A paralysis poser: a growing COVID concern

Purpose of Study: Report a rare case of onset of seronegative, juvenile dermatomyositis likely potentiated by Covid-19 infection Methods Used: Case analysis and literature research Summary of Results: A 7 year-old previously healthy male presented with 3 weeks of progressive, bilateral upper and lower extremity weakness, difficulty swallowing, voice changes, periorbital edema, and rash. Recent history was notable for diagnoses of COVID-19 one month prior to presentation and streptococcal pharyngitis 2 months prior to presentation. Notably, there is a family history of systemic lupus erythematosus. On examination, the patient demonstrated bilateral periorbital swelling with purple discoloration of the upper eyelids, a violaceous, pruritic, macular rash on his upper extremities and on his abdomen. Musculoskeletal exam was significant for severe axial (strength 2/5) and proximal (strength 3/5) muscleweakness with notable inability to sit unsupported or maintain head control. His neurologic exam was nonfocal;however, diffuse hyporeflexia in both upper and lower extremities were elicited. Initial screening labs were notable for mild transaminitis;positive ANA (1:80 in speckled pattern), negative ANCA, negative dsDNA/Anti- Sm, elevated aldolase of 10.3, CK 464, and LDH 665;normal thyroid studies and normal inflammatory markers. MRI with and without contrast of the spine indicated diffuse myositis of all muscle groups. Due to concern for autoimmune mediated myositis, Rheumatology was involved early in the patient's course. Empiric treatment was initiated early in the patient's presentation with IVIG, steroids, methotrexate, and plaquenil leading to gradual improvement in symptoms. Subsequent muscle biopsy was consistent with juvenile dermatomyositis (JDM). Conclusion(s): JDM is rare, occurring in 1 to 15 per million children. It classically presents with proximal myopathy and dermatologic findings of Gattron's papules, a heliotrope and malar rash. Its pathophysiology is not yet well defined but is thought to be a humoral mediated autoimmune disease. Muscle biopsies characteristically show perifascicular and perivascular infiltration. Early diagnosis and treatment with steroids, immune modulators, and physical therapy is critical to limit muscle atrophy. Viral infections are known triggers of rheumatologic diseases broadly;however, the more pronounced type 1 interferon response associated with COVID-19, which is known to be a driving pathway of JDM, may be a risk factor for severe, recalcitrant disease. Future research is needed to better identify involved pathophysiology and target future treatment efforts. Additionally, more education and case reports could focus on dermatologic presentations of individuals with pigmented skin. Copyright © 2023 Southern Society for Clinical Investigation.

Otolaryngologic Manifestations in Long COVID-19

Introduction: Due to the upper respiratory nature of COVID- 19 infection, otolaryngologic manifestations of acute disease have become well documented within the literature. However, the long-term sequelae of COVID-19 infection have yet to be completely understood. This study aims to explore ear, nose, and throat complaints of patients who experienced COVID-19 at least 3 months prior and are still symptomatic. Method(s): A retrospective review of previous COVID-19- positive patients who followed up in otolaryngology clinic between March 2020 and January 2022 was performed. Demographics, preexisting comorbidities, date of initial COVID-19 infection, long-haul symptoms, and intubation status were recorded. Result(s): A total 170 patients, 93 male and 77 female, with an average age of 57.2+/-15.0 years (range 23-89) were included in this study. Most of these patients originally contracted COVID-19 from March to May of 2020;therefore, this patient cohort represents a predominately unvaccinated group. Patients followed up in otolaryngology clinic ranging between 3 and 10 months after initial infection. The most common long-haul complaint was dysphonia and dyspnea, followed by voice changes, anosmia and dysgeusia, and reflux. Conclusion(s): This study is the first of its kind to examine long-haul otolaryngologic complaints in previously COVID- 19-positive patients. As millions of people around the world have passed this virus, it is important to identify possible longterm sequelae and encourage specialized follow-up when appropriate. Further studies examining course and management of these symptoms are needed.

Epiglottic Abscess in a Healthy but Unvaccinated Patient With COVID: Predilection for the Upper Airway?

Introduction: With new SARS-CoV-2 variants emerging such as Delta and Omicron, it is important to reevaluate patterns of presentation and affected patient characteristics. SARS-CoV-2 infection may be shifting from a primary insult of the lower airway to one primarily affecting the upper airway. Method(s): This is a report of a novel case of SARS-CoV-2 infection causing an epiglottic abscess during the peak of the Omicron wave. A literature review showed no previous reports of this specific entity. Result(s): An otherwise healthy, unvaccinated 25-year-old man presented with 3 days of throat pain and mild cough. He had no subjective or objective fevers, malaise, voice changes, or difficulty breathing. White blood cell count was normal. A computed tomography neck with intravenous (IV) contrast revealed edema and gas formation of the epiglottis with a small developing abscess. Flexible fiber-optic laryngoscopy showed an edematous epiglottis with prolapse posteriorly to the pharyngeal wall and mild arytenoid edema without involvement of the vocal folds. He was intubated in the operating room, and incision and drainage of the epiglottic abscess was performed. He was given steroids and broad-spectrum IV antibiotics and extubated without difficulty on postoperative day 2. Intraoperative cultures unfortunately did not speciate to guide antibiotic therapy. He continued to improve clinically and was discharged home on postoperative day 3 with a course of amoxicillin/clavulanate. Conclusion(s): This case highlights a unique presentation of COVID in a young, unvaccinated patient that was successfully managed with operative drainage. He was without any medical comorbidities or immunodeficiency. It is possible that current COVID variants have a predilection for the upper airway as evidenced by this case.