty. However, it demonstrated a significant reduction in the risk of PE and fatal PE (RR, 0.25; 95% CI, 0.12-0.55 and RR, 0.09; 95% CI, 0.011-0.81, respectively) by pooling observational studies with very low certainty. IVC filter did not improve mortality in both RCTs and observational studies (RR, 1.44; 95% CI, 0.86-2.43 and RR, 0.63; 95% CI, 0.3-1.31, respectively). Conclusion: In trauma patients, moderate risk reduction of PE and fatal PE was demonstrated among observational data but not RCTs. The desirable effect is not robust to outweigh the undesirable effects associated with IVC filter complications. Current evidence suggests against routinely using prophylactic IVC filters.

Remdesivir use in severe and critical COVID-19 patients might be associated with lower incidence of arterial thrombotic events.

INTRODUCTION: Venous thromboembolism (VTE) and arterial thrombotic (AT) events are a striking feature of severe COVID-19, however, relationship of remdesivir use and the risk of thrombotic events is unknown and has not been investigated before. METHODS: We retrospectively analyzed a cohort of 876 consecutive hospitalized severe and critical COVID-19 patients who were treated with remdesivir and compared them to 876 case-matched control patients. All patients were treated in our tertiary-level institution in period from 10/2020 to 6/2021. VTE and AT were diagnosed by objective imaging and laboratory methods. RESULTS: After exclusion of 71 VTE and 37 AT events present at the time of hospital admission, there were a total of 70 VTE (35 in the remdesivir and 35 in the control group) and 38 AT events occurring during hospitalization (13 in the remdesivir and 25 in the control group). There was a similar cumulative post-admission VTE incidence among both remdesivir and matched control patients (P = 0.287). Significantly lower cumulative post-admission AT incidence was observed among patients treated with remdesivir than among matched control patients (1.7% vs 3.3%, HR = 0.51, P = 0.035). Tendency for lower AT rates was evident in subgroups of patients stratified according to the type of AT, as well as according to the intensity of required oxygen supplementation at the time of remdesivir use. CONCLUSION: Remdesivir use in severe and critical COVID-19 patients might be associated with lower occurrence of AT during hospitalization, whereas similar rates of VTE events were observed among both patients treated with remdesivir and control patients.

Spectrum of Serious Neurological and Psychiatric Adverse Events in Indian COVID-19 Vaccine Recipients: A Systematic Review of Case Reports and Case Series.

Indian data regarding serious neurological and psychiatric adverse events, following coronavirus disease 2019 (COVID-19) vaccination, are lacking. We, therefore, systematically evaluated cases of post-vaccinal serious neurological and psychiatric adverse reactions published from India. A systematic review of cases published from India, which were archived in PubMed, Scopus, and Google Scholar databases, was performed; pre-print databases along with ahead-of-print contents were searched in addition. Retrieved articles, as on June 27, 2022, were evaluated following PRISMA guidelines. EndNote 20 web tool was used to make a PRISMA flow chart. Individual patients' data were compiled in a tabular form. The protocol of the systematic review was registered with PROSPERO (CRD42022324183). A total of 64 records describing 136 instances of serious neurological and psychiatric adverse events were identified. More than 50% (36/64) reports were from the following four states, namely, Kerala, Uttar Pradesh, New Delhi, and West Bengal. The mean age of persons developing these complications was 44.89 ± 15.77 years. In the majority, adverse events occurred within 2 weeks of administration of the first dose of COVISHIELD vaccine. Immune-mediated central nervous system (CNS) disorders were identified in 54 instances. Guillain-Barre syndrome and other immune-mediated peripheral neuropathies were reported in 21 cases. Post-vaccinal herpes zoster was recorded in 31 vaccine recipients. Psychiatric adverse events were recorded in six patients. In Indian recipients of COVID-19 vaccine, a variety of serious neurological complications were reported. The overall risk appears minuscule. Immune-mediated central and peripheral neuronal demyelinations were the most frequently reported post-vaccinal adverse events. A large number of cases of herpes zoster have also been reported. Immune-mediated disorders responded well to immunotherapy.

Thrombotic and Thromboembolic Complications After Vaccination Against COVID-19: A Systematic Review.

Thromboembolic complications after the COVID-19 vaccination have been reported from all over the world. We aimed to identify the thrombotic and thromboembolic complications that can arise after receiving various types of COVID-19 vaccines, their frequency, and distinguishing characteristics. Articles published in Medline/PubMed, Scopus, EMBASE, Google Scholar, EBSCO, Web of Science, the Cochrane Library, the CDC database, the WHO database, ClinicalTrials.gov, and servers like medRxiv.org and bioRxiv.org, as well as the websites of several reporting authorities between December 1, 2019, and July 29, 2021, were searched. Studies were included if they reported any thromboembolic complications post-COVID-19 vaccination and excluded editorials, systematic reviews, meta-analyses, narrative reviews, and commentaries. Two reviewers independently extracted the data and conducted the quality assessment. Thromboembolic events and associated hemorrhagic complications after various types of COVID-19 vaccines, their frequency, and distinguishing characteristics were assessed. The protocol was registered at PROSPERO (ID-CRD42021257862). There were 59 articles, enrolling 202 patients. We also studied data from two nationwide registries and surveillance. The mean age of presentation was 47 ± 15.5 (mean ± SD) years, and 71.1% of the reported cases were females. The majority of events were with the AstraZeneca vaccine and with the first dose. Of these, 74.8% were venous thromboembolic events, 12.7% were arterial thromboembolic events, and the rest were hemorrhagic complications. The most common reported event was cerebral venous sinus thrombosis (65.8%), followed by pulmonary embolism, splanchnic vein thrombosis, deep vein thrombosis, and ischemic and hemorrhagic stroke. The majority had thrombocytopenia, high D-dimer, and anti-PF4 antibodies. The case fatality rate was 26.5%. In our study, 26/59 of the papers were of fair quality. The data from two nationwide registries and surveillance revealed 6347 venous and arterial thromboembolic events post-COVID-19 vaccinations. COVID-19 vaccinations have been linked to thrombotic and thromboembolic complications. However, the benefits far outweigh the risks. Clinicians should be aware of these complications because they may be fatal and because prompt identification and treatment can prevent fatalities.

A rare case of Guillain barre syndrome with overlapping cerebral sinus venous thrombosis masquerading as acute psychosis following COVID-19 vaccination

Guillain barre syndrome (GBS) is a rare autoimmune condition that has a prevalence of 1-2 per 100,000 people each year. Cerebral sinus venous thrombosis (CSVT) occurs at a rate of three to four cases per one million individuals annually. Both have variable clinical presentation with significant morbidity. The therapeutic management of CSVT and GBS presents unique challenges due to peculiar relationship and overlap in presentation. Reports suggest that psychosis may result from autoimmune encephalitis after receiving the COVID-19 vaccination. Hereby the reported case is of a female who is 18 years of age presenting with acute psychotic and catatonic symptoms following covid 19 vaccination with weakening of limbs which suspected an underlying organic pathology. Magnetic resonance imaging was normal but magnetic resonance venogram showed transverse and sigmoid sinus thrombosis and later GBS with CSVT after Covid-19 vaccination was diagnosed. The case was chosen to report a rare condition with an atypical

Cirrhosis and COVID-19: Diffuse venous thrombosis and its clinical implication

A 60-year-old woman with Hepatitis C infection, cirrhosis, recurrent hepatic hydrothorax, and hepatocellular carcinoma was hospitalized with Coronavirus disease-2019 (COVID-19). After her initial discharge, she was re-admitted three weeks later with decompensated liver disease. Imaging revealed extensive thrombosis in the portal vein, superior mesenteric vein, splenic vein and bilateral brachial veins. Given the acute onset and extent of the thrombosis, the patient received therapeutic anticoagulation despite elevated prothrombin time/ international normalized ratio, thrombocytopenia and low fibrinogen. Cirrhotic patients with COVID-19 maybe at high risk of thrombosis, which can present with significant hepatic decompensation.Copyright © 2022 The Author(s)

Acquired hemophilia A and deep vein thrombosis attributable to the Pfizer-BioNTech SARS-CoV-2 mRNA vaccine-case report

Background: Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder that occurs in a sporadic, nonhereditary pattern. It is caused by circulating autoantibodies against clotting factor VIII that are triggered by several conditions. Moreover, AHA is clinically distinct from the inherited form of hemophilia A, with a different natural history and management approach, necessitating a high-index of suspicion in at-risk patients. Coronavirus disease 2019 (COVID-19) has emerged as a multisystemic disease whose manifestations are continuously being evaluated. There are few case reports of AHA associated with COVID-19 infection, while one case of AHA has been associated with COVID-19 vaccination. Similarly, deep venous thrombosis (DVT) frequently complicates COVID-19 infection, but two cases of DVT have been reported following COVID-19 vaccination. We report the occurrence of both AHA and DVT in a 63-year-old male patient within one week of receiving his first dose of the Pfizer-BioNTech SARS-CoV-2 mRNA vaccine. Case Description: Patient is a 63-year-old male who presented with a 3-day history of left lower extremity (LLE) swelling and pain. He was hemodynamically stable, but examination showed exquisite tenderness, ecchymosis, and pitting edema at the calf of the LLE. He had normal platelet counts at presentation but had mild anemia (11.9 g/dL) and elevated activated partial thromboplastin time (APTT) of 68.0 seconds. Venous Doppler ultrasound showed acute DVT in the left popliteal vein, necessitating commencement on heparin drip. He developed progressively worsening hematomas, symptomatic anemia that required red cell transfusions, and persistently elevated APTT despite stopping the heparin drip. Work up for pulmonary embolism, malignancy, and disseminated intravascular coagulopathy (DIC) were negative. Antiphospholipid antibodies and lupus anticoagulant were also negative. He had low factor VIII levels, tested positive for factor VIII inhibitor, and PTT mixing studies were consistent with acquired factor inhibitor. Treatment involved administration of Factor Eight Inhibitor Bypassing Activity (FEIBA) as well as intravenous methylprednisolone and cyclophosphamide. Following resolution of active bleeding with evidence of stable hemoglobin concentration, he was discharged home on oral prednisone and cyclophosphamide. Conclusion(s): This case report highlights the possibility of AHA and DVT as rare, potentially life-threatening adverse events that could occur following COVID-19 vaccination, which is currently the most effective tool employed in controlling the COVID-19 pandemic.Copyright © Annals of Blood. All rights reserved.

Cerebral Venous Thromboses in a Patient With No Reported Risk Factors: A Case Report.

Stroke is a neurologic condition caused either by brain ischemia or brain hemorrhage, where most cases are a result of ischemic brain injury. Stroke more commonly affects the arterial blood supply of the brain, but in rare cases, it is evoked by the occlusion of the venous sinuses that drain blood from the brain. This phenomenon is known as cerebral venous sinus thrombosis (CVST), also referred to as cerebral sinovenous thrombosis. The pathogenesis of CVST is not completely understood, although common risk factors associated with the condition include obesity, hypercoagulable states, oral contraceptive use, intracranial infections, trauma, and, more recently, coronavirus disease 2019 (COVID-19). Immediate medical intervention is required because CVST can result in increased intracranial pressure and diffuse cerebral edema, which can bring about fatal complications that can lead to early death. However, CVST is challenging to diagnose, as its clinical presentation is highly variable. It can range from headaches to signs of elevated intracranial pressure, including nausea, vomiting, and vision problems. In this case report, the patient is a 25-year-old previously healthy African American female who presented with a weeklong headache and acute onset of delirium an hour prior to arrival at the hospital. The patient had prior emergency department (ED) visits from different facilities where head imaging was performed and showed negative results allowing her to return home. The patient was then brought by a friend to our ED due to altered mental status and agitation. Initial computed tomography of the head did not reveal acute abnormalities; however, magnetic resonance angiography and magnetic resonance venography revealed evidence of venous sinus thrombosis and lack of flow requiring urgent attention. The patient was then referred to endovascular neurology, but despite medical intervention, the patient's medical status deteriorated, and she was declared brain dead. Although rare, this case report emphasizes the atypical presentation and the severity of CVST where a young individual with no significant past medical history presented with neurological symptoms that rapidly progressed to complications that caused her early death.

Cerebral venous sinus thrombosis following ChAdOx1 nCoV-19 AstraZeneca COVID-19 vaccine.

A woman in her mid-twenties was admitted with headache, ultimately leading to a diagnosis of cerebral venous sinus thrombosis 10 days after receiving a first dose of the AstraZeneca ChAdOx1 nCoV-19 vaccine (Vaxzevria). We report this case from clinical investigations to outcomes and discuss the issues raised by it regarding the ChAdOx1 nCoV-19 vaccine.

The impact of remote work on worker's health.

Remote work was brought to the forefront with the arrival of the COVID-19 public health emergency. Although there is no evidence of a direct cause-and-effect relationship between venous disease and work, the current medical consensus is that work can severely intensify its progression. Here, we report the case of a worker at a financial institution, who had been working remotely for around one year and had stopped exercising regularly for the same period. In January 2021, he presented intense pain and marked edema in the soleus area of the right lower limb, which prompted a visit to the emergency department. Laboratory analyses showed slight increases in d-dimer (720 ng/mL) and C-reactive protein (5 mg/dL) levels. A venous Doppler ultrasound of the lower limbs revealed the presence of an occlusive thrombus in the right soleus veins, reaching the right popliteal vein with associated venous dilation. The diagnosis of right, popliteal-distal acute deep vein thrombosis was thus reached. It is clearly impossible to change some of the risk factors of chronic venous insufficiency; however, other aspects such as obesity and working conditions can be the object of preventive actions that generate changes. We thus highlight the importance and possibility of a multidisciplinary approach to this theme, which could evolve into the establishment of a protocol for the prevention and treatment of venous diseases according to each job position.

O home office ganhou um papel de destaque com a chegada da emergência de saúde pública relativa à COVID-19. Embora não haja evidência da relação direta de causa e efeito de doença venosa com o trabalho, existe consenso atual, na opinião médica, de que o trabalho pode agravar seriamente o seu desenvolvimento. É relatado o caso de um profissional de instituição bancária, em teletrabalho há cerca de 1 ano, momento em que suspendeu também a prática de exercício físico. Em janeiro de 2021, iniciou quadro de dor intensa e edema acentuado na região solear do membro inferior direito, motivo pelo qual recorreu ao Serviço de Urgência. No estudo analítico, foram destacadas ligeiras elevações dos D-dímeros (720 ng/mL) e proteína C-reativa (5 mg/dL). A ecografia com estudo de Doppler venoso dos membros inferiores revelou presença de trombo oclusivo nas veias soleares direitas com extensão à veia poplítea direita com dilatação venosa associada. Admitiu-se, então, o diagnóstico de trombose venosa profunda poplíteo-distal direita de características agudas. É evidente que é impossível modificar alguns dos fatores de risco para a insuficiência venosa crônica; porém, outros fatores como obesidade e condições de trabalho podem ser alvo de ações preventivas que gerem modificações. Assim, ressaltam-se a importância e a possibilidade da abordagem multidisciplinar ao tema, o que poderia evoluir para o estabelecimento de um protocolo de prevenção e tratamento de doenças venosas em função do posto de trabalho executado.

Thrombotic Presentation of MIS-C After COVID-19 Infection in a Nine-Year-Old Boy

Introduction: SARS-CoV-2 is the cause of the recent pandemic. Although children are less affected by the virus, they can present with various presentations ranging from asymptomatic or fatigue and fever to multisystem inflammatory syndrome in children (MIS-C). Case Presentation: In this case report, we presented a case of a 9-year-old boy who presented with bilateral deep vein thromboses (DVTs) of the femoral and iliac veins as his main presentation of MIS-C, which occurred following a COVID-19 infection. A complete history was taken from the patient, and then a series of tests, including complete blood counts (CBCs), liver function tests (LFTs), and D-dimer, were performed. Bilateral doppler sonography to confirm the event and its location, as well as a decent follow-up method, were performed. Levels of anti-Xa assays followed the toxic levels of enoxaparin. The child was treated with a regimen of enoxaparin and corticosteroids, with a dosage of 1 mg/kg/12 h for both. The child was in the hospital for two weeks, after which he got better and was managed as an out-patient with a regularly scheduled appointment. Finally, once the radiologic evidence of DVTs was cleared, the patient tapered off his enoxaparin over the course of three weeks. Conclusion(s): Thrombotic events following COVID-19-associated MIS-C are an unlikely yet deadly event, especially in children. Prompt treatment with anticoagulants and corticosteroids alongside monitoring the patients are strongly advised.Copyright © 2022, Author(s).

Deep Venous Thrombosis in Elderly Inpatients with Pneumonia

Background: The occurrence of deep vein thrombosis (DVT) in COVID-19 pneumonia has raised wide concern recently, but few studies have reported the incidence of DVT in other types of pneumonia. We evaluate the prevalence, risk factors and treatment of DVT in the elderly inpatients with pneumonia. Method(s): A cohort of 550 elderly inpatients (>= 75 years old) with pneumonia between 2017 and 2021 were reviewed. They were divided into DVT group and non-DVT groups on the basis of whether pneumonia was combined with new-found DVT. Clinical data were collected retrospectively. Patients with DVT were divided into anticoagulant group and non-anticoagulant groups on the basis of whether they received anticoagulant therapy. Result(s): Ninety-seven patients were included in the DVT group;453 in the non-DVT group. The incidence of DVT was 17.64%. Hospital stays were significantly longer for DVT patients than for non-DVT counterparts (p = 0.005). Coronary heart disease, heart failure, hyperlipidemia, bed rest, and elevated D-dimer were independent risk factors for DVT (p < 0.05). The rate of anticoagulant therapy in DVT group was 63.92% (62/97 cases). Follow-up showed that the continuous anticoagulant treatment rate was 48.39% (30/62 cases) at 3 months and 30.65% (19/62 cases) at 6 months. Conclusion(s): Elderly inpatients with pneumonia are at high risk of DVT. The combination of DVT and pneumonia may lead to prolonged hospitalization. Coronary heart disease, heart failure, hyperlipidemia, bed rest and elevated D-dimer are independent risk factors for DVT in these patients. The rate of regular anticoagulant treatment is low because of the high risk of bleeding.Copyright © 2022, Taiwan Society of Geriatric Emergency & Critical Care Medicine.