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1.
IDCases ; 29: e01579, 2022.
Article in English | MEDLINE | ID: covidwho-1936494

ABSTRACT

Myocarditis is an acute or chronic inflammatory reaction of the heart muscle frequently associated with viral infections and post-viral immune-mediated responses. Recently the SARS-CoV-2 virus has been identified as a cause of myocarditis in COVID-19 patients. The role of cardiac MRI in such patients hence has become a subject of concern. Thus, we present a case of post-COVID-19 myocarditis where cardiac MRI was helpful in establishing the diagnosis.

2.
Journal of Hypertension ; 40:e174, 2022.
Article in English | EMBASE | ID: covidwho-1937722

ABSTRACT

Objective: Although acute myocarditis has not been observed as an adverse event in landmark trials of COVID-19 vaccines, it has been reported as a rare complication in real-world. The study aims to report a single-center experience on this issue. Design and method: We identified five cases of acute myocarditis with consistent temporal association to administration of COVID-19 vaccine and described clinical, serological, echocardiographic and cardiac magnetic resonance findings both in the acute phase and after a median follow up of 6 months. Results: All five patients received a COVID-19 vaccination dose within 24 to 96 hours before the onset of symptoms. Four patients received an mRNA vaccine (Comirnaty or Spikevax) and one received the adenovirus vaccine (Janssen). Only one patient had a known prior COVID-19 infection. All patients presented with chest pain and troponin I elevation occurring after the first vaccine dose in four cases. All patients tested negative for acute COVID-19 infection by polymerase chain reaction at admission. Blood tests revealed no or only mild inflammatory serological changes. Only one patient developed an increase in white blood cell count. None had specific changes on electrocardiography and echocardiography demonstrated preserved left ventricular systolic function and no regional wall motion abnormalities in all patients. Three patients underwent coronary angiography since risk factors and troponin trends raised clinical suspicion of acute coronary syndrome, none showed evidence of obstructive coronary artery disease. All patients had a mild to moderate disease not complicated by acute heart failure or arrhythmias. Cardiac Magnetic Resonance was performed in four cases and showed myocardial oedema and late gadolinium enhancement during the acute phase with persistence of areas of late gadolinium enhancement after a median follow-up of 6 months. None had further symptoms or hospitalizations since discharge. Conclusions: Acute myocarditis following COVID-19 vaccination is a well-defined clinical entity. Our findings suggest an immune rather than inflammatory pathogenesis and a benign course without clinical complication after a median follow-up of 6 months, but further studies are needed to define the prognostic significance of persistent findings on cardiac magnetic resonance.

3.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925550

ABSTRACT

Objective: NA Background: A variety of neurologic disorders have been described in patients after receiving the COVID-19 vaccines. Acute disseminated encephalomyelitis (ADEM) have been reported especially in the younger population following any vaccination, including the Covid-19 vaccines. Reports of ADEM in the elderly patients are scarce. Design/Methods: An 83 year old male with history of hypertension, presented with suddenonset of progressive multifocal neurological deficits including blurry vision, upper extremity weakness, numbness and clumsiness with imbalance resulting in multiple falls. A few days later, he reported dysphagia, intermittent expressive aphasia and confusion. Thirteen days prior, he received his second dose of Moderna vaccine. Examination showed mild bilateral upper motor neuron and cerebellar signs. Laboratory tests were unremarkable except for elevated ESR (72), low Vitamins-B12 (311 pg/mL), and D (14.9 ng/mL) levels, and iron deficiency anemia. MRI brain with gadolinium revealed non-enhancing multifocal and confluent supra/infratentorial T2/FLAIR hyperintensity lesions. Cerebrospinal fluid (CSF) analysis showed pleocytosis (whitecell count 13 with 60% lymphocytes), elevated protein (54), and glucose (80), suggestive of underlying inflammation. CSF cytology, meningoencephalitis panel, VDRL, JC-virus PCR, India-ink, acid-fast, bacterial and fungus cultures were negative. HIV antibody was negative. Intravenous Ceftriaxone was initiated until CSF cultures returned negative. Serum anti-MOG and anti-NMO were negative. Repeat imaging within a week showed decreased confluent T2 hyperintensities, but also demonstrated new areas of patchy involvement. The patient received intravenous methylprednisolone 1000 mg daily for 5 days. In the following weeks, his symptoms improved remarkably. Results: NA Conclusions: This 83 year old patient presented with multiple neurologic symptoms, confluent T2-Flair white matter hyperintensities on imaging studies, 13 days post Covid-19 vaccination. Workup for other inflammatory and infectious etiologies was unrevealing. Symptoms improved after intravenous corticosteroids treatment. ADEM is a consideration. Theoretical and actual concerns of vaccine-related neurologic diseases exist, timely recognition and treatment can alter the course and disease progression.

4.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925423

ABSTRACT

Objective: To describe safety and efficacy of tolebrutinib in patients with relapsing multiple sclerosis at Week 72 (Month 18) in the long-term safety (LTS) extension of the phase 2b trial. Background: In the phase 2b trial (NCT03889639), tolebrutinib, a CNS-penetrant Bruton's tyrosine kinase inhibitor, was well tolerated over 12 weeks with dose-dependent reduction in new gadolinium-enhancing T1 and new/enlarging T2 lesions. Design/Methods: The LTS extension (NCT03996291) consists of 2 parts: patients continued their core study tolebrutinib dose (5, 15, 30, or 60 mg/day) double-blind until the phase 3 study dose was selected (Part A), and currently receive tolebrutinib 60 mg/day open-label (Part B). Long-term safety and tolerability is the primary objective. Secondary endpoints include annualized relapse rate (ARR) and change from baseline in Expanded Disability Status Scale (EDSS) score. Results: 124 of 125 patients treated in the extension completed Part A and transitioned to Part B. One patient (on 5 mg/day) discontinued Part A due to progressive disease and 6 discontinued Part B due to a variety of reasons, including adverse event (AE;n=2), lack of efficacy (n=1), progressive disease (n=1), and emigration (n=2). To date, no new safety signals have been observed. The most common treatment-emergent AEs (TEAEs) were headache (12.8% [16/125]), COVID-19 (12.8% [16/125]), nasopharyngitis (10.4% [13/125]), upper respiratory tract infection (8.0% [10/125]), and arthralgia (5.6% [7/125]). There was no suggestion of a dose effect for TEAE or serious AE in Part A and no emergence of new safety signals for patients switching to 60 mg in Part B. ARR on tolebrutinib 60 mg was 0.17 (95% CI: 0.11, 0.27);84.7% of patients were relapse-free at the LTS Week 72 cut-off. Mean EDSS scores remained stable to LTS Week 72. Conclusions: Through LTS Week 72, tolebrutinib 60 mg continues to show favorable safety and tolerability, and low ARR.

5.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925410

ABSTRACT

Objective: Present a case of lupus myelitis occurring in a patient already receiving immunosuppression. Background: Neurologic complications of systemic lupus erythematosus span the central and peripheral nervous systems. We present a case of lupus myelitis in a patient previously well controlled with immunosuppression. Design/Methods: N/A Results: A 24-year-old woman with history of systemic lupus erythematosus presented with acute onset inability to walk due to bilateral leg weakness and numbness, associated with constipation and urinary retention. A week before, she experienced runny nose, sore throat, headache and neck pain radiating down her shoulders. Her medication regimen prior to admission included mycophenolate mofetil 1500 mg BID, hydroxychloroquine 200 mg daily, and prednisone 2.5 mg daily. Examination revealed bilateral lower limb weakness, more pronounced on right, hyperesthesia in the right leg, decreased proprioception bilaterally. She had intact pinprick, light touch, and vibration sense. Ankle reflexes were absent bilaterally. Laboratory testing showed pancytopenia, elevated anti-DsDNA (107 IU/mL), ESR of 69 mm/h, low serum C3/C4 and proteinuria. COVID-19 testing was negative. CSF analysis showed WBC of 890/mm3 , neutrophil predominance (93%), decreased glucose (32 mg/dL) and elevated protein (129 g/L). CSF cultures were negative. Aquaporin-4 receptor antibodies testing is pending. MRI of thoracic spine revealed patchy FLAIR hyperintensities at the level of T2, T4 and T10- T11 with mild enhancement at the level of the lesion T10-11, following intravenous gadolinium. The patient was treated IV methylprednisolone followed by cyclophosphamide and maintenance daily oral steroids with significant improvement of motor symptoms. She had mild residual right dorsiflexion weakness. Urinary and bowel function normalized. Conclusions: Lupus myelitis is a rare and potentially devastating complication of systemic lupus erythematosus. The timely recognition is crucial for proper management. CSF picture resembles an infection and may be misleading. While aquaporin-4 receptor antibodies report is pending, her very good recovery with methylprednisolone and cyclophosphamide strongly suggests lupus myelitis.

6.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925395

ABSTRACT

Objective: Report the safety and efficacy of evobrutinib over 2.5 years in an open-label extension (OLE). Background: Evobrutinib, a covalent, blood-brain barrier-penetrating Bruton's tyrosine kinase inhibitor, was well tolerated and effective at reducing gadolinium-enhancing lesions in a double-blind, randomized phase II trial in patients with relapsing multiple sclerosis (pwRMS;NCT02975349). Design/Methods: In the 48-week (W) double-blind period (DBP), pwRMS (n=267) received placebo (switched to evobrutinib 25mg once-daily at W24), evobrutinib 25mg once-daily, 75mg once-daily, or 75mg twice-daily, or open-label dimethyl fumarate (DMF;240mg twice-daily). At W48 patients could enter the OLE (DMF: 4-8W washout);evobrutinib 75mg once-daily (median ~48W) then 75mg twice-daily. The latest available OLE data are now reported. Results: Of 267 DBP patients, 213 (80%) entered the OLE;164 (61%) completed ≥132W of OLE treatment. Treatment-emergent adverse events (TEAEs) were reported by 165/213 patients (77.5%);59 (27.7%) had a treatment-related TEAE. Six serious TEAEs were deemed treatment-related. Severe/opportunistic infections (≥Grade 3) were reported by 9/213 patients (4.2%);3 were fatal (Covid-19 pneumonia [n=2] and E. coli sepsis [n=1];not considered treatment-related). At OLE W120, most patients had IgG (91%), IgA (88%) and IgM (82%) within normal ranges. Overall mean CD19+ B cells levels were 0.218×10 cells/mL (OLE baseline) and 0.122×10 cells/mL (OLE W96). ALT/AST elevations were observed only in patients previously receiving DMF/evobrutinib 25mg and occurred within 12W of OLE initiation. Amylase/lipase increases occurred in 6 (2.8%)/24 (11.3%) patients, but without clinical signs and symptoms. Based on all available OLE data, ARR was 0.12 (95%CI 0.07-0.20) for patients receiving 75mg twice-daily in the DBP. 6 6 Conclusions: Evobrutinib safety and efficacy data over 2.5 years in pwRMS continue to show acceptable tolerability, with no new safety signals, and maintained efficacy.

7.
European Journal of Preventive Cardiology ; 29(SUPPL 1):i403-i405, 2022.
Article in English | EMBASE | ID: covidwho-1915607

ABSTRACT

Background/Introduction: Active myocarditis is regarded as an absolute contra-indication to competitive sports. Subclinical SARS-CoV-2 myocarditis/myocardial damage has been demonstrated 2-5% in athletes. However, the prognosis in elite athletes after SARS-CoV-2 cardiac involvement, with potentially detrimental effects on recovery, is currently unknown. Purpose: We aimed to investigate the prevalence and clinical course of cardiac abnormalities in elite athletes after SARS-CoV-2 infection. Methods: We retrospectively and prospectively included elite athletes in the COMMIT (COvid-19 Myocardial Manifestations in Intensive Top-level sports) cohort. Outcomes of interest were 1) incidence and clinical course of cardiac abnormalities on CMR, defined as reduced EF, increased EDV, presence of late gadolinium enhancement (LGE) (excluding hinge point fibrosis), increased T1 and/or T2 time);2) clinically important arrhythmias defined as premature ventricular complex, (non-)sustained ventricular tachycardia on exercise ECG or 4-8 days Holter monitoring;3) cardiac- symptoms/ events. SARS-CoV-2 infection was diagnosed with a positive- PCR or antibody test if unvaccinated. Results: We included 85 elite SARS-CoV-2 recovered athletes (34% women), mean age 26.5 (±7) years, with main athletic disciplines (≥10 hours/week) football (27%), cycling (12%), water polo (9%), field hockey (9%), and rowing (8%). Mean time between infection and CMR was 2.6 months (±3). Mean CMR LVEDV/BSA was 120.6 ml/m2 (±21), LVEF 57.3% (±5), RVEDV/BSA 126.2 ml/m2 (±22), RVEF 54% (±4), and 1/85 (1.2%) showed increased T1 time after infection. In 4/85 (4.7%) myocardial LGE was present (Figure 1 and 2). In cases with LGE, after 11 (±2) months of follow-up, one demonstrated complete resolution (i.e. no LGE present) after 3 months. One case showed persistent inflammation on three sequential CMRs (1, 3, 6 months post-COVID-19);at 9 months CMR demonstrated no inflammation, but persistent LGE. Two elite athletes had unchanged LGE, one at 3 months, and one at 5 and 9 months. No clinically important arrhythmias were found in athletes with LGE. At a mean follow-up of 7.8 (±3.3) months, no symptoms/events were reported, and all had returned to sports. Pre-/post-SARS-CoV-2 infection CMR was available in 13/85 athletes;in this subgroup, no pathologic LGE or clinically important changes in ventricular volumes/function were found. Conclusion: This longitudinal cohort of elite athletes demonstrates that infection with SARS-CoV-2 is associated with 4.7% of myocardial abnormalities, with varying clinical courses. There were no important arrhythmias, and we found no evidence of deleterious effects of sports after COVID-19. Prospective studies with comprehensive arrhythmia monitoring and long-term follow-up are needed to establish whether intensive sports is associated with long-term deleterious cardiac effects. (Figure Presented).

8.
Endocrine Practice ; 27(6):S165-S166, 2021.
Article in English | EMBASE | ID: covidwho-1859547

ABSTRACT

Introduction: Hashimoto's encephalopathy (HE) is a rare immune–mediated complication of Hashimoto thyroiditis. It is presented as subacute onset of altered mental status with confusion, seizures and myoclonus. It is a diagnosis of exclusion and requires that all other possible causes of cognitive impairment are excluded with a response to steroid therapy and evidence of thyroid autoimmunity in a patient. Here, we present a case of HE in a patient who presented with altered mental status and visual hallucinations despite no history or symptoms of thyroid disorder. Case Description: A 77 year old male with past medical history of hypertension presented with altered mental status, lethargy, and visual hallucinations. Per patient’s wife, patient started to get somnolent and was having memory problems six weeks prior to presentation. His mental status gradually deteriorated, and he started to have visual hallucinations. He was somnolent and noted to have myoclonus and twitching on admission. Magnetic resonance imaging (MRI) of the brain with gadolinium showed chronic microvascular changes with no acute intracranial pathology or masses. Electroencephalogram (EEG) showed no signs of epileptiform activity. Infectious disease work up, including complete blood count, urinalysis, sexually transmitted diseases, and cerebrospinal fluid (CSF) analysis, was negative. Blood glucose levels, serum electrolytes, liver function tests, blood urea nitrogen, and creatinine were normal. Coronavirus disease 2019 (COVID-19) was negative. CSF analysis for autoimmune encephalopathy and Creutzfeldt-Jakob disease was negative. Thyroid function tests were normal. Thyroid peroxidase antibody (TPOAb) was negative (8.6 IU/mL [reference range (RR): < 9.0 IU/mL]) and TgAb was positive (8.2 ng/ mL [RR: < 4 IU/ mL]). With suspicion of Hashimoto's encephalopathy, he was started on intravenous Solu-Medrol 1 g for five days. He was then switched to oral prednisone 60 mg daily, which he received for ten days. His mental status improved upon day 14 of admission. On day 17 of admission, he was discharged on oral prednisone 40 mg daily with taper for five weeks. He was evaluated in the clinic few months after discharge. His mental status had improved significantly, and he was back to his baseline in about two months after discharge as per his wife. Repeat thyroid function tests, TPOAb, and TgAb were negative. Discussion: The incidence of Hashimoto’s encephalopathy (HE) is 2.1 per 100,000 individuals in the general population, and is more common in women than men. This case highlights that HE should be considered in patients with subacute presentation of neurological problems, which cannot be explained with other possible diagnosis, despite no symptoms of thyroid disease such as the patient in this case study. Therefore, HE should be evaluated for in patients with cognitive impairment for prompt diagnosis and treatment with steroid therapy in order to improve the prognosis in these patients.

9.
Cardiogenetics ; 12(2):133-141, 2022.
Article in English | EMBASE | ID: covidwho-1818054

ABSTRACT

Eosinophilic pancarditis (EP) is a rare, often unrecognized condition caused by endomyocardial infiltration of eosinophil granulocytes (referred as eosinophilic myocarditis, EM) associated with pericardial involvement. EM has a variable clinical presentation, ranging from asymptomatic cases to acute cardiogenic shock requiring mechanical circulatory support (MCS) or chronic restrictive cardiomyopathy at high risk of progression to dilated cardiomyopathy (DCM). EP is associated with high in‐hospital mortality, particularly when associated to endomyocardial thrombosis, coronary arteries vasculitis or severe left ventricular systolic dysfunction. To date, there is a lack of consensus about the optimal diagnostic algorithm and clinical management of patients with biopsy‐proven EP. The differential diagnosis includes hypersensitivity myocarditis, eosinophil granulomatosis with polyangiitis (EGPA), hypereosinophilic syndrome, parasitic infections, pregnancy‐related hypereosinophilia, malignancies, drug overdose (particularly clozapine) and Omenn syndrome (OMIM 603554). To our knowledge, we report the first case of pancarditis associated to eosinophilic granulomatosis with polyangiitis (EGPA) with negative anti‐neutrophil cytoplasmic antibodies (ANCA). Treatment with steroids and azathioprine was promptly started. Six months later, the patient developed a relapse: treatment with subcutaneous mepolizumab was added on the top of standard therapy, with prompt disease activity remission. This case highlights the role of a multimodality approach for the diagnosis of cardiac involvement associated to systemic immune disorders.

10.
Eur J Pediatr ; 181(7): 2879-2883, 2022 Jul.
Article in English | MEDLINE | ID: covidwho-1813679

ABSTRACT

Myocarditis is a rare complication of the COVID-19 mRNA vaccine. We previously reported a case series of 15 adolescents with vaccine-associated myocarditis, 87% of whom had abnormalities on initial cardiac magnetic resonance (CMR), including late gadolinium enhancement (LGE) in 80%. We performed follow-up CMRs to determine the trajectory of myocardial recovery and better understand the natural history of vaccine-associated myocarditis. Case series of patients age < 19 years admitted to Boston Children's Hospital with acute vaccine-associated myocarditis following the BNT162b2 vaccine who had abnormal CMR at the time of initial presentation, and underwent follow-up testing. CMR assessment included left ventricular (LV) ejection fraction, T2-weighted myocardial imaging, LV global native T1, LV global T2, extracellular volume (ECV), and late gadolinium enhancement (LGE). Ten patients (9 male, median age 15 years) with vaccine-associated myocarditis underwent follow-up CMR at a median of 92 days (range 76-119) after hospital discharge. LGE was persistent in 80% of patients, though improved from prior in all cases. Two patients (20%) had abnormal LV global T1 at presentation, which normalized on follow-up. ECV decreased between acute presentation and follow-up in 6/10 patients; it remained elevated at follow-up in 1 patient and borderline in 3 patients. CONCLUSION: CMR performed ~3 months after admission for COVID-19 vaccine-associated myocarditis showed improvement of LGE in all patients, but persistent in the majority. Follow-up CMR 6-12 months after acute episode should be considered to better understand the long-term cardiac risks. WHAT IS KNOWN: • Myocarditis is a rare side effect of COVID-19 mRNA vaccine. •Late gadolinium enhancement is present on most cardiac magnetic resonance at the time of acute presentation. WHAT IS NEW: •Late gadolinium enhancement improved on all repeat cardiac magnetic resonance at 3-month follow-up. •Most patients still had a small amount of late gadolinium enhancement, the clinical significance of which is yet to be determined.


Subject(s)
COVID-19 , Myocarditis , Adolescent , Adult , BNT162 Vaccine , COVID-19/prevention & control , COVID-19 Vaccines/adverse effects , Child , Contrast Media/adverse effects , Follow-Up Studies , Gadolinium/adverse effects , Humans , Magnetic Resonance Imaging , Magnetic Resonance Spectroscopy , Male , Myocarditis/diagnostic imaging , Myocarditis/etiology , Myocardium/pathology , Predictive Value of Tests , Vaccines, Synthetic , Ventricular Function, Left , Young Adult , mRNA Vaccines
11.
Int J Environ Res Public Health ; 19(8)2022 04 15.
Article in English | MEDLINE | ID: covidwho-1809877

ABSTRACT

Cardiac magnetic resonance (CMR) is a second-line imaging test in cardiology. Balanced enlargement of heart chambers called athlete's heart (AH) is a part of physiological adaptation to regular physical activity. The aim of this study was to evaluate the diagnostic utility of CMR in athletes with suspected structural heart disease (SHD) and to analyse the relation between the coexistence of AH and SHD. We wanted to assess whether the presence of AH phenotype could be considered as a sign of a healthy heart less prone to development of SHD. This retrospective, single centre study included 154 consecutive athletes (57 non-amateur, all sports categories, 87% male, mean age 34 ± 12 years) referred for CMR because of suspected SHD. The suspicion was based on existing guidelines including electrocardiographic and/or echocardiographic changes suggestive of abnormality but without a formal diagnosis. CMR permitted establishment of a new diagnosis in 66 patients (42%). The main diagnoses included myocardial fibrosis typical for prior myocarditis (n = 21), hypertrophic cardiomyopathy (n = 17, including 6 apical forms), other cardiomyopathies (n = 10) and prior myocardial infarction (n = 6). Athlete's heart was diagnosed in 59 athletes (38%). The presence of pathologic late gadolinium enhancement (LGE) was found in 41 patients (27%) and was not higher in athletes without AH (32% vs. 19%, p = 0.08). Junction-point LGE was more prevalent in patients with AH phenotype (22% vs. 9%, p = 0.02). Patients without AH were not more likely to be diagnosed with SHD than those with AH (49% vs. 32%, p = 0.05). Based on the results of CMR and other tests, three patients (2%) were referred for ICD implantation for the primary prevention of sudden cardiac death with one patient experiencing adequate intervention during follow-up. The inclusion of CMR into the diagnostic process leads to a new diagnosis in many athletes with suspicion of SHD and equivocal routine tests. Athletes with AH pattern are equally likely to be diagnosed with SHD in comparison to those without AH phenotype. This shows that the development of AH and SHD can occur in parallel, which makes differential diagnosis in this group of patients more challenging.


Subject(s)
Cardiomegaly, Exercise-Induced , Cardiomyopathies , Heart Diseases , Athletes , Cardiomyopathies/diagnostic imaging , Contrast Media , Female , Gadolinium , Humans , Magnetic Resonance Spectroscopy , Male , Predictive Value of Tests , Retrospective Studies
12.
Egyptian Journal of Radiology and Nuclear Medicine ; 53(1), 2022.
Article in English | EMBASE | ID: covidwho-1799082

ABSTRACT

Background: Variable neuroimaging findings have been reported in patients with coronavirus disease 2019 (COVID-19). In addition to respiratory symptoms, many neurologic manifestations of COVID-19 are increasingly reported and variable neuroimaging findings have been observed in patients with COVID-19. Our aim was to describe findings observed in hospitalized patients with COVID-19, presenting with acute neurologic manifestations and undergoing computed tomography (CT) or magnetic resonance imaging (MRI) of the brain. Methods: We performed a retrospective study involving patients with laboratory-confirmed SARS-COV-2 infection, admitted to our hospital between July 1 and December 30, 2020. Patients who presented with acute neurologic symptoms and required neuroimaging were only included in the study. Neuroimaging examinations were evaluated for the presence of, infarction, hemorrhage and encephalopathy. The frequency of these findings was correlated with clinical variables, including presence of comorbidities, requirement for intensive care unit admission, and duration between admission and onset of neurologic signs and symptoms as documented in the hospital medical records. Results: A total of 135 patients underwent at least one cross-sectional imaging of the brain, the median age of these patients was 63 years, and 72% were men. Disturbed level of consciousness was the most common neurologic symptom (80.7%). Acute neuroimaging findings were found in 34 patients (25.2%) including;acute ischemic infarcts (16/135;11.9%), intracranial hemorrhages (9/135, 6.7%), cerebral venous thrombosis (2/135;1.5%), posterior reversible encephalopathy syndrome (1/135;0.7%), and hypoxic-ischemic encephalopathy (6/135, 4.4%). There was no statistically significant difference in patient age (p = 0.062), sex (0.257), presence of comorbidities (p = 0.204), intensive care unit admission (p = 0.326) and duration between admission and onset of neurologic signs and symptoms (p = 0.755), in patients with positive versus negative neuroimaging studies. Conclusions: Our study showed that cerebrovascular complications, ischemic and hemorrhagic were the most frequent imaging finding in hospitalized patients with COVID-19. Knowledge about these potentially serious complications can help optimize management for these patients.

13.
Arch Cardiol Mex ; 2022 Apr 07.
Article in Spanish | MEDLINE | ID: covidwho-1780412

ABSTRACT

Background: The disease caused by coronavirus (COVID-19) affects the cardiovascular system, whether by direct viral aggression or indirectly through systemic inflammation and multiple organ compromise. A widely used method to determine cardiac injury is troponin measurement. The aim of this study is to evaluate the prevalence of cardiac involvement (CINV) in a population recovered from COVID-19, referred to cardiac MRI (CMR), who did not present troponin elevation. Methods: There were 156 patients that recovered from COVID-19 and who did not present troponin elevation referred to CMR. CINV was considered to be the presence of: late gadolinium enhancement (LGE), edema, myocarditis, pericarditis, left ventricular systolic dysfunction (LVSD) and/or depressed right ventricular systolic dysfunction (RVSD). Results: Prevalence of CINV was 28.8%, being more frequent in men (p=0.002), in patients who required hospitalization (p=0.04) and in those who experienced non-mild cases of infection (p=0.007). RVSD (17.9%) and LVSD (13.4%) were the most frequent findings. The rate of myocarditis was 0.6%. LGE manifested in 7.1% of patients and its presence was related to less left ventricular ejection fraction (LVEF) (p=0.0001) and right ventricular ejection fraction (RVEF) (p=0.04). Conclusion: In patients who recovered from COVID-19, 28.8% of CINV was found. It was more frequent in men, in patients who required admission and in patients with cases of non-mild infection. The patients that presented LGE had less LVEF and RVSF.


Antecedentes: La enfermedad por coronavirus 2019 (COVID-19) afecta al sistema cardiovascular, ya sea mediante la agresión directa viral o indirectamente por medio de la inflamación sistémica y afectación multiorgánica. Las troponinas son ampliamente utilizadas para determinar lesión cardiaca. La finalidad de este estudio es evaluar la prevalencia de afectación cardiaca (ACARD) en una población recuperada de COVID-19, derivada a resonancia magnética cardiaca (RMC), sin elevación de troponinas al momento del estudio. Métodos: Ciento cincuenta y seis pacientes que se recuperaron de COVID-19 y que no presentaron elevación de troponinas fueron derivados a RMC. Se consideró ACARD a la presencia de: realce tardío de gadolinio (RTG), edema, miocarditis, pericarditis, deterioro de la función sistólica del ventrículo izquierdo (DFSVI) y/o depresión de la función sistólica del ventrículo derecho (DFSVD). Resultados: La prevalencia de ACARD fue del 28.8%, siendo más frecuente en hombres (p = 0.002), en pacientes que requirieron hospitalización (p = 0.04) y en aquellos que cursaron cuadro no leve de infección (p = 0.007). La DFSVD (17.9%) y la DFSVI (13.4%) fueron las hallazgos más frecuentes. La frecuencia de miocarditis fue del 0.6%. El RTG se manifestó en el 7.1% de los pacientes y se relacionó con menor fracción de eyección del ventrículo izquierdo (FEVI) (p = 0.0001) y derecho (FEVD) (p = 0.04). Conclusión: La prevalencia de ACARD fue del 28.8%. Esta es más frecuente en hombres, en pacientes que requirieron internación y que cursaron cuadros de infección no leve. La miocarditis presentó una prevalencia muy baja. Los pacientes que presentaron RTG tuvieron menor FEVI y FSVD.

14.
Journal of the American College of Cardiology ; 79(9):3334, 2022.
Article in English | EMBASE | ID: covidwho-1768658

ABSTRACT

Background: Acute myocarditis is a rare complication of messenger RNA (mRNA) COVID-19 vaccination. Case: A 36-year-old female with hypertension, smoking, prior alcohol use, chronic pancreatitis and prior COVID-19 infection was transferred for surgical intervention for median arcuate ligament syndrome (MALS). She noted abdominal pain, chest discomfort, dyspnea, orthopnea, and lower extremity edema which began 5 days after the second dose of BNT162b2 COVID-19 vaccine. Physical exam revealed rales, abdominal distention and pitting edema. 12 lead ECG showed a nonspecific ST abnormality. Troponins were 19,222 ng/L (ref < 17 ng/L). Brain natriuretic peptide level was 4734 pg/mL (ref<100 pg/mL). Testing for active COVID-19 infection was negative. Chest x-ray demonstrated a right pleural effusion. Transthoracic echocardiogram revealed apical wall akinesis. Cardiac catheterization showed normal coronary vasculature. Cardiac MRI showed late gadolinium enhancement (LGE) in the basal anterolateral, mid-anterior and midanterolateral walls. Decision-making: Myocarditis should be suspected with elevated cardiac biomarkers, new unexplained heart failure and normal coronary angiography. Despite apical dysfunction, Takutsubo (stress) cardiomyopathy was less likely given CMR findings of LGE. Acute COVID-19 infection is well known to be associated with acute myocarditis but testing was negative. Testing for other potential etiologies (HIV, EBV, toxicology) was also negative. There was no history of collagen-vascular disease. Surgical and gastrointestinal consultations noted symptoms were consistent with acute heart failure rather than MALS. Timing was most consistent with vaccine induced myocarditis given onset within days of second injection with an mRNA vaccine. Based on the above findings decision was made to begin the patient on guideline directed medical therapy (GDMT) with diuretics, ace inhibition and beta blockade. Conclusion: While most common in young males, myocarditis following shortly after mRNA vaccine administration should be considered in patients without another etiology and with appropriate timing of symptom development. Most patients will improve with GDMT.

15.
Am Heart J Plus ; 14: 100125, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1767825

ABSTRACT

Purpose: This study assessed a functional protocol to identify myocarditis or myocardial involvement in competitive athletes following SARS-CoV2 infection. Methods: We prospectively evaluated competitive athletes (n = 174) for myocarditis or myocardial involvement using the Multidisciplinary Inquiry of Athletes in Miami (MIAMI) protocol, a median of 18.5 (IQR 16-25) days following diagnosis of COVID-19 infection. The protocol included biomarker analysis, ECG, cardiopulmonary stress echocardiography testing with global longitudinal strain (GLS), and targeted cardiac MRI for athletes with abnormal findings. Patients were followed for median of 148 days. Results: We evaluated 52 females and 122 males, with median age 21 (IQR: 19, 22) years. Five (2.9%) had evidence of myocardial involvement, including definite or probable myocarditis (n = 2). Three of the 5 athletes with myocarditis or myocardial involvement had clinically significant abnormalities during stress testing including ventricular ectopy, wall motion abnormalities and/or elevated VE/VCO2, while the other two athletes had resting ECG abnormalities. VO2max, left ventricular ejection fraction and GLS were similar between those with or without myocardial involvement. No adverse events were reported in the 169 athletes cleared to exercise at a median follow-up of 148 (IQR108,211) days. Patients who were initially restricted from exercise had no adverse sequelae and were cleared to resume training between 3 and 12 months post diagnosis. Conclusions: Screening protocols that include exercise testing may enhance the sensitivity of detecting COVID-19 related myocardial involvement following recovery from SARS-CoV2 infection.

16.
Front Cardiovasc Med ; 9: 852931, 2022.
Article in English | MEDLINE | ID: covidwho-1765662

ABSTRACT

Acute myocarditis was recently demonstrated in previously healthy young male patients after receipt of mRNA SARS-CoV-2 vaccines. Herein, we report on a 21-year-old man who presented with acute fatigue, myalgia, and chest pain 2 days after his second SARS-CoV-2 vaccination with BNT162b2. Cardiac magnetic resonance (CMR) showed acute myocarditis, with mildly impaired LV-function and abundant subepicardial late gadolinium enhancement (LGE). Control CMR after 3 months showed full functional recovery and complete disappearance of LGE. The benefits of SARS-CoV-2 vaccination may significantly exceed the very rare and, in this case, fully reversible adverse effects.

17.
JACC Basic Transl Sci ; 7(3): 294-308, 2022 Mar.
Article in English | MEDLINE | ID: covidwho-1757448

ABSTRACT

The mechanisms of coronavirus disease-2019 (COVID-19)-related myocardial injury comprise both direct viral invasion and indirect (hypercoagulability and immune-mediated) cellular injuries. Some patients with COVID-19 cardiac involvement have poor clinical outcomes, with preliminary data suggesting long-term structural and functional changes. These include persistent myocardial fibrosis, edema, and intraventricular thrombi with embolic events, while functionally, the left ventricle is enlarged, with a reduced ejection fraction and new-onset arrhythmias reported in a number of patients. Myocarditis post-COVID-19 vaccination is rare but more common among young male patients. Larger studies, including prospective data from biobanks, will be useful in expanding these early findings and determining their validity.

18.
Journal of the American College of Cardiology ; 79(9):2374, 2022.
Article in English | EMBASE | ID: covidwho-1757975

ABSTRACT

Background: Vaccine-associated Myocarditis (VAM) is increasingly documented as a complication of COVID-19 mRNA vaccines. In the United States, as of 10/16/2021 188.9 million are fully vaccinated with mRNA vaccines. VAM has an incidence of 4.8 cases per million post 2nd dose of mRNA vaccines. We present a case of mRNA VAM in a young male and challenges faced in screening and management of this rare condition in a time where clearer guidelines are needed. Case: 45 y/o male with no PMH presented with acute onset sharp midsternal chest pain associated with dyspnea and diaphoresis. Patient received the 2nd dose of the Moderna vaccine three days prior. Initial EKG: ST-elevations in leads V2-V4;troponin 4.37 (peaked at 7.3);CRP 25.8. Coreg was initiated. Emergent cardiac catheterization: nonobstructive CAD, mildly reduced systolic function 50%. Subsequent echo: EF 40% with mild hypokinesis in apical segments. Colchicine was started. Symptoms resolved and patient was discharged with avoidance of strenuous activity. 1st follow-up: improved symptomatology. Lisinopril was added. Repeat echo: EF 60%. 2nd follow-up 2 weeks later: he had presyncope. Holter: no arrhythmia. Cardiac MRI: multifocal mid-myocardial and subepicardial late gadolinium enhancement in apical and basal segments consistent with myocarditis. After 2 months, the patient was asymptomatic and exercise tolerant. Decision-making: New data from the CDC, and the Israeli National Database indicate a causal relationship between the new mRNA vaccines and the increase in VAM. This complication predominantly affects young males like this patient within 7 days post 2nd dose. In this age group, observed numbers of VAM were > 10 times more than expected. This data incited a high index of suspicion which led to the diagnosis. Conclusion: Since this vaccine technology will likely monopolize future vaccine production, this condition is expected to increase in prevalence and the medical community needs to remain vigilant. Better guidance is needed on how best to screen and manage. Further research is thus warranted. We maintain that mRNA vaccines provide benefits which far outweigh this often self-limited complication.

19.
Biomed Chromatogr ; 36(6): e5365, 2022 Jun.
Article in English | MEDLINE | ID: covidwho-1739127

ABSTRACT

Favipiravir is a potential antiviral medication that has been recently licensed for Covid-19 treatment. In this work, a gadolinium-based magnetic ionic liquid was prepared and used as an extractant in dispersive liquid-liquid microextraction (DLLME) of favipiravir in human plasma. The high enriching ability of DLLME allowed the determination of favipiravir in real samples using HPLC/UV with sufficient sensitivity. The effects of several variables on extraction efficiency were investigated, including type of extractant, amount of extractant, type of disperser and disperser volume. The maximum enrichment was attained using 50 mg of the Gd-magnetic ionic liquid (MIL) and 150 µl of tetrahydrofuran. The Gd-based MIL could form a supramolecular assembly in the presence of tetrahydrofuran, which enhanced the extraction efficiency of favipiravir. The developed method was validated according to US Food and Drug Administration bioanalytical method validation guidelines. The coefficient of determination was 0.9999, for a linear concentration range of 25 to 1.0 × 105  ng/ml. The percentage recovery (accuracy) varied from 99.83 to 104.2%, with RSD values (precision) ranging from 4.07 to 11.84%. The total extraction time was about 12 min and the HPLC analysis time was 5 min. The method was simple, selective and sensitive for the determination of favipiravir in real human plasma.


Subject(s)
COVID-19 , Ionic Liquids , Liquid Phase Microextraction , Amides , COVID-19/drug therapy , Chromatography, High Pressure Liquid/methods , Furans , Gadolinium , Humans , Liquid Phase Microextraction/methods , Magnetic Phenomena , Pyrazines
20.
Critical Care Medicine ; 50(1 SUPPL):170, 2022.
Article in English | EMBASE | ID: covidwho-1691890

ABSTRACT

INTRODUCTION: Myocarditis is increasingly being reported after mRNA COVID-19 vaccination especially in young individuals. We aim to compile the clinical, laboratory, and investigational data on reported cases of post-COVID-19 vaccination in adults and assess the clinical features, investigational findings, and prognosis in this meta-analysis. METHODS: PubMed database was searched using keywords for post-COVID-19 vaccination myocarditis for articles published before July 6th, 2021. 37 unique studies were identified. Case reports and case series published in English which reported individual patient data on adults aged 18 years or older that were hospitalized for presumed post mRNA vaccination myocarditis are included in our study. Pre-prints were included if they had individual patient data. Editorials, correspondence, reviews, perspectives, original articles were excluded. 13 articles met our criteria for inclusion. Individual participant data was tabulated on a spreadsheet. Age, time of presentation, and length of stay are expressed as Median. The rest of the findings are mentioned as frequency (n). RESULTS: Post mRNA vaccination myocarditis is predominantly seen in males with a mean age of 27.5 years and more after their second dose of vaccination. It is reported after both Pfizer-BioNTech and Moderna vaccine use. The median time of hospital presentation was 3 days after vaccination. The main presenting symptom is chest pain in 96.7% of the patients. Troponin was elevated and cardiac MRI showed late gadolinium enhancement in all the patients. The mean hospital length of stay was 5.5 days. All the patients made a good recovery. CONCLUSION: Post COVID-19 myocarditis is possibly a hypersensitivity reaction to mRNA vaccines. It is predominantly seen in young males and is characterized by chest pain, elevated troponin, and abnormal cardiac MRI. The condition carries a good prognosis. Further investigations are necessary to understand the underlying pathogenesis.

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