Free floating aorto-iliac thrombosis: A rare complication of COVID-19 pneumonia

Arterial thrombosis encountered during sars-cov2 infections is a rare complication with a poor prognosis compared to venous ones. They generally occur in severe and critical clinical forms of covid19 [1,2]. The physiopathology of arterial thrombosis, even if not completely understood highlights hypercoagulability and excessive inflammation as risk factors with a major role of the endothelial lesions in their occurrence. The presence of cardiovascular risk factors in patients infected with covid19 is also discussed as a predisposing factor for arterial thrombosis [2,3]. We report the case of a North African male patient hospitalized for acute respiratory distress syndrome (ARDS) secondary to covid19 pneumonia, complicated by the occurrence of multiple arterial thrombosis of the aorto-iliac axis with the rare finding of two free floating thrombus in the aorta and the right common iliac artery. Clinically, the patient had developed acute bilateral lower limb ischemia and multi-organ failure and the evolution was dramatic with rapid worsening of the patient…s health and eventually his death. Thromboembolic complications are frequent during covid19 infection but the aortic localization is very rare. Its diagnosis is difficult and it has a poor prognosis. Our objective through this case report is to increase knowledge about arterial thromboembolic events while discussing their link to the sars-cov2 viral infection. © 2022

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support

Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome. © 2022 Elsevier Ltd

The burden of viral infections in pediatric intensive care unit between endemic and pandemic coronavirus infections: A tertiary care center experience

Objectives: To measure the prevalence of viral infections, length of stay (LOS), and outcome in children admitted to the pediatric intensive care unit (PICU) during the period preceding the COVID-19 pandemic in a MERS-CoV endemic country. Methods: A retrospective chart review of children 0–14 years old admitted to PICU with a viral infection. Results: Of 1736 patients, 164 patients (9.45%) had a positive viral infection. The annual prevalence trended downward over a three-year period, from 11.7% to 7.3%. The median PICU LOS was 11.6 days. Viral infections were responsible for 1904.4 (21.94%) PICU patient-days. Mechanical ventilation was used in 91.5% of patients, including noninvasive and invasive modes. Comorbidities were significantly associated with intubation (P-value = 0.025). Patients infected with multiple viruses had median pediatric index of mortality 2 (PIM 2) scores of 4, as compared to 1 for patients with single virus infections (p < 0.001), and a median PICU LOS of 12 days, compared to 4 in the single-virus group (p < 0.001). Overall, mortality associated with viral infections in PICU was 7 (4.3%). Patients with viral infections having multiple organ failure were significantly more likely to die in the PICU (p = 0.001). Conclusion: Viral infections are responsible for one-fifth of PICU patient-days, with a high demand for mechanical ventilation. Patients with multiple viral infections had longer LOS, and higher PIM 2 scores. The downward trend in the yearly rate of PICU admissions for viral infections between the end of the MERS-CoV outbreak and the start of the COVID-19 pandemic may suggest viral interference that warrants further investigations. © 2022 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases

Case report: Covid-19 and disseminated tuberculosis coinfection unveiling catastrophic antiphospholipid antibody syndrome: An association or de novo phenomenon

Background: Disseminated infections such as tuberculosis are known to result in a systemic inflammatory response leading to thrombosis, with increasing reported cases of thrombotic event being observed in patients infected with covid-19. This is the first reported case on co-infection with COVID-19 pneumonia and disseminated tuberculosis causing catastrophic antiphospholipid syndrome (CAPS). Method(s): The report highlighted the challenges in the diagnosis and management which include the use of corticosteroid in setting of systemic infections. Another diagnostic dilemma was to explain the cause of myositis by tuberculous or autoimmune. Case Presentation: We report a 26-year- old man with HbE trait thalassemia who reported unintentional weight loss, night sweats for 1 month prior to the diagnosis of covid-19 infection on 10th March 2022. Seven days later, he was hospitalized for suspected perforated appendix. Computed tomography (CT) abdomen revealed hepatosplenomegaly, prostatitis, seminal vesiculitis. Multiple matted abdominal lymph nodes were not amenable for biopsy. Soon, he appeared toxic, dyspneic required non-invasive ventilation with bilateral parotitis. He had raised erythrocyte sedimentation (ESR) 52 mm/hour, C-reactive protein (CRP) 221 mg/dl, lactate dehydrogenase (LDH) 730U/L. Direct Coomb's antibody was positive but did not have any form of haemolysis. Complement 3 (0.45 g/L) and complement 4 (0.1 g/L) levels were low. Serum IgG4, procalcitonin, anti-nuclear antibody, cultures and virology were negative. Sputum for acid fast bacilli (AFB) was positive on Auramine O stain but the Ziehl-Nelson (ZN) stain and tuberculous PCR (GeneXpert) were negative. Diagnosis of disseminated tuberculosis was made but his abdominal pain persisted despite being on anti-tuberculous therapy (ATT), and he had new evidence of splenic infarct. CT angiogram also revealed celiac trunk and superior mesenteric artery thrombosis. Antiphospholipid (aPL) test was positive for lupus anticoagulant, beta 2 glycoprotein 1 and anti-cardiolipin antibodies. Therapeutic anticoagulation and plasma exchange were initiated for probable CAPS followed by intravenous immunoglobulin and corticosteroid. Thereafter, the patient developed severe bilateral pelvic girdle pain with evidence of myositis on the MRI (Figure 2). Serum creatine kinase was never elevated. Anti-PL- 7 and anti Ro-52 were borderline elevated. He recovered well and ambulant before discharged home. Conclusion(s): Our case highlight the complexicity of presentation of CAPS who manifested as multiple arterial thrombosis. The diagnosis of disseminated tuberculosis relied strongly on microbiological, imaging and clinical presentation as histopathological evidence was not feasible. Management challenges were deciding on corticosteroid in disseminated infection and the need for confirmation of persistent positive aPL test and to monitor myositis symptom to help guide decision making. (Figure Presented).

Clinical Dilemma of Diabetic Ketoacidosis and COVID-19 Infection

The COVID-19 Pneumonia with diabetic ketoacidosis is a dreadful health condition. Diabetic ketoacidosis is one of the severe metabolic complications and it can be precipitated by infection. We presented a case of 48 years female with no known comorbidities who presented with COVID-19 symptoms and with Diabetic Ketoacidosis. The case presented with elevated inflammatory markers, high anion gap metabolic acidosis with type I respiratory failure. During admission, the oxygen saturation had marked drop, later her improvement was steady followed by gradual tapering of the oxygenation. Marked improvement was noticed in the subsequent follow-up. COVID-19 infection can be precipitated by preexisting diabetes or newly diagnosed diabetes and the severity of COVID-19 infection is more pronounced in patients with diabetes mellitus, thus should be managed timely and accordingly. The scarce studies among the COVID-19 cases with diabetic ketoacidosis reflect the need for further studies for the availability of a wider range of information. Copyright © 2021, Kathmandu University. All rights reserved.

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).

Guillain-Barre syndrome in SARS CoV-2: Case series of uncommon neurological complication from tertiary care center, Bengaluru, South India

Coronavirus disease is an infectious disease caused by severe acute respiratory syndrome-coronavirus 2 virus. It predominantly affects respiratory system causing fever, cough, and breathlessness. But it can also affect central nervous system and peripheral nervous system. It is important that physicians keep a high index of suspicion for patients with neurologic symptoms following a recent or during COVID-19 infection. The low rate of initial diagnosis is alarming, as few of the percentage of patients with Guillain-Barre syndrome will develop respiratory muscle weakness requiring invasive ventilation. The ability to recognize the disease process could lead to life saving management. Furthermore, the initiation of therapy such as plasma exchange or intravenous immunoglobulin leads to an accelerated recovery time. [ FROM AUTHOR]

A Retrospective Analysis of the Effects of Time on Compliance and Driving Pressures in ARDS.

BACKGROUND: The evolution of compliance and driving pressure in ARDS and the effects of time spent on noninvasive respiratory support prior to intubation have not been well studied. We conducted this study to assess the effect of the duration of noninvasive respiratory support prior to intubation (ie, noninvasive ventilation [NIV], high-flow nasal cannula [HFNC], or a combination of NIV and HFNC) on static compliance and driving pressure and retrospectively describe its trajectory over time for COVID-19 and non-COVID-19 ARDS while on mechanical ventilation. METHODS: This is a retrospective analysis of prospectively collected data from one university-affiliated academic medical center, one rural magnet hospital, and 3 suburban community facilities. A total of 589 subjects were included: 55 COVID-19 positive, 137 culture positive, and 397 culture-negative subjects. Static compliance and driving pressure were calculated at each 8-h subject-ventilator assessment. RESULTS: Days of pre-intubation noninvasive respiratory support were associated with worse compliance and driving pressure but did not moderate any trajectory. COVID-19-positive subjects showed non-statistically significant worsening compliance by 0.08 units per subject-ventilator assessment (P = .24), whereas COVID-19-negative subjects who were either culture positive or negative showed statistically significant improvement (0.12 and 0.18, respectively; both P < .05); a statistically similar but inverse pattern was observed for driving pressure. CONCLUSIONS: In contrast to non-COVID-19 ARDS, COVID-19 ARDS was associated with a more ominous trajectory with no improvement in static compliance or driving pressures. Though there was no association between days of pre-intubation noninvasive respiratory support and mortality, its use was associated with worse overall compliance and driving pressure.

Environmental Contamination by SARS-CoV-2 During Noninvasive Ventilation in COVID-19.

BACKGROUND: Environmental contamination by SARS-CoV-2 from patients with COVID-19 undergoing noninvasive ventilation (NIV) in the ICU is still under investigation. This study set out to investigate the presence of SARS-CoV-2 on surfaces near subjects receiving NIV in the ICU under controlled conditions (ie, use of dual-limb circuits, filters, adequate room ventilation). METHODS: This was a single-center, prospective, observational study in the ICU of a tertiary teaching hospital. Four surface sampling areas, at increasing distance from subject's face, were identified; and each one was sampled at fixed intervals: 6, 12, and 24 h. The presence of SARS-CoV-2 was detected with real-time reverse transcriptase-polymerase-chain-reaction (RT-PCR) test on environmental swabs; the RT-PCR assay targeted the SARS-CoV-2 virus nucleocapsid N1 and N2 genes and the human RNase P gene as internal control. RESULTS: In a total of 256 collected samples, none were positive for SARS-CoV-2 genetic material, whereas 21 samples (8.2%) tested positive for RNase P, thus demonstrating the presence of genetic material unrelated to SARS-CoV-2. CONCLUSIONS: Our data show that application of NIV in an appropriate environment and with correct precautions leads to no sign of surface environmental contamination. Accordingly, our data support the idea that use of NIV in the ICU is safe both for health care workers and for other patients.

Characterization of SARS-CoV-2 Aerosols Dispersed During Noninvasive Respiratory Support of Patients With COVID-19.

BACKGROUND: In the midst of the COVID-19 pandemic, noninvasive respiratory support (NRS) therapies such as high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) were central to respiratory care. The extent to which these treatments increase the generation and dispersion of infectious respiratory aerosols is not fully understood. The objective of this study was to characterize SARS-CoV-2 aerosol dispersion from subjects with COVID-19 undergoing NRS therapy. METHODS: Several different aerosol sampling devices were used to collect air samples in the vicinity of 31 subjects with COVID-19, most of whom were receiving NRS therapy, primarily HFNC. Aerosols were collected onto filters and analyzed for the presence of SARS-CoV-2 RNA. Additional measurements were collected in an aerosol chamber with healthy adult subjects using respiratory therapy devices under controlled and reproducible conditions. RESULTS: Fifty aerosol samples were collected from subjects receiving HFNC or NIV therapy, whereas 6 samples were collected from subjects not receiving NRS. Only 4 of the 56 aerosol samples were positive for SARS-CoV-2 RNA, and all positive samples were collected using a high air flow scavenger mask collection device placed in close proximity to the subject. The chamber measurements with healthy subjects did not show any significant increase in aerosol dispersion caused by the respiratory therapy devices compared to baseline. CONCLUSIONS: Our findings demonstrate very limited detection of SARS-CoV-2-containing aerosols in the vicinity of subjects with COVID-19 receiving NRS therapies in the clinical setting. These results, combined with controlled chamber measurements showing that HFNC and NIV device usage was not associated with increased aerosol dispersion, suggest that NRS therapies do not result in increased dispersal of aerosols in the clinical setting.

The Effectiveness of NIV and CPAP Training on the Job in COVID-19 Acute Care Wards: A Nurses' Self-Assessment of Skills.

Background: Noninvasive ventilation (NIV) in COVID-19 patients outside of intensive care unit (ICU) settings was a feasible support during the pandemic outbreak. The aim of this study was to assess the effectiveness of an "on the job" NIV training program provided to 66 nurses working in 3 COVID-19 wards in an Italian university hospital. Methods: A quasi-experimental longitudinal before−after study was designed. The NIV Team education program, provided by expert ICU nurses, included: 3 h sessions of training on the job during work-shifts about the management of helmet-continuous positive airway pressure (CPAP) Venturi systems, and NIV with oronasal and full-face masks. An eleven-item "brief skills self-report tool" was administered before and after the program to explore the perception of NIV education program attendees about their level of skills. Results: In total, 59 nurses responded to the questionnaire. There was an improvement in the skill levels of the management of Helmet-CPAP (median before training 2, inter-quartile range (IQR) 0−6; median after training 8, IQR 3−9; p < 0.0001), and mask-NIV (median before training 2, IQR 0−6; median after training 8, IQR 3−9; p < 0.0001). Conclusions: Training on the job performed by expert ICU nurses can be a valuable and fast means to implement new Helmet-CPAP and mask-NIV skills outside of ICUs.

Persistent pneumothorax with bronchopleural fistula in COVID lung - An emerging challenge.

Bronchopleural fistula (BPF) is an uncommon entity in patients with coronavirus disease 2019 (COVID-19). It may arise due to various causes ranging from the disease itself to complications of treatment. If left untreated, it may increase the morbidity, hospital stay, and adversely affect the outcome. We hereby present a series of cases with a persistent pneumothorax and associated BPF due to varying etiologies. While three of our cases developed a pneumothorax while on non-invasive ventilation, other three were on oxygen therapy. One patient developed a spontaneous pyopneumothorax and septicemia and succumbed to the complications. Another patient on non-invasive ventilation died due to complications of pregnancy. The management of each case varied depending on their clinical presentation.

Helmet noninvasive ventilation for COVID-19 patients (Helmet-COVID): statistical analysis plan for a randomized controlled trial.

BACKGROUND: Noninvasive respiratory support is frequently needed for patients with acute hypoxemic respiratory failure due to coronavirus disease 19 (COVID-19). Helmet noninvasive ventilation has multiple advantages over other oxygen support modalities but data about effectiveness are limited. METHODS: In this multicenter randomized trial of helmet noninvasive ventilation for COVID-19 patients, 320 adult ICU patients (aged ≥14 years or as per local standards) with suspected or confirmed COVID-19 and acute hypoxemic respiratory failure (ratio of arterial oxygen partial pressure to fraction of inspired oxygen < 200 despite supplemental oxygen with a partial/non-rebreathing mask at a flow rate of 10 L/min or higher) will be randomized to helmet noninvasive ventilation with usual care or usual care alone, which may include mask noninvasive ventilation, high-flow nasal oxygen, or standard oxygen therapy. The primary outcome is death from any cause within 28 days after randomization. The trial has 80% power to detect a 15% absolute risk reduction in 28-day mortality from 40 to 25%. The primary outcome will be compared between the helmet and usual care group in the intention-to-treat using the chi-square test. Results will be reported as relative risk  and 95% confidence interval. The first patient was enrolled on February 8, 2021. As of August 1, 2021, 252 patients have been enrolled from 7 centers in Saudi Arabia and Kuwait. DISCUSSION: We developed a detailed statistical analysis plan to guide the analysis of the Helmet-COVID trial, which is expected to conclude enrollment in November 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT04477668 . Registered on July 20, 2020.