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1.
J Clin Med ; 11(15)2022 Jul 25.
Article in English | MEDLINE | ID: covidwho-1957365

ABSTRACT

We previously observed an increase of serum interleukins (IL) and a reduction of most lymphocyte subpopulations in hospitalized COVID-19 patients. Herein, we aimed to evaluate the changes in serum IL-6, IL-10, and IL-17A levels and cytometric lymphocyte profiles in 144 COVID-19 patients at admission and after one week, also in relation to steroid treatment before hospitalization. After one week of hospitalization, we found that: (i) total lymphocytes were increased in all patients; (ii) neutrophils and IL-6 were reduced in mild/moderate patients; (iii) B lymphocytes were increased in severe patients; (iv) T lymphocyte populations increased in mild/moderate patients. In the eight patients that died during hospitalization, total leukocytes increased while T, T helper, T cytotoxic, T regulatory, and NK lymphocytes showed a reducing trend in five of the eight patients. Even if seven days are too few to evaluate the adaptive immunity of patients, we found that the steroid therapy was associated with a reduced COVID-19 inflammation and cytokine activation only in patients with severe disease, while in patients with less severe disease, the steroid therapy seems to have immunosuppressive effects on lymphocyte populations, and this could hamper the antiviral response. A better knowledge of cytokine and lymphocyte alterations in each COVID-19 patient could be useful to plan better treatment with steroids or cytokine targeting.

2.
Indian Journal of Pharmaceutical Sciences ; 84(3):617-630, 2022.
Article in English | EMBASE | ID: covidwho-1957666

ABSTRACT

Drug repositioning may be a promising way to find potential therapies against coronavirus disease 2019. Although chloroquine and hydroxychloroquine showed controversial results against the coronavirus disease 2019 disease, the potential common and diverging mechanisms of action are not reported and need to be dissected for better understanding them. An integrated strategy was proposed to systematically decipher the common and diverging aspects of mechanism of chloroquine and hydroxychloroquine against coronavirus disease 2019-disease network based on network pharmacology and in silico molecular docking. Potential targets of the two drugs and coronavirus disease 2019 related genes were collected from online public databases. Target function enrichment analysis, tissue enrichment maps and molecular docking analysis were carried out to facilitate the systematic understanding of common and diverging mechanisms of the two drugs. Our results showed that 51 chloroquine targets and 47 hydroxychloroquine targets were associated with coronavirus disease 2019. The core targets include tumor necrosis factor, glyceraldehyde 3-phosphate dehydrogenase, lymphocyte-specific protein-tyrosine kinase, beta-2 microglobulin, nuclear receptor coactivator 1, peroxisome proliferator-activated receptor gamma and glutathione disulfide reductase. Both chloroquine and hydroxychloroquine had good binding affinity towards tumor necrosis factor (affinity=-8.6 and -8.4 kcal/mol, respectively) and glyceraldehyde 3-phosphate dehydrogenase (-7.5 and -7.5 kcal/mol). Chloroquine and hydroxychloroquine both had good affinity with angiotensin-converting enzyme 2, 3-chymotrypsin-like protease and transmembrane serine protease 2. However, hydroxychloroquine manifested better binding affinity with the three proteins comparing with that of chloroquine. Chloroquine and hydroxychloroquine could have potential to inhibit over-activated immunity and inflammation. The potential tissue-specific regulation of the two drugs against severe acute respiratory syndrome coronavirus 2 infection may related with the lung, liver, brain, placenta, kidney, blood, eye, etc. In conclusion, our data systematically demonstrated chloroquine and hydroxychloroquine may have potential regulatory effects on coronavirus disease 2019 disease network, which may affect multiple organs, protein targets and pathways. Routine measurements of the chloroquine and hydroxychloroquine blood concentrations and tailored therapy regimen may be essential. But, further rigorous and high quality randomized controlled clinical trials are warranted to validate the antiviral effects of chloroquine and hydroxychloroquine against severe acute respiratory syndrome coronavirus 2. Our proposed strategy could facilitate the drug repurposing efforts for coronavirus disease 2019 treatment.

3.
Turk Geriatri Dergisi ; 25(2):230-235, 2022.
Article in English | EMBASE | ID: covidwho-1957656

ABSTRACT

Introduction: To investigate the effects of the COVID-19 pandemic on epidural steroid injection treatment in elderly patients and to inform our colleagues to take possible precautions concerning treatment strategies. Materials and Methods: Retrospectively, patients who received lumbar epidural steroid injections between January 2019 and March 2021 were included in the study. The procedures performed between January 2019 and January 2020 before the pandemic were classified as Group A, and those performed during the pandemic period between March 2020 and March 2021 were classified as Group B. Demographic data, baseline pain scores, and waiting times for procedures and medical treatments in both groups were compared. Results: There were 186 and 81 patients in groups A and B, respectively. The mean age was 74 in Group B and 73 in Group A. Lumbar spinal stenosis and disc herniation were the most common diagnoses in both groups. The waiting time for epidural steroid injection was 39.4 days (0–160) in group B and 23.4 days (0–149) in group A. There was no significant difference between the two groups in terms of medical treatment for neuropathic pain. Conclusions: COVID-19 has caused a significant decrease and delay in the number of epidural procedures related to lower back pain in elderly patients. In the future, this decrease may create a burden on the health system. However, more observational and prospective studies are needed to inform our colleagues about the possible effects of COVID-19 on the elderly.

4.
Iranian Journal of Microbiology ; 14(3):276-284, 2022.
Article in English | EMBASE | ID: covidwho-1957623

ABSTRACT

Background and Objectives: Candida auris (C. auris) is the first fungal pathogen considered a global health threat. Be-cause, C. auris is associated with multidrug resistance and associated diseases such as diabetes, sepsis, lung and kidney disease. This study investigated the prevalence and mortality of C. auris infection during Covid-19 pandemic. Materials and Methods: Databases were searched for peer-reviewed articles published in the English language up to Jan 18, 2022. Heterogeneity across studies was evaluated using Cochrane’s Q test and the I2 index. The pooled point prevalences and their corresponding 95% confidence intervals (CIs) were estimated usingthe random-effects model. Results: In our meta-analysis, 11 eligible articles were included. The total pooled prevalence estimation of C. auris infection among COVID-19 patients was 13% (95% CI: 8%, 19%). The estimated pooled mortality rate of C. auris infection was 37% (95% CI: 15%, 61%). In terms of specific conditions, the pooled risk of mortality was higher in people with diabetes 65% (95% CI: 0.45%, 83%), in cases with >21 days admission inintensive care unit (ICU) 44% (95% CI: 21%, 0.68%), and after receiving steroids 43% (95% CI: 18%, 69%). Conclusion: Our study highlights the high prevalence rate of C. auris infection, particularly among people with a history of metabolic disorders.

5.
Journal of Clinical and Diagnostic Research ; 16(7):TC01-TC05, 2022.
Article in English | EMBASE | ID: covidwho-1957580

ABSTRACT

Introduction: Rhino-cerebral Mucormycosis (RCM), in the pre-Coronavirus Disease-2019 (COVID-19) era, was thought to be solely associated with an immunocompromised state. However,anunforeseenoutbreakinthenumberofmucormycosis cases was seen with the increase in Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) infection. Aim: To study and investigate the clinical characteristics, imaging findings, associated risk factors, and clinical outcomes in COVID-19 associated mucormycosis. Materials and Methods: A retrospective cohort study was conducted comprising 480 cases of COVID-19 associated mucormycosis who presented to the institution between April 2020 and September 2020. The clinical and radiological data were studied and analysed. results: Out of a total of 480 cases, 443 (92.29%) were found to suffering from diabetes mellitus and 392 patients (81.66%) had a history of steroids intake in the studied population. Facial or per orbital swelling followed by pain were the most frequent presenting complaints found in 188 (39.16%) and 162 (33.75%) patients, respectively. Nasal septum and middle turbinate were the most common sites of disease involvement on nasal endoscopic examination. On radiological imaging, maxillary (438;91.25%) was the most commonly involved sinus followed by ethmoids (395;82.29%). Premaxillary/retroantral fat and orbits were the most common sites of extra sinonasal spread of infection found in 278 (57.91%) and 244 (50.83%) patients, respectively. About 238 (49.58%) patients showed bony erosion and dehiscence. Intracranial complications were seen in 73 (15.21%) patients. Glycated Haemoglobin (HbA1c) levels showed significant value with higher disease staging. Oxygen supplementation was frequently associated with extrasinus spread of infection. A total of 44 (9.17%) patients succumbed to death despite aggressive antifungal treatment. conclusion: COVID-19 associated RCM shows frequent and extensive spread to extrasinus regions, especially with uncontrolled diabetes mellitus, steroid administration, and oxygen supplementation. High clinical suspicion, early imaging, and prompt institution of antifungal therapy can aid in reducing mortality rate.

6.
Journal of Clinical and Diagnostic Research ; 16(7):NC01-NC05, 2022.
Article in English | EMBASE | ID: covidwho-1957574

ABSTRACT

Introduction: Rhino-orbito-cerebral Mucormycosis (ROCM) is an uncommon but devastating fungal infection caused by Mucoraceae family fungi, which are angiotropic and filamentous, with significantly high morbidity and mortality despite treatment. Post Coronavirus Disease-2019 (COVID-19), there was a sudden surge in ROCM cases nationwide due to immunologically and metabolically compromised status. Aim: To describe retinal manifestations in ROCM in a tertiary eye care centre of Northern India. Materials and Methods: An analytic, cross-sectional and hospital-based study was conducted in Regional Institute of Ophthalmology, PGIMS Rohtak, Haryana, India, from May 2021 to September 2021. This study was conducted on 200 admitted patients of RCOM in the institute, which was only designated Nodal centre in Haryana, India. Detailed history was recorded in every patient regarding presenting symptoms, history of COVID-19, hospital stay, oxygen inhalation, steroid intake and immunisation. Thorough ocular examination was done in every patient including visual acuity, ocular movements and pupillary reactions. Dilated fundus examination was done by Indirect Ophthalmoscopy (IDO) for posterior segment evaluation. Contrast Enhanced Magnetic Resonance Imaging (CE-MRI) brain with orbit and Paranasal Sinus (PNS) was done in every patient to see the extent of spread and planning further management. Results: Out of 200 patients of ROCM, majority of patients (64/200) were of 51-60 year age group (32%) followed by 41-50 year age group (28%). Out of 200 cases of ROCM, 146 patients (73%) had history of COVID-19 infection in past and 134 (67%) patients had history of hospital stay during COVID-19 infection. Oxygen (O2) supplementation was given to 98 patients either at home or during hospital stay. History of steroid intake was present in 34 patients and 46 patients received injection Remedsivir. Only 12 patients had vaccine against COVID-19 and none of them were fully vaccinated. Most common presenting symptom was unilateral nasal stiffness (22%) followed by loss of vision (17%). Most common predisposing factor was Diabetes Mellitus (DM) in 78 patients (39%) followed by steroid intake in 34 patients (17%). Out of 200 patients, only 60 patients had retinal manifestations and most common was Central Retinal Artery Occlusion (CRAO) (35/60) and the main mechanism is the direct infiltration of central retinal artery due to angioinvasion of fungi from the orbit. Conclusion: CE-MRI brain with orbit is an important tool in diagnosing and monitoring progression of RCOM but it cannot provide information regarding retinal findings like CRAO, central retinal venous occlusion (CRVO), disc pallor and optic atrophy. Thus, the fundus examination of every ROCM patient should be emphasised, as it not only helps in categorising ROCM but also tells about the visual potential of affected eye. Patients with CRAO and combined vascular occlusion should be considered for exenteration on urgent basis, so that intracranial spread can be prevented and patient's life can be saved.

7.
Sexually Transmitted Infections ; 98:A25, 2022.
Article in English | EMBASE | ID: covidwho-1956902

ABSTRACT

Case A 20-year old was seen at the height of the Omicron wave of the COVID-19 pandemic with a two day history of a first episode of painful genital ulceration. Her last sexual contact was one week previously. She had no other symptoms and no medical or drug history. There was bilateral inguinal lymphadenopathy and a unilateral 1cm slightly indurated shallow vulval ulcer with slough. She was treated empirically for secondarily infected primary herpes. Three days later she presented with increased pain and negative HSV PCR and STI/ BBV tests. She had large bilateral genital ulcers (figure 1) and was admitted. Repeat swabs for HSV, VZV and syphilis were negative. She had a neutrophilia, raised CRP and negative EBV and CMV IgM. A routine nasopharyngeal swab identified SARS-CoV-2 and a full respiratory virus PCR panel was otherwise negative. She disclosed a sore throat and fevers the week before the onset of her vulval symptoms but was reassured by negative home antigen tests. She had received the second dose of an mRNA COVID-19 vaccine four months previously but no booster. She was discharged after five days and treated with a reducing course of oral steroids. At four weeks her ulcers were healing well. Discussion There are few published cases of Lipschütz ulcers associated with COVID-19 and this case adds to the burgeoning evidence of the possible dermatological manifestations of the disease and crucially it illustrates the value of prompt access to sexual health services during the pandemic. (Figure Presented).

8.
British Journal of Dermatology ; 186(6):e258, 2022.
Article in English | EMBASE | ID: covidwho-1956711

ABSTRACT

SARS-CoV-2 vaccines have been associated with various dermatological adverse events including bullous eruptions (Tomayko M, Damsky W, Fathy R et al. Subepidermal blistering eruptions, including bullous pemphigoid, following COVID-19 vaccination. J Allergy Clin Immunol 2021;148: 750- 751;Gambichler T, Boms S, Susok L et al. Cutaneous findings following COVID-19 vaccination: review of world literature and own experience. J Eur Acad Dermatol Venereol 2021;36: 172- 80). Certainly, the association could be coincidental, or it is also possible that a subclinical bullous pemphigoid (BP) was unmasked by vaccination. We present a unique case of BP-like eruption after COVID-19 mRNA vaccine that also posed a dilemma of further suitable vaccination in a patient with platelet disorder. A 57-year-old woman had her first dose of the Pfizer COVID-19 vaccine on 2 February 2021 on her left arm and within 24 h of receiving it she developed bruising of the entire arm. The patient was hospitalized for further investigations when she developed a bullous rash on her left arm that eventually involved her face and legs. Treatment with systemic steroids was commenced. Owing to her complex medical history including platelet disorder and Ehlers-Danlos syndrome, we were posed with a dilemma of a further suitable vaccination. After a multidisciplinary team meeting, the patient has been encouraged to receive a Moderna vaccine for the second dose. Clinicians should be aware of BP-like disease that may develop after COVID-19 mRNA vaccination. However, with the underlying cause of BP being uncertain, the rarity of its occurrences and the greater risks of SARS-CoV-2 infection, it is important to encourage full vaccination including completion in those with blisters after the first dose. Further studies are required to study the natural history of BP-like disease associated with the COVID-19 vaccines.

9.
British Journal of Dermatology ; 186(6):e246, 2022.
Article in English | EMBASE | ID: covidwho-1956707

ABSTRACT

With the outbreak of the emergent coronavirus, there have been sparse reports of severe cutaneous adverse reactions in some severely ill patients (Chen XY, Yan BX, Man XY. TNFα inhibitor may be effective for severe COVID-19: learning from toxic epidermal necrolysis. Ther Adv Respir Dis 2020;14: 1753466620926800). It is thought that this is due to clonal expansion of CD8+ cytotoxic T lymphocytes and natural killer cells that occurs during the cytokine storm elicited by the virus or the use of unconventional drugs to treat patients (Rossi CM, Beretta FN, Traverso G et al. A case report of toxic epidermal necrolysis (TEN) in a patient with COVID-19 treated with hydroxychloroquine: are these two partners in crime? Clin Mol Allergy 2020;18: 19;Saha M, D'Cruz A, Paul N et al. Toxic epidermal necrolysis and co-existent SARS-CoV-2 (COVID-19) treated with intravenous immunoglobulin:'Killing 2 birds with one stone'. J Eur Acad Dermatol Venereol 2020;35: e97-8). In a minority of cases, viral or autoimmune forms of toxic epidermal necrolysis (TEN) may be implicated (Chen et al.;Rossi et al.). However, very little research, has been done to decipher the association or pathogenesis with TEN and the novel virus. We report an interesting case of a 51-year-old woman who developed a rash on her face, flanks and periumbilical area immediately after an intensive care admission with respiratory failure secondary to confirmed COVID-19 pneumonitis. The patient had a background of gout on allopurinol and type 2 diabetes. There were no changes in medications. While admitted, she was started on broad spectrum antibiotics. On examination, there were large, confluent patches of erythema with a targetoid appearance on the face, upper limbs and trunk, and tense blistering over the forearms. Biopsy showed full thickness epidermal necrosis and subepidermal bullous formation. An autoimmune and bullous screen was negative. Prognosis was poor with the critical care team considering end-of-life management. However, with the diagnosis of a reversible condition, supportive therapy was continued. With continued intensive care intervention, steroids and barrier protection, her TEN gradually resolved as she recovered from COVID-19, and she had a favourable outcome with only residual milia and signs of re-epithelialization.

10.
British Journal of Dermatology ; 186(6):e245, 2022.
Article in English | EMBASE | ID: covidwho-1956705

ABSTRACT

A 17-year-old-male presented to an acute medical take with severe mouth pain, and poor oral intake. This occurred 6 days after a positive SARS CoV-2 test, with which he had only mild symptoms. He was unvaccinated against SARS CoV-2. Clinically, he had a severe ulcerated mucositis present on his lips, buccal mucosa and lateral edge of the tongue. He had not been commenced on any new medications prior. There was no other skin involvement. Viral swabs for herpes simplex virus and varicella zoster virus were negative. His presentation was in keeping with a reactive infectious mucocutaneous eruption (RIME) secondary to COVID-19 infection. This typically presents with severe painful mucositis with mild nonspecific skin manifestations. This entity was previously classically described in association with Mycoplasma infection. Since the emergence of COVID-19, several cutaneous manifestations have been observed. There is only one other published case of RIME associated with COVID-19 infection. This was in a similarly aged male presenting with severe mucositis and lack of significant cutaneous involvement. The patient was treated with a 5-day course of 40 mg oral prednisolone, which led to complete resolution with no scarring or subsequent recurrence. A literature review revealed only one other case of RIME associated with COVID-19, which was successfully treated with oral steroid therapy. The case exemplifies new, emerging presentations related to COVID-19 infection that may present to dermatology services.

11.
British Journal of Dermatology ; 186(6):e248, 2022.
Article in English | EMBASE | ID: covidwho-1956704

ABSTRACT

A 58-year-old man known to dermatology services, established on guselkumab for psoriasis and methotrexate for psoriatic arthritis, attended with an acute onset purpuric rash distributed over both his lower limbs, one day after his third dose of SARS-CoV-2 Pfizer-BioNTech vaccine (booster). He had received his initial vaccinations 6 months prior with no reported reactions. He denied any previous SARS-CoV-2 infection or recent symptoms suggestive of COVID-19. There had been no new recent medications and no systemic symptoms were reported. Examination revealed a nonblanching, palpable, purpuric rash distributed over both lower limbs, clinically in keeping with cutaneous vasculitis. Baseline observations were satisfactory including blood pressure and temperature. Bedside investigations included a urinalysis which revealed no proteinuria or haematuria. Punch biopsies were taken and were consistent with a leucocytoclastic vasculitis (LCV). He was managed symptomatically with potent topical steroids with good clinical response. LCV is classified as a cutaneous, small vessel vasculitis, exclusively characterized by deposition of immune complexes in the dermal capillaries and venules (Baigrie D, Bansal P, Goyal A, Crane JS. Leukocytoclastic vasculitis. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing, 2021). LCV following both first and second SARS-CoV-2 vaccinations has been documented in recent literature with a few reports following a third booster dose, and in particular within an immunocompromised population. This particular case has raised questions regarding delayed immune response following SARS-CoV-2 vaccine in this subgroup. The pathophysiology of SARS-CoV-2 vaccine-induced LCV has not been extensively researched;however, it is felt to be caused by offtarget immune activation after the vaccination (Dicks AB, Gray BH. Images in vascular medicine: leukocytoclastic vasculitis after COVID-19 vaccine booster. Vasc Med 2022;27: 100-1).

12.
British Journal of Dermatology ; 186(6):e253, 2022.
Article in English | EMBASE | ID: covidwho-1956703

ABSTRACT

We present the case of a severe cutaneous reaction following COVID-19 vaccination. A 60-year-old white woman presented to our service with an extensive painful, pruritic rash affecting her bilateral lower limbs. This was on a background of psoriasis, psoriatic arthritis and notably inoculation against COVID-19 with the Johnson & Johnson vaccine hours prior to onset. There was no history of new medications, illicit drug use or infections. On examination, extensive palpable purpura was noted circumferentially at both lower limbs from the knee distally. Tense bullae were described at her bilateral ankles. She was apyrexial. Her cardiopulmonary and gastrointestinal examinations were normal. A punch biopsy taken from her right lower limb demonstrated findings consistent with leucocytoclastic vasculitis (LCV). Direct immunofluorescence demonstrated IgA deposits within the vasculature. IgA LCV secondary to COVID-19 vaccination was proposed on the basis of histological and clinical findings. Treatment consisted of oral steroids, oral antibiotics for secondary infection and wound dressings. Opioid analgesia and nitrous oxide were implemented for severe pain associated with dressing changes. As her urinary protein creatinine ratio was in excess of 100 mg dL-1 and microscopic haematuria was noted on urine microscopy, she was referred to nephrology. We note case reports of patients diagnosed with LCV up to 2 weeks following COVID-19 vaccination (Cavalli G, Colafrancesco, De Luca G et al. Cutaneous vasculitis following COVID- 19 vaccination. Lancet Rheumatol 2021;3: E743-4). In this case, onset of symptoms occurred within hours. While this presentation may have been coincidental, the relationship between immune complex vasculitis, COVID-19 infection (Iraji F, Galehdari H, Siadat AH, Bokaei Jazi S. Cutaneous leukocytoclastic vasculitis secondary to COVID-19 infection: a case report. Clin Case Rep 2020;9: 830-4) and vaccination (Cavalli et al.) has been reported in the literature and represents the most likely diagnosis.

13.
British Journal of Dermatology ; 186(6):e250-e251, 2022.
Article in English | EMBASE | ID: covidwho-1956700

ABSTRACT

Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 infection (PIMS-TS) is a novel condition which has recently emerged during the COVID-19 pandemic, consisting of persistent fever, inflammation, and evidence of single- or multiorgan dysfunction, with additional features where any other microbial causes has been excluded (https://www.rcpch.ac.uk/resources/paediatric-multisysteminflammatory- syndrome-temporally-associated-covid-19-pimsguidance). A 16-year-old healthy male presented with a 48-h history of headache, fever, diarrhoea, vomiting and a widespread rash. One month prior he had contracted SARS-CoV-2 with no complications. On examination there was a maculopapular rash across the trunk and buttocks with petechiae present on the lower limbs and flexural folds in addition to an erythematous rash across the nasal dorsum and cheeks. Blood tests revealed lymphopaenia, thrombocytopenia, hypertriglyceridaemia and raised C-reactive protein and ferritin. Autoimmune screen and SARS-CoV-2 polymerase chain reaction tests were negative. A skin biopsy revealed features of a SARS-CoV-2 related urticarial reaction pattern. The patient was treated for myocarditis, fulfilling the diagnosis of PIMS-TS. He was transferred to a specialist intensive care unit and treated with intravenous immunoglobulins and steroids, infliximab, aspirin and topical steroids. He is currently undergoing investigations for encephalitis post admission. PIMS-TS is a rare syndrome that shares features with Kawasaki disease, toxic shock syndrome, macrophage activation syndrome and bacterial sepsis. Haemophagocytic lymphohistiocytosis has also been linked to SARS-CoV-2 (Retamozo S, Brito-Zerón P, Sisó- Almirall A et al. Haemophagocytic syndrome and COVID-19. Clin Rheumatol 2021;40: 1233-44). Clinicians should consider PIMS-TS as a differential in any child presenting with a fever, rash and evidence of systemic inflammation. Early recognition, involvement of a multidisciplinary team and prompt referral to critical care is essential in managing this life-threatening condition.

14.
British Journal of Dermatology ; 186(6):e255, 2022.
Article in English | EMBASE | ID: covidwho-1956699

ABSTRACT

A 13-year-old boy presented with oral pain and mucositis on a background of preceding sore throat, fever and malaise. His lips were swollen and ulcerated with tonsillar exudate visible. Reverse transcriptase polymerase chain reaction testing for SARS-CoV-2 was positive, and inflammatory markers were raised (C-reactive protein 77 mg L-1, erythrocyte sedimentation rate 31 mm h-1);additional virology (herpes simplex virus, cytomegalovirus, Epstein-Barr virus and HIV) was negative. Intravenous fluids, ceftriaxone, acyclovir and analgesia including morphine were commenced. He was unable to tolerate soluble oral steroid rinses. Over 24 h, his oral mucositis progressed with the additional development of conjunctival injection and nontargetoid, erythematous papules. A diagnosis of erythema multiforme (EM) major in conjunction with COVID-19 infection was made. His condition deteriorated with oral intubation required to maintain airway patency and deep sedation for pain control. During a 13-day paediatric intensive care admission he developed an extensive rash including ulceration of the external genitalia. There was marked ulceration of the trachea but fortunately tracheostomy was avoided. The patient has subsequently recovered well. A variety of cutaneous features, including EM, have been described in conjunction with COVID-19 infection. The incidence of distinct rashes varies between adults and children with EM uncommon in both groups but seemingly more frequent in paediatric patients (Bennardo L, Nistoc®o SP, Dastoli S et al. Erythema multiforme and COVID-19: what do we know? Medicina (Kaunas) 2021;57: 828). The relationship of EM to outcome from COVID-19 infection itself is yet to be fully established. As with other infections, EM in children with COVID-19 exhibits a range of clinical presentations. This case highlights the severe end of the disease spectrum and underlines the role of the multidisciplinary team in management.

15.
British Journal of Dermatology ; 186(6):e252-e253, 2022.
Article in English | EMBASE | ID: covidwho-1956698

ABSTRACT

Since the approval of vaccines for SARS-CoV-2, dermatologists have sought to characterize the adverse cutaneous effects associated with those vaccines. We describe two cases of pityriasis rubra pilaris (PRP) following vaccination against COVID-19. A 51-year-old man initially developed an erythematous scaly rash in his groin and over his knees 3 days following the first dose of the Pfizer COVID-19 vaccine. He presented after the second dose, as the rash worsened, affecting 60% body surface area (BSA). On examination there was an erythematous skin eruption extending from his scalp to both arms and the proximal thighs with sparing of the periumbilical area. There was no evidence of palmoplantar hyperkeratosis. The second case is a 51-year-old man presented with an itchy, erythematous rash affecting >80% BSA, 2 days after his first dose of the AstraZeneca COVID-19 vaccine. On examination there were multiple erythematous annular plaques, some of which were becoming more confluent, with islands of sparing. There was no evidence of palmoplantar hyperkeratosis. Differential diagnosis in both included drug-induced psoriasis and PRP. Histopathological diagnosis was consistent with PRP. Management of both cases included ruling out occult malignancy and infectious causes. Both patients were treated with acitretin and topical steroids. It is important to recognize this serious adverse event early so appropriate treatment can be initiated. When the culprit is the COVID-19 vaccine, typical features like palmoplantar hyperkeratosis may not be present. If PRP occurs after the first dose then discussion with the patient, weighing the risks and benefits including worsening of disease compared with the possibility of severe disease/death from COVID-19, is needed.

16.
British Journal of Dermatology ; 186(6):e252, 2022.
Article in English | EMBASE | ID: covidwho-1956690

ABSTRACT

A 44-year-old man of Pakistani origin presented to emergency 6 days following his first dose of the AstraZeneca (AZ) SARSCoV- 2 vaccine. He developed flu-like symptoms followed by erythematous pruritic rash. Physical examination showed a maculopapular rash associated with purpura and targetoid lesions affecting his distal extremities, trunk and mucous membranes. He also had crusting and ulceration of his oral and genital mucosal areas. He had no other significant past medical history. A biopsy was taken from his right arm and sent for urgent histology and direct immunofluorescence. Histology revealed parakeratotic scale with interface dermatitis comprising basal layer vacuolation and lymphocyte exocytosis. The epidermis showed prominent dyskeratotic keratinocytes scattered throughout the epidermis. The papillary dermis showed a mild perivascular lymphocytic infiltrate including eosinophils and melanophages. Other investigations showed leucocytosis (12 × 109 L-1), high eosinophils (0.9 × 109 L-1), raised liver enzymes with alkaline phosphatase 159 U L-1 and alanine aminotransferase 172 U L-1. A full infection screen, including herpes simplex virus, SARS-CoV-2 and atypical viral infection, was negative. Immunology was also reported as negative. Based on the findings, a diagnosis of erythema multiforme (EM) secondary to AZ vaccine was made. He was treated with topical steroids and emollients, leading to resolution of his skin and mucosal areas in 4-6 weeks. Recently, there have been a few reported cases of EM in patients with COVID-19 (Jimenez-Cauhe J, Ortega-Quijano D, Carretero- Barrio I et al. Erythema multiforme-like eruption in patients with COVID-19 infection: clinical and histological findings. Clin Exp Dermatol 2020;45: 892-5) and two patients who have had the Pfizer-BioNTech vaccine [Kim M, Kim J, Kim M et al. Generalized erythema multiforme-like skin rash following the first dose of COVID-19 vaccine (Pfizer-BioNTech). J Eur Acad Dermatol Venereol 2021], but the information is limited. Our case emphasizes the need for further studies into the cutaneous adverse effects related to COVID-19vaccines.

17.
BJOG: An International Journal of Obstetrics and Gynaecology ; 129:113, 2022.
Article in English | EMBASE | ID: covidwho-1956651

ABSTRACT

Objective: PLGF point of care blood test is a NICE validated tool recommended between 20 and 34+6 weeks gestation to diagnose and predict early onset of preeclampsia. During the Covid pandemic, we pioneered and assessed the clinical utility of this point of care blood test in NHS Wales by doing a pilot study of 6 months at our district hospital with 2700 deliveries/annum. Design: Prospective study Method: Patients presenting at maternity day assessment unit with new onset hypertension, proteinuria or worsening chronic hypertension were selected. This simple point of care blood test with a turnaround time of 15 minutes was conducted by the triage midwife at the bedside. Patients were classified into red (<12 pg./ml), amber (≥12-< 100 pg./ml) and green (≥100 pg/ml) alert groups. We interpreted our results using the PARROT trial flowchart and clinical decisions were made based on the risk stratification and overall clinical picture. Results: Cases in the Red alert group and high blood pressure were admitted and to our surprise all 6 cases developed severe preeclampsia (3 of which developed HELLP) within the same week. They were delivered after stabilization of blood pressure and prophylactic steroids for the preterm fetus. The amber group was managed with increased outpatient surveillance until a maximum of 37 -38 weeks. Using the reported high negative predictive value of 97.5% in the green group (PARROT trial), we could reassure 64% of the green group patients to prolong the pregnancy without inpatient admission and continue antenatal care till term. Our cohort experience of 34 patients found that overall 68% of the cases were managed with outpatient surveillance. Conclusions: PLGF is now incorporated into our routine practice. The amber to green risk stratification helped in reducing unnecessary inpatient admissions and improved patient experience by alleviating maternal anxiety. There were no stillbirths and it prevented iatrogenic preterm deliveries by giving clinicians reassurance in their decisions. The Red alert group with PLGF <12 pg./ml, was highly suggestive of placental dysfunction needing early delivery. The Amber alert group (with the PLGF ≥12 and <100 pg/ml) may be cared with increased outpatient surveillance. Those patients in the Green alert group (with the PLGF ≥100 pg./ml) were reassured and cared for till term, if possible. The underlying caveats always being PLGF was always supplemented by a complete clinical evaluation to determine early prediction and management of pre-eclampsia.

18.
European Journal of Clinical Pharmacology ; 78:S99-S100, 2022.
Article in English | EMBASE | ID: covidwho-1955954

ABSTRACT

Introduction: Human steroid 5α-reductase 2 (SRD5A2) coded by SRD5A2 gene is an enzyme that catalyzes the reduction of testosterone to dihydrotestosterone. Dutasteride, an SRD5A2 inhibitor, is a widely used antiandrogen for the treatment of benign prostate hyperplasia. Multiple variations have been identified in the SRD5Ar gene. Some of these variations may affect the efficacy and safety of SRD5A2 inhibitors. Dutasteride has also been investigated for intermediate and high-risk nonmuscle- invasive urothelial bladder cancer treatment with the combination of BCG (Bacillus Calmette-Guerin). Objectives: The study aims to evaluate the potential impact of V89L (rs523349) and A49T (rs9282858) variations on the SRD5A2 gene on dutasteride efficacy and safety in bladder cancer patients that have been enrolled in Phase 2 clinical trial entitled 'Efficacy and safety of a 5-alpha reductase inhibitor, dutasteride, added to Bacillus Calmette Guerin (BCG) immunotherapy in the prevention of recurrence and progression of intermediate and high risk non-muscle invasive bladder cancer: A single-arm, Phase 2 clinical trial' Methods: Twenty-one patients on BCG and dutasteride in the Phase 2 clinical trial were included in the study. Genomic DNA was obtained from whole blood samples, and evaluation of V89L (rs523349) (G>C) and A49T (rs9282858) (C>T) variations on the SRD5A2 gene was performed by using TaqMan SNP Genotyping Assay. The severity of the adverse events was graded by the United States National Cancer Institute- Common Terminology Criteria for Adverse Events 5.0. The causality assessment of adverse drug reactions was performed using Liverpool Causality Assessment Tool, Naranjo Algorithm, and World Health Organization-Uppsala Drug Monitoring Centre Causality Assessment System. The response to dutasteride was evaluated as the presence of bladder cancer recurrence. The Chi-Square test was used for testing the relationship between categorical variables. P values of <0.05 were considered significant. Results: All patients were homozygous GG for V89L variation on the SRD5A2 gene. Regarding the A49T variation, only one patient was homozygous CC, 8 patients were homozygous TT and 12 patients were heterozygous TC. One of the 8 patients (%12) was homozygous TT and 3 of 12 patients (%25) were heterozygous TC had bladder cancer recurrence. There was no statistically significant difference between bladder cancer recurrence and A49T variation (p=0.803). None of the adverse events were associated with dutasteride treatment whereas some of the adverse events, mostly urinary tract infections, were associated with the BCG. Other adverse events were upper respiratory tract infections, COVID-19, abdominal pain, vomiting, and loss of appetite. Serious adverse events were coronary artery disease, dyspnea, hypotension, and urethral stricture. None of the serious adverse events were associated with dutasteride or BCG treatment. Conclusion: Neither V89L nor A49T variation on the SRD5A2 gene was found to be associated with the efficacy and safety of dutasteride in medium and high-risk bladder cancer patients. Further studies of these variations with larger sample sizes and/or healthy control groups may lead to a better understanding of the impact of these variations on the efficacy and safety of dutasteride.

19.
International Journal of Pharmaceutical and Clinical Research ; 14(6):720-727, 2022.
Article in English | EMBASE | ID: covidwho-1955696

ABSTRACT

Background: Due to the inclusion of respiratory tract and aerosol-generating procedures, oral and maxillofacial surgery (OMFS) is regarded one of the high-risk specialty. COVID19's impact on inpatient illness patterns and operations in OMFS, on the other hand, has yet to be investigated. Aim: To look at the effect of COVID-19 on disease patterns in OMFS inpatients, as well as to identify context-relevant important services in the OMFS field for future policy and resource distribution considerations. Methods and Materials: A total of 149 patients were included in the study after obtaining written informed consent from the relatives of patients. RT-PCR tests were carried out for all the study participants included in the study. Further there was collection of data regarding the stay in hospitals, administration of antifungal drugs like injection amphotericin, pocasonazole and tablet pocasonazole. Then there was tabulation of data regarding various surgical interventions carried out. There was comparison of these data between the COVID and non COVID patients. Results: When there analysis of study participants in which administration of oxygen was carried out then it was found that 49.23% of study participants getting oxygen were NON COVID patients while 50.77% of such study participants were COVID patients. The difference was not significant statistically. When there analysis of study participants in which administration of steroids was carried out then it was found that 45.56% of study participants getting steroids were NON COVID patients while 54.54% of such study participants were COVID patients. The difference was significant statistically. When there analysis of study participants who got discharged from hospital then it was found that 60.42% of study participants getting normal were NON COVID patients while 39.58% of such study participants were COVID patients. The difference was significant statistically Conclusion: In a comparative investigation, we first provided epidemiological findings on the effect of COVID19 on oral and maxillofacial surgery illness pattern. During the pandemic, the shift in illness pattern and burden will have a long-term influence on OMFS patient care, education, and training. Our research provides data for health policymakers to think about relocating medical resources and improving medical education and services.

20.
Intern Med ; 61(9): 1403-1410, 2022 May 01.
Article in English | MEDLINE | ID: covidwho-1951859

ABSTRACT

We present three cases with an atypical clinical course of organizing pneumonia (OP) secondary to coronavirus disease 2019 (COVID-19). Three patients were discharged with satisfactory improvement after standard steroid therapy for COVID-19. Shortly after the completion of treatment, the patients experienced a flare-up of symptoms. Imaging results showed new lesions in the lungs. Transbronchial lung cryobiopsy showed histological findings consistent with OP in all cases. Steroids were administered, and a good therapeutic response was observed. This report is the first to describe pathologically confirmed OP that developed after recovery from COVID-19. Careful follow-up is advisable for patients who have recovered from COVID-19.


Subject(s)
COVID-19 , Cryptogenic Organizing Pneumonia , Pneumonia , Cryptogenic Organizing Pneumonia/diagnosis , Humans , Lung/diagnostic imaging , Lung/pathology , Pneumonia/drug therapy
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