COVID-19 associated spontaneous hemorrhagic cholecystitis

Hemorrhagic cholecystitis is a rare disorder associated with considerable morbidity and mortality. The clinical presentation of hemorrhagic cholecystitis is non-specific and imaging findings can be difficult to accurately interpret without a high level of suspicion. Most recent reports of hemorrhagic cholecystitis have been associated with concurrent therapeutic anticoagulation. Here, we report imaging findings of a case of acute, spontaneous hemorrhagic cholecystitis in a 67-year-old male patient admitted for hypoxic respiratory failure secondary to COVID-19 pneumonia. © 2022

Post-discharge clinical, laboratory and radiographic features of coronavirus disease 2019 (COVID-19) patients at university hospitals in Japan.

Objectives: Coronavirus disease 2019 (COVID-19) has affected nearly half million people in Japan. However, information on the prolonged symptoms as well as laboratory and radiographic findings after hospital discharge remains limited. Methods: We retrospectively collected the symptoms, laboratory test results, and chest imaging results of COVID-19 patients at the time of the hospital admission and the ambulatory visits after discharge at two university hospitals between July and December 2020. Patients: A total of 126 COVID-19 patients, including of 88 with mild to moderate disease and 38 with severe to critical disease, were included. The time between symptom onset and the first outpatient visit was 46 days (Interquartile range, 39 to 55). Results: At the ambulatory visits, 36.5% of patients had at least one symptom. The most frequent symptom was shortness of breath (12.8%), followed by cough (11.1%), and fatigue (8.8%). Of 120 patients with post-discharge laboratory test results, 27 patients (22.5%) had abnormal alanine aminotransferase levels, and 35 patients (29.1%) had lymphocytopenia, including 24 and 27 mild and moderate patients. Of 122 patients with post-discharge chest computed tomography (CT) scans, 105 (83.3%) had abnormal findings. This abnormality was found in both mild to moderate and severe patients. Conclusions: Shortness of breath, abnormal liver function test results and chest CT images often persisted for at least one month after discharge, even when symptoms were mild or moderate during hospitalization.

The Effect of Carriage of CYP3A5*3 and CYP3A4*22 Polymorphic Variants on the Safety of Remdesivir Therapy in Patients with COVID-19

The aim of the study was to assess the association of polymorphic variants CYP3A5*3 6986 A>G rs776746 and CYP3A4*22 rs35599367 C>T with the safety parameters of remdesivir therapy in patients with COVID-19. Material and methods. The study included 156 patients admitted to the City Clinical Hospital No. 15 of the Moscow Health Department with COVID-19 diagnosis, who received remdesivir as an antiviral drug. The frequency of adverse reactions (bradycardia, dyspeptic disorders), as well as various laboratory parameters (ALT, AST, creatinine, ferritin, interleukin-6, and d-dimer levels) were compared between the carriers of wild-type and polymorphic variants of the studied genes. Results. Carriers of CYP3A5*3 polymorphic variants (GA+AA) had higher ALT levels after the treatment with remdesivir than carriers of the wild variant (GG). When comparing the level of interleukin-6 after therapy with remdesivir, carriers of the polymorphic variant of the CYP3A4*22 (CT) gene had a significantly higher level of this cytokine. Conclusion. An association between the carriage of polymorphic variants of CYP3A5*3 and an increase in the level of liver enzymes was found. Polymorphic variants of CYP3A4*22 were associated with higher levels of interleukin-6. Additional pharmacogenetic studies are required to assess the possibilities of personalizing antiviral therapy for COVID-19.

De Ritis ratio and cardiovascular disease: evidence and underlying mechanisms

Aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (De Ritis ratio) has been used as a marker of alcohol-related liver disease, liver fibrosis and muscle disease. This article reviewed the literature on the association of De Ritis ratio with cardiovascular disease (CVD). Recent studies support an association between elevated De Ritis ratio and prognosis of patients with diabetes mellitus, cancers, diseases characterized by multiorgan failure, CVD, stroke and corona virus disease (COVID)-19. Elevated De Ritis ratio may indicate increased cardiometabolic risk associated with overt or occult hepatic and extrahepatic diseases and may be a metabolic trait indicating abnormalities at the level of basic metabolism that foresees the development of future metabolic diseases. De Ritis ratio correlates positively with age, female sex, C-reactive protein and impaired renal function and inversely with diabetes mellitus, obesity and metabolic syndrome. Epidemiological studies suggest an association of elevated De Ritis ratio with CVD and strongly support an association between elevated De Ritis ratio and increased risk for all-cause and CVD-related mortality. The strength and direction of the association between De Ritis ratio and cardiovascular risk factors cannot explain the association between De Ritis ratio and CVD or CVD mortality. Elevated De Ritis ratio may represent cardiometabolic risk that is not mediated (or poorly mediated) by traditional risk factors and may be seen as an emerging nonstandard marker of cardiometabolic risk. De Ritis ratio requires standardization in terms of reference range and interpretation. Future epidemiological, clinical and laboratory (biochemical) studies are required to further investigate De Ritis ratio as a marker of cardiometabolic risk and CVD. © Journal of Laboratory and Precision Medicine. All rights reserved.

It's not the shunt: an atypical cause of fever in an infant with hydrocephalus

Case Report:We present a 5-year-old male with two days of fever, cough, vomiting, and loose stools. His history is significant for premature birth (35 weeks gestational age) and shunted hydrocephalus. A ventriculoperitoneal (VP) shunt was placed 6 days prior to presentation. Parental report included episodes of post-tussive, nonbloody, non-bilious emesis, poor oral intake, tachypnea, and increased work of breathing. Physical examination demonstrated a dehydrated infant with sunken fontanelles. He had no notable rash, no lymphadenopathy, and clear conjunctiva. His VP shunt site appeared normal without swelling or erythema. Initial evaluation showed elevated inflammatory markers -ESR 51 and CRP 12.32 mg/dL. A viral respiratory PCR panel returned positive for coronavirus (not SARS-CoV-2). A head CT scan and shunt radiography series showed no abnormalities with his shunt. The following morning, Radiology reported an incidental retropharyngeal fluid collection on a re-read of the patient's initial CT scan. A neck CT was obtained and demonstrated a fluid pocket with secondary mass effect in addition to bilateral cervical lymphadenopathy. Screening blood cultures were negative. The patient remained febrile (tmax 103.6F) and developed a transaminitis (ALT 264.9, AST 654), elevated fibrinogen 476, elevated INR 1.4, and low albumin 2.1. Abdominal ultrasound showed a normal the liver and biliary tract. His transaminitis resolved without treatment. The next day, the patient developed lip erythema and conjunctival injection. An echocardiogram showed a dilated right coronary artery (z-score of 3.59) and his inflammatory markers (ESR 26, CRP 9.63) remained elevated. Treatment was initiated with IVIG and moderate-dose aspirin. The patient defervesced, and he remained afebrile for over 48 hours prior to discharge. A repeat echocardiogram 2 days later showed a slight reduction in coronary artery dilatation (z-score 3.39). Hewas discharged on lowdose aspirin, and followed up with cardiology as an outpatient. Kawasaki's Disease (KD) is most common in children from ages 1 to 4 years and is classically characterized by persistent fever with a constellation of symptoms including limbal sparing conjunctivitis, cervical lymphadenopathy, polymorphous rash, strawberry tongue, oral changes, and extremity changes. Our patient presented at a younger age with a concurrent diagnosis of coronavirus upper respiratory tract infection. His atypical hospital course and incidental finding of retropharyngeal edema and transaminitis increased the clinical suspicion for KD. His symptoms rapidly improved after administration of IVIG. Younger patients are at an increased risk for severe complications of KD including coronary aneurysm. KD has been shown in the literature to have an association with coronavirus infection as well as presentation with retropharyngeal edema. Clinicians should consider KD in their differential even if patients do not meet all criteria for diagnosis on initial presentation. Copyright © 2023 Southern Society for Clinical Investigation.

Clinical profile and outcome of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 infection: a single-center observational study from South India

Background: Multisystem inflammatory syndrome in children (MIS-C) is a post-infectious sequelae of acute COVID-19 infection affecting children. This study was done over a period of 12 months from December 2020 to November 2021 to describe the clinical presentation, laboratory abnormalities, and outcome of children with MIS-C. Method(s): Seventy-eight children below 12 years of age who satisfied the WHO diagnostic criteria for MIS-C were included in the study. Clinical parameters were recorded at admission. Relevant laboratory investigations, radiological studies, and outcome were documented. Result(s): The most commonly affected age group was 6-12 years with a female predominance. COVID RTPCR was negative in all patients. Most cases presented 2-6 weeks after the onset of acute COVID-19 infection. Lethargy, poor feeding, vomiting, abdominal pain, loose stools, cough, and cold are common symptoms of MIS-C syndrome in children and the common signs were rash, conjunctival congestion, hypotension, tachycardia, tachypnea, and hypoxemia. Gastrointestinal system was the commonly affected followed by the hepatic, renal, and cardiovascular systems. Coronary artery abnormalities were seen in 20% of cases. IVIg was the mainstay of therapy used in 95% of patients. Mortality was 1.3%. Cases responded well to IVIg and steroids. Conclusion(s): Overall, the short-term outcome was favorable with low mortality in our study cohort. One-fifth of children had coronary artery abnormalities during acute phase underscoring the need for long-term follow-up. Copyright © 2022, The Author(s).

Comparison of initial presentations of murine typhus and Multisystem-Inflammatory Syndrome in children in a typhus-endemic area

Purpose of Study: In areas endemic for murine typhus, it can be difficult to distinguish from other febrile syndromes. During COVID-19 surges, we identified several cases of typhus. Presenting symptoms and quantitative lab values at and during admission were compared between patients who were diagnosed with murine typhus or multisystem-inflammatory syndrome in children (MIS-C). Methods Used: Retrospective data was collected at a tertiary care center from July 2020 to March 2022. Inclusion criteria were patients under 21 years of age diagnosed at discharge with murine typhus or MIS-C based on clinical and laboratory evidence, serologic data, and expert consultation. Patients found to have an alternate diagnosis, and those without serologic testing were excluded. Subjects were grouped as either MIS-C or typhus based final diagnosis. Categorical data included headache, fatigue, mucocutaneous changes, rash, con-junctival injection, sore throat, rhinorrhea, palpitations, shortness of breath, chest pain, abdominal pain, nausea/vomiting, diarrhea, myalgia, and appetite change at initial presentation. The categorical data were compared using chi-square test. Quantitative data included age, maximum temperature in first 24 hours of hospitalization, duration of symptoms prior to admission, C-reactive protein, erythrocyte sedimentation rate, platelet count, white blood cell count (WBC), absolute neutrophil count (ANC), absolute lymphocyte count, serum sodium, alanine aminotransferase, hemoglobin (Hgb), and albumin (Alb). Means of the quantitative data were compared with a one-tailed 2- Sample T-Test. The maximum and minimum laboratory values during admission were also compared. Additional demographic data including gender and date of initial presentation was also collected. Summary of Results: There were 7 patients in the MIS-C group and 19 in the typhus group. The average age of MIS-C patients, 6.5 years of age vs. 11.5,was significantly lower (p < 0.5) than the typhus group. Initial mean WBC (cells x 103/mm3) was higher in MIS-C than typhus (12.21, SD = 3.52, vs. 7.85, SD = 3.52, p < 0.05), as was ANC (8.9, SD = 3.7vs. 5.12, SD = 2.05, p < 0.05). During hospitalization, minimum Hgb (g/dL) was 9.3, SD = 2.07, and11.49, SD = 1.67, in MIS-C and typhus respectively (p < 0.05). Minimum albumin (g/dL) was also lower in MIS-C than typhus (2.32, SD = 0.86 vs. 2.8, SD = 0.45, p < 0.05). There were no other statistically significant differences in categorical or quantitative data. Typhus cases typically occurred in the summer and fall months. There was no clear seasonality of MIS-C, but occurred during local COVID-19 surges. Conclusion(s): The initial presenting symptoms of typhus and MIS-C were similar. WBC and ANC were higher in MIS-C, while age, Hgb and Alb were lower. These parameters may aid in distinguishing the diseases. A high clinical suspicion for both typhus and MIS-C in endemic areas for typhus is crucial. A rapid detection for typhus would aid in distinguishing these diseases and allow prompt treatment interventions. Copyright © 2023 Southern Society for Clinical Investigation.

Cardiac tamponade as the first presentation of thymoma: A case report during COVID-19 pandemic

We report a case of neoplastic cardiac tamponade, a life-threatening condition, as the initial presentation of an anterior mediastinal malignancy. A 69-year-old gentleman with no known history of malignancy presented to the emergency department with shortness of breath, reduced effort tolerance and chronic cough. Clinically, he was not in distress but tachycardic. He was subjected to echocardiography which revealed large pericardial effusion with tamponade effect. Pericardiocentesis drained 1.5 L of haemoserous fluid. CECT thorax, abdomen and pelvis revealed an anterior mediastinal mass with intrathoracic extension complicated with mass effect onto the right atrium and mediastinal vessels. Ultrasound-guided biopsy histopathology examination revealed thymoma. Due to locally advanced disease, tumour resection was not possible, and patient was referred to oncology team for chemoradiotherapy. We report this case study not only due to the rarity of the case but also to highlight its diagnostic challenge due to the COVID-19 pandemic. Copyright © The Author(s) 2022.

COVID-19 associated Mucormycosis (CAM): Implications for perioperative physicians - A narrative review

Mucormycosis once considered a rare disease with an incidence of 0.005 to 1.7 per million, has become one of the greatest menaces during the coronavirus disease (COVID-19) pandemic. India alone has contributed to nearly 70% of the global caseload of COVID-associated mucormycosis (CAM) and it had even been declared as a notifiable disease. Second wave of COVID-19 pandemic saw a steep rise in the incidence of mucormycosis and these patients have been presenting to anesthesiologists for various surgical procedures due to its primary or secondary sequelae. Rhino-orbito-cerebral mucormycosis (ROCM) is the commonest manifestation and is caused by Rhizopus arrhizus. Injudicious use of corticosteroids in vulnerable patients could have been a major contributing factor to the sudden rise in ROCM during the pandemic. Concerns related to anesthetic management include COVID-19 infection and post COVID sequalae, common presence of uncontrolled diabetes mellitus, possibility of difficult mask-ventilation and/or intubation, various drug therapy-associated adverse effects, and interaction of these drugs with anesthetic agents. Thorough preoperative optimization, multidisciplinary involvement, perioperative care, and vigilance go a long way in improving overall outcomes in these patients. Copyright © 2022 Saudi Journal of Anesthesia Published by Wolters Kluwer - Medknow.

Analyzing pregnancy course and outcomes in women with varying degrees of severity of novel coronavirus infection COVID-19 in Saint Petersburg: the lessons from pandemic.

Introduction. Today, two years after the first outbreak of the novel coronavirus infection (NCI) COVID-19, there is still insufficient data to fully assess risks and pattern of the course of this infectious disease in pregnant women. Aim(s): to conduct a comparative analysis of perinatal pregnancy outcomes as well as clinical and laboratory data in COVID-19 patients at the time of delivery and those suffering from the disease during pregnancy. Materials and Methods. A retrospective comparative study was carried out after analyzing pregnancy and childbirth histories in 191 women admitted for delivery in three obstetric medical organizations of Saint Petersburg in the years 2020-2021. Perinatal outcomes of pregnancy as well as clinical and laboratory data in patients suffering from COVID-19 during pregnancy were analyzed: Group 1-57 patients with asymptomatic and mild form of verified COVID-19;Group 2-50 patients with COVID-19 of moderate and severe course;Group 3-52 patients who underwent COVID-19 in the third trimester of pregnancy. Group 4 (control) consisted of 32 women lacking COVID-19. Results. Comparing delivery outcomes in Group 1 vs. Group 2 revealed a significantly higher rate of urgent deliveries - 54 (94.7 %) and 38 (76.0 %) (chi2 = 7.76) respectively, as well as a significantly lower number of premature births - 3 (5.3 %) and 12 (24.0 %) (chi2 = 7.76) respectively. Comparison of Group 1 vs. Group 3 showed significantly fewer natural births - 33 (57.8 %) and 42 (80.8 %) (chi2 = 6.63) respectively, but a greater rate of caesarean section - 24 (42.0 %) and 10 (19.2 %) (chi2 = 6.63). Comparison of Group 1 vs. Group 4 revealed a significantly higher number of women with acute and progressive fetal hypoxia (fetal distress) - 16 (28.1 %) and 2 (6.3 %) (chi2 = 6.05) respectively. These data allow us to state about an impact of the severity of infectious process SARS-CoV-2-caused disease and its timeframe during pregnancy on the timing and method of delivery. No significant data were obtained that might allow to state that the infectious process directly caused increased rate of premature birth in pregnant women with moderate and severe COVID-19. At hospital admission and discharge, patients with mild and asymptomatic COVID-19 were significantly less likely to have neutrophilia - 5 (8.8%) and 42 (84.0%) (chi2 = 61.2;p < 0.001) respectively, increased aspartate aminotransferase - 4 (7.0 %) and 38 (76.0 %) (chi2 = 53.15;p < 0.001), lactate dehydrogenase (LDH) - 0 (0.0 %) and 12 (24.0 %) (chi2 = 15.41;p < 0.001), C-reactive protein (CRP) - 6 (10.5 %) and 49 (98.0 %) (chi2 = 81.58;p < 0.001), creatinine reduction - 0 (0.0 %) and 11 (22.0 %) (chi2 = 13.98;p < 0.001) respectively. In groups with severe, mild and asymptomatic COVID-19, a strong direct correlation was established the CRP level and leukocyte count, between level of serum CRP and alanine aminotransferase;a less noticeable relationship was observed between serum CRP and LDH concentrations, CRP and total protein level. Conclusion. It was shown that no specific effect of SARS-CoV-2 infection was exerted on majority of parameters related to normal course of labor, as well as on condition of neonates born to patients with COVID-19 of varying severity. In patients with COVID-19 at the time of delivery, changes in clinical and laboratory parameters corresponded to the disease severity. Copyright © 2022 Rostovskii Gosudarstvennyi Meditsinskii Universitet. All rights reserved.

The importance of LDH/Albumin, LDH/Lymphocyte, and LDH/Platelet ratios in the evaluation of COVID-19 B.1.1.7 variant

Objectives: The aim is to investigate the usefulness of lactate dehydrogenase (LDH)/Albumin, LDH/Lymphocyte and LDH/Platelet ratios on the prognosis of coronavirus disease (COVID-19) Alpha (B.1.1.7) variant pneumonia. Method(s): A total of 113 patients who were diagnosed with COVID-19 pneumonia and 60 healthy control group were included in this study. The cases were divided into 2 as classic COVID-19 group, and COVID-19 B.1.1.7 variant group. Complete blood count (CBC) and biochemical parameters of the patients were analyzed retrospectively. Patients with COVID-19 B.1.1.7 variant group were also grouped according to the length of stay in the hospital and the days of hospitalization. Result(s): LDH/Albumin, LDH/Platelet, and LDH/Lymphocyte ratios were found to be higher in COVID-19 B.1.1.7 variant group when compared to the control group (p<0.001). The ferritin, neutrophils/lymphocyte (NLR) ratio, procalcitonin (PCT) and LDH/Albumin had the highest area under the curve (AUC) values in the COVID-19 B.1.1.7 variant group (0.950, 0.802, 0.759, and 0.742, respectively). Albumin, Lymphocytes and hemoglobin values were significantly higher in the COVID-19 B.1.1.7 variant group than in the classic COVID-19 group (p<0.05). Conclusion(s): LDH/Albumin and LDH/Lymphocyte ratios may be useful for clinicians in predicting the risk of progression to pneumonia in COVID-19 B.1.1.7 variant patients. Copyright © 2022 the author(s), published by De Gruyter.