Metabolic Disease and The Risk of Post-COVID Conditions: A Retrospective Cohort Study (preprint)

Objective: To examine the influence of having a baseline metabolic disorder (diabetes, hypertension, and/or obesity) on the risk of developing new clinical sequelae potentially related to SARS-CoV-2 in a large sample of commercially insured adults in the US. Design, setting, and participants Deidentified data were collected from the IBM/Watson MarketScan Commercial Claims and Encounters (CCAE) Databases and Medicare Supplemental and Coordination of Benefits (MDCR) Databases from 2019 to 2021. A total of 839,344 adults aged 18 and above with continuous enrollment in the health plan were included in the analyses. Participants were grouped into four categories based on their COVID-19 diagnosis and whether they had at least one of the three common metabolic disorders at baseline (diabetes, obesity, or hypertension). Measures and methods ICD-10-CM codes were used to determine new symptoms and conditions after the acute phase of SARS-CoV-2 infection, defined as ending 21 days after initial diagnosis date, or index period for those who did not have a COVID-19 diagnosis. Propensity score matching (PSM) was used to create comparable reference groups. Cox proportional hazard models were conducted to estimate hazard ratios and 95% confidence intervals. Results Among the 772,377 individuals included in the analyses, 36,742 (4.8%) without and 20,912 (2.7%) with a baseline metabolic disorder were diagnosed with COVID-19. On average, COVID-19 patients with baseline metabolic disorders had more 2.4 more baseline comorbidities compared to those without baseline metabolic disorders. Compared to adults with no baseline metabolic condition, the risks of developing new clinical sequelae were highest among COVID-19 patients with a baseline metabolic condition (HRs ranging from 1.51 to 3.33), followed by those who had a baseline metabolic condition but with no COVID-19 infection (HRs ranging from 1.33 to 2.35), and those who had COVID-19 but no baseline metabolic condition (HRs ranging from 1.34 to 2.85). Conclusions In a large national cohort of commercially insured adults, COVID-19 patients with a baseline metabolic condition had the highest risk of developing new clinical sequelae post-acute infection phase, followed by those who had baseline metabolic condition but no COVID-19 infection and those who had COVID-19 but no baseline metabolic disorder.

The practice of drug emergency supply in China from a policy mix perspective (preprint)

Background This study aims to analyze relevant policy texts, explore and determine the focal points and inadequacies of the Chinese government in guaranteeing supplies of medicines, and provide advice on how to make better policies about drug supply when public health emergencies occur.Methods We selected 559 documents that guided the support of drug supply during emergencies issued by governments at both the national and provincial levels from December 1, 2019, to February 28, 2023. In addition, we developed a four-dimensional analysis framework of the issuing agency, issuing period, policy tools, and drug supply chain to analyze specific policy items, determine their basic characteristics, and quantitatively analyze them from a policy mix perspective.Results The analysis using policy tools showed that the national government tended to call on stakeholders in all aspects of drug supply to fulfil their responsibilities, and both national and provincial governments tended to use incentive tools, such as opening up urgent drug supply tracks and applying financial incentives to promote drug supply. However, managing stakeholders’ behaviors in drug supply and the capacity building to guarantee drug supply are still lacking and require improvement. From the perspective of the drug supply chain, the national government has paid much attention to the distribution of drugs, whereas attention to the supply of drug substances has been lacking. As various stages of the COVID-19 pandemic, the number of policies related to drug supply increased slowly after a surge at the beginning of the pandemic and then rapidly decreased. From the policy mix perspective, the analysis showed that incentives were lacking in drug research and development, and capacity building was not discussed much in the drug manufacturing process.Conclusions We suggest enhancing the complementarity and cohesion of the policy content issued by national and provincial governments, strengthening the coordination and connection between policymaking bodies, optimizing the internal structure of policy tools, improving the performance of various policy strategies, and using appropriate policy tools to create policies suited to various stages of emergencies and drug supply chains.

Management of patients with Long Covid: A qualitative study exploring the roles of nurses in healthcare pathways (preprint)

Aim Investigate the various roles played by nurses in the care of patients afflicted with Long COVID. Background Effectively managing Long Covid requires a multidisciplinary approach - a healthcare pathway that necessitates collaboration among various members of the medical profession to monitor the patient. Among these professions, nursing plays a crucial role. This article compiles information on how nurses are involved in the care of patients afflicted with Long Covid: What roles do they play in enhancing the care of these patients? Are these roles distinct from those they perform in other chronic conditions? Methods We conducted a qualitative study among healthcare professionals in France and enrolled eighteen participants in our study. Semi-structured interviews were conducted with professionals working across various care sectors in France, including private practice, hospitals, schools, and research. A thematic content analysis was performed, and emerging themes were subsequently discussed until the most significant categories were identified. This study was conducted in accordance with the COREQ checklist. Results Nurses play a wide range of roles within their practices, depending on their practice settings. For instance, a nurse practitioner may work in a range of settings such as hospital outpatient clinics, private group practices, inpatient units, or urgent care units. Depending on their work environment, nurses' roles within healthcare pathways may encompass screening and guidance, clinical patient monitoring, providing relational support, patient education, collaborative care and coordination as well as involvement in research. Conclusion The predominant role identified in our study involves coordinating the management of the Long Covid syndrome. The next step would be the implementation of a city-hospital Long Covid healthcare pathway. Implication for the Nursing & Health Policy Perspectives Nursing work is difficult to specify, as it includes numerous recognised and unrecognised aspects. The results of this study highlight a new essential role which is that of coordinating the health pathways of patients suffering from Long Covid.

Extended Duration and Intense Manifestations of COVID-19-Linked Cytotoxic Lesions of the Corpus Callosum: Case Reports and Literature Review (preprint)

While clinical instances of cytotoxic lesions of the corpus callosum (CLOCCs) are well-documented, international reports specific to COVID-19-related cases remain limited. This paper presents the case of a 40-year-old female patient admitted due to "sudden dizziness and poor limb coordination for 7 weeks following fever." She tested positive for COVID-19 and experienced symptoms like dizziness, temporary confusion, nausea, vomiting, cerebellar speech issues, and ataxia after fever onset. Later, she developed pyramidal tract symptoms and behavioral abnormalities. Head MRI revealed abnormal high signal in the splenium of the corpus callosum and abnormal signals in the left cerebellar peduncle on DWI. With no significant medical history and exclusion of other causes during treatment (including steroid therapy and two doses of intravenous immunoglobulin), a follow-up MRI after one month showed the lesions had disappeared. However, clinical recovery was slow, with residual symptoms persisting for almost a year, including involuntary tremors in the upper limbs and head. Phenytoin, gabapentin, and pregabalin showed limited effectiveness in treatment, but Arotinolol and donepezil led to slight improvement in involuntary tremors. This case suggests that COVID-19-associated CLOCCs might have a protracted course and severe symptoms, demanding differentiation from ischemic cerebrovascular diseases, particularly in early stages.

The macroeconomic and epidemiological impacts of Covid-19 in Pakistan. (preprint)

'Coronavirus Disease 2019' (C19) is a respiratory illness caused by 'new Coronavirus' SARS-CoV-2. The C19 pandemic, which engulfed the world in 2021, also caused a national C19 epidemic in Pakistan, who responded with initial forced lockdowns (15-30 March 2020) and a subsequent switch to a smart lockdown strategy, and, by 31 December 2020, Pakistan had managed to limit confirmed cases and case fatalities to 482,506 (456 per 100,000) and 10,176 (4.8 per 100,000). The early switch to a smart lockdown strategy, and successful follow-up move to central coordination and effective communication and enforcement of Standard Operating Procedures, was motivated by a concern over how broad-based forced lockdowns would affect poor households and day-labour. The current study aims to investigate how the national Pakistan C19 epidemic would have unfolded under an uncontrolled baseline scenario and an alternative set of controlled non-pharmaceutical intervention (NPI) policy lockdown scenarios, including health and macroeconomic outcomes. We employ a dynamically-recursive version of the IFPRI Standard Computable General Equilibrium model framework (Lofgren, Lee Harris and Robinson 2002), and a, by now, well-established epidemiological transmission-dynamic model framework (Davies, Klepac et al 2020) using Pakistan-specific 5-year age-group contact matrices on four types of contact rates, including at home, at work, at school, and at other locations (Prem, Cook & Jit 2017), to characterize an uncontrolled spread of disease. Our simulation results indicate that an uncontrolled C19 epidemic, by itself, would have led to a 0.12% reduction in Pakistani GDP (-721mn USD), and a total of 0.65mn critically ill and 1.52mn severely ill C19 patients during 2020-21, while 405,000 Pakistani citizens would have lost their lives. Since the majority of case fatalities and symptomatic cases, respectively 345,000 and 35.9mn, would have occurred in 2020, the case fatality and confirmed case numbers, observed by 31. December 2020 represents an outcome which is far better than the alternative. Case fatalities by 31. December 2020 could possibly have been somewhat improved either via a more prolonged one-off 10 week forced lockdown (66% reduction) or a 1-month forced lockdown/2-months opening intermittent lockdown strategy (33% reduction), but both sets of strategies would have carried significant GDP costs in the order of 2.2%-6.2% of real GDP.

Neuroblastic Tumor Recurrence Associated With Opsoclonus Myoclonus Ataxia Syndrome Relapse a Decade After Initial Resection and Treatments.

Opsoclonus myoclonus ataxia syndrome (OMAS) is a rare disorder that causes significant neurodevelopmental sequelae in children. Approximately half of pediatric OMAS cases are paraneoplastic, typically associated with localized neuroblastic tumors. Since early persistence or relapse of OMAS symptoms is common even after tumor resection, OMAS relapses may not routinely prompt reevaluation for recurrent tumors. We report a 12-year-old girl with neuroblastic tumor recurrence associated with OMAS relapse a decade after initial treatment. Providers should be aware of tumor recurrence as a trigger for distant OMAS relapse, raising intriguing questions about the role of immune surveillance and control of neuroblastic tumors.

How Did the COVID-19 Pandemic Affect Audit Fees and Delays? (preprint)

We investigate the association of location-specific severity of the 2019 Coronavirus pandemic (COVID) with changes in audit fees and delays following the pandemic’s onset. Employing data on lengths of stay-at-home (S@H) mandates to proxy for COVID’s disrupting effects on audits, we find that audit fees did not change in response to initial S@H mandates. However, S@H is positively associated with increases in audit delays and in the likelihood of late filings. We drill down to explore three underlying mechanisms that can directionally moderate the associations between lengths of S@H and changes in the audit outcomes: increased audit risk, auditors’ likely reliance on virtual auditing tools, and difficulties in audit team coordination, and find results consistent with our expectations. Our findings are important for understanding the pandemic’s effect on audits and have implications for future audits in regard to virtual auditing and audit team coordination.

Evaluation of Core Coordination Strategies and Concept of Operations implemented during activation of Public Health Emergency Operations Center for COVID-19 Response in Pakistan (preprint)

Background: Public health emergency management systems encountered difficulties in developing countries, especially in Pakistan. The COVID-19 pandemic was extremely challenging for different agencies, departments, and institutions in Pakistan. Public health emergency management depends on a well-established public health emergency operations center that could generate a coordinated response to escalated incidents. We conducted an assessment of public health emergency response and coordination implemented during the COVID-19 pandemic management at a strategic level in Pakistan. Methods: This was mix-method study including qualitative and quantitative data collection processes implemented in 2022-23. Primary data was collected by using a structured questionnaire, and secondary data was collected by desk review. The agencies engaged in pandemic response at the national level in Pakistan were included in the assessment. Results: The overall score of the emergency response coordination system during COVID-19 was 49% for all agencies. We found that agencies faced challenges in leadership, legislation, and financing issues during the pandemic response (44%). None of the agencies had a fully developed framework for joint planning and response system for health emergencies. Roles and responsibilities attached to designated agencies in response were relatively clear (55%) for most of the agencies. Conclusion: An effective public health emergency response is based on multi-departmental coordination, resource mobilization, and correct information. Pakistan must proactively address these and other relevant challenges for future pandemic response.

Cerebral Venous Sinus Thrombosis After a Third Dose of mRNA COVID-19 Vaccine in an Adolescent: A case report (preprint)

Background: Several effective vaccines against Coronavirus disease 2019 (COVID-19) have been developed to control the spread of the disease. A few cases of thrombosis have been reported post-vaccination, especially among young adult women immunized with viral vector-based vaccines; although pediatric cases of cerebral venous sinus thrombosis (CVST) have been rarely reported after messenger ribonucleic acid (mRNA) vaccine administration. Case presentation: Here, we report a case of CVST in a 14-year-old girl immunized with the BNT16B2b2 vaccine. Other than this recent COVID-19 vaccination, there were no precipitant risk factors in her medical history. Laboratory work-up showed low levels of protein S activity. Further research revealed no pathological gene mutation. She was treated with anticoagulant therapy and discharged with mildly impaired coordination/movement of the fingers. Conclusion: CVST may occur following a mRNA COVID-19 vaccination, even among children. Further investigations are needed to establish whether thrombotic events are merely incidental or are a complication associated with mRNA-based vaccines.

Midwife-led Pandemic Telemedicine Services for Maternal Health and Gender-Based Violence Screening in Bangladesh: An Implementation Research Case Study (preprint)

Background The COVID-19 pandemic disrupted maternal and newborn health services in Bangladesh, increasing the large gaps in service utilization that existed prior to the pandemic. As part of its response, Bangladesh initiated remote antenatal and postnatal care telemedicine services led by midwives in 36 sub-district hospitals across five of Bangladesh’s 64 districts. Gender-based violence screening and referral were integrated into the service to address a reported rise in violence following the country’s pandemic lockdown.Methods Mixed-methods implementation research was used to develop a case study describing the design and implementation of the telemedicine program. Qualitative analysis comprised document review, key informant interviews, and focus group discussions. Quantitative analysis employed descriptive statistics to compare service use trends before and after implementation.Results Challenges included the unanticipated need to introduce a scheduling system in all intervention hospitals and that many women were not reachable by phone due to lack of access or network coverage. Some women were also reluctant to discuss gender-based violence. However, maternity care service use increased, with 19%-31% more women receiving skilled maternal and newborn care than otherwise would have. In addition, there was a doubling of cases of postpartum hemorrhage and eclampsia that were identified and effectively responded to.Conclusions Maternal health and gender-based violence telemedicine led by midwives was an effective, low-cost intervention in Bangladesh for addressing pandemic and pre-pandemic gaps in service use. Other low and middle-income countries planning to implement remote maternal health interventions via midwives should consider whether a scheduling system needs to be introduced, as well as limitations around mobile phone access and connectivity. Future research should include care quality oversight and improvement.

Assessing Public Health Preparedness and Response in the European Union. A Review of Eu-Level Simulation Exercises and After Action Reviews (preprint)

Background: In order to improve preparedness and response capacities in the European Union, a good overview of capacities at both country and union level is needed. The International Health Regulations (2005) Monitoring and Evaluation framework aims to assess capacities in countries. It includes semi-quantitative tools such as the State Parties Annual Report (SPAR) and the Joint External Evaluation (JEE). After Action Reviews (AAR) and Simulation Exercises (SimEx) were included to identify weaknesses in the functionality of capacities which are not addressed by SPAR and JEE. This study presents an analysis of the use of these tools on a regional level, in Europe. It aims to identify their added value by comparing them to standardised monitoring tools and lessons learned from COVID-19, and considers ways to improve their use in assessing capacities in the EU.Methods: We included 17 SimEx and 2 AAR organized by the European Commission between 2005 and 2018. We categorized a total of 357 recommendations according to the IHR (2005) core capacities they addressed and their target audience. We analysed data using language analysis software. Recommendations to countries were compared to SPAR and JEE indicators. Recommendations to EU agencies were compared to the current mandates of the EU agencies, and to lessons learnt during COVID-19.Results: Of all the extracted recommendations, 59% targeted EU agencies, 18% targeted countries, and 16% targeted both. Recommendations mainly addressed areas of IHR coordination (C2), heath emergency management (C7) and risk communication (C10), and not low scoring areas. Recommendations complement SPAR indicators by identifying gaps in functionality. Eight out of ten early lessons learnt during the Covid-19 pandemic had been raised earlier as recommendations from exercises. Exercise reports assessed did not include or result in action plans for implementation, but COVID-19 has accelerated implementation of some recommendations.Conclusion: SimEx/AAR provide valuable insight into public health preparedness at EU level, as they assess functionality of response mechanisms, point out gaps, and provide training and awareness for participants, who often have key roles in public health emergencies. Better follow-up and implementation of recommendations can improve the regional preparedness for international public health incidents.

Adaptation of a community health outreach model during the COVID-19 pandemic: The case of the Mexican Consulates in the United States of America (preprint)

The Ventanillas de Salud (VDS – “Health Windows”) are a culturally sensitive outreach program within the 49 Mexican Consulates in the United States that provides information and health care navigation support to underserved and uninsured Mexican immigrants. During the COVID-19 pandemic the VDS rapidly transitioned to remote operations adding new services. Based on the EquIR implementation framework, this qualitative study investigates from an equity perspective how adaptations to improve emergency preparedness were performed. We conducted motivational interviews with three actors – six VDS coordinators, eight partner organizations, and ten VDS users– to document specific needs of the target population and identify implementation processes to adapt and continue outreach services. The VDS adapted their model by adding new services for emerging needs, by switching service provision modalities, and by expanding the network of partner organizations. According to the VDS staff, these adaptations increased their topics, depth, reach, and diversified their users. Users had mostly positive opinions about the VDS adaptation, although they highlighted some heterogeneity across service provision. The VDS is a public health intervention able to serve a marginalized population and its implementation offers valuable lessons to complement health systems and to improve preparedness and resiliency for future crises.

An agent-based model of the 2020 international policy diffusion in response to the COVID-19 pandemic with particle filter (preprint)

Global problems, such as pandemics and climate change, require rapid international coordination and diffusion of policy. These phenomena are rare however, with one notable example being the international policy response to the COVID-19 pandemic in early 2020. Here we build an agent-based model of this rapid policy diffusion, where countries constitute the agents and with the principal mechanism for diffusion being peer mimicry. Since it is challenging to predict accurately the policy diffusion curve, we utilize data assimilation, that is an ``on-line'' feed of data to constrain the model against observations. The specific data assimilation algorithm we apply is a particle filter because of its convenient implementation, its ability to handle categorical variables and because the model is not overly computationally expensive, hence a more efficient algorithm is not required. We find that the model alone is able to predict the policy diffusion relatively well with an ensemble of at least 100 simulation runs. The particle filter however improves the fit to the data, reliably so from 500 runs upwards, and increasing filtering frequency results in improved prediction.

Probable association between mRNA COVID-19 vaccine and opsoclonus-myoclonus-ataxia syndrome.

Opsoclonus-myoclonus-ataxia syndrome (OMAS) in children is most often of paraneoplastic origin, but it can also result from infectious processes, toxic and metabolic disorders, and organic events that cause damage to the brainstem or cerebellum. Post-vaccination OMAS has also been reported. We report the case of a 15-year-old girl who developed OMAS 24 hours after her first dose of mRNA COVID-19 (BioNTech) vaccine.

The use of evidence to guide decision-making during the COVID-19 pandemic: Divergent perspectives from a qualitative case study in British Columbia, Canada (preprint)

Background: The challenges of evidence-based decision-making in a public health emergency have never been so notable as during the COVID-19 pandemic. Questions about the decision-making process, including what forms of evidence were used, and how evidence informed – or did not inform – policy have been debated. Methods: We examined decision-makers' observations on evidence-use in early COVID-19 policy-making in British Columbia (BC), Canada through a qualitative case study. From July 2021- January 2022, we conducted 18 semi-structured key informant interviews with BC elected officials, provincial and regional-level health officials, and civil society actors involved in the public health response. The questions focused on: 1) the use of evidence in policy-making; 2) the interface between researchers and policy-makers; and 3) key challenges perceived by respondents as barriers to applying scientific evidence to COVID-19 policy decisions. Data were analyzed thematically, using a constant comparative method. Framework analysis was also employed to generate analytic insights across stakeholder perspectives. Results: Overall, while many actors’ impressions were that BC's early COVID-19 policy response was evidence-informed, an overarching theme was a lack of clarity and uncertainty as to what evidence was used and how it flowed into decision-making processes. Perspectives diverged on the relationship between 'government' and public health expertise, and whether or not public health actors had an independent voice in articulating evidence to inform pandemic governance. Respondents perceived a lack of coordination and continuity across data sources, and a lack of explicit guidelines on evidence-use in the decision-making process, which resulted in a sense of fragmentation. The tension between the processes involved in research and the need for rapid decision-making was perceived as a barrier to using evidence to inform policy. Conclusions: Areas to be considered in planning for future emergencies include: information flow between policy-makers and researchers, coordination of data collection and use, and transparency as to how decisions are made—all of which reflect a need to improve communication. Based on our findings, clear mechanisms and processes for channeling scientific evidence into decision-making need to be identified, and doing so will strengthen preparedness for future public health crises.

Miller-Fisher syndrome after first dose of Oxford/AstraZeneca coronavirus disease 2019 vaccine: a case report.

INTRODUCTION: Miller-Fisher Syndrome (MFS) is a variant of Guillain-Barré syndrome (GBS), an acute immune-mediated neuropathy, which manifests as a rapidly evolving areflex motor paralysis. This syndrome presents as a classic triad: ophthalmoplegia, areflexia, and ataxia. MFS is usually benign and self-limited. CASE REPORT: A Caucasian patient was admitted to our hospital with the flu, loss of bilateral strength in the lower limbs and upper limbs and sudden-onset ataxia 7 days after receiving a first dose of the Oxford/AstraZeneca COVID-19 vaccine. On neurological examination, the patient had Glasgow Coma Scale score of 15, with absence of meningeal signs; negative Babinski sign; grade 2 strength in the lower limbs and grade 4 strength in the upper limbs; axial and appendicular cerebellar ataxia; and peripheral facial diparesis predominantly on the right, without conjugate gaze deviation. Cerebrospinal fluid (CSF) was collected on admission, and analysis revealed albuminocytological dissociation with CSF protein of 148.9 mg/dL; leukocytes, 1; chlorine, 122; glucose, 65 mg/mL; red cells, 2; and non-reactive venereal disease research laboratory test result. The COVID-19 IgG/IgM rapid immunological test was negative. Electroneuromyography revealed a recent moderate-grade and primarily sensory and motor demyelinating polyneuropathy with associated proximal motor block. DISCUSSION AND CONCLUSION: Miller-Fisher Syndrome may be related to events other than infections prior to neuropathy, as in the case reported here. The patient presented strong correlations with findings for MFS reported in the literature, such as the clinical condition, the results of electroneuromyography, and results of the CSF analysis typical for MFS. When treatment was provided as proposed in the literature, the disease evolved with improvement. Ultimately, the diagnosis of incomplete MFS was made, including acute ataxic neuropathy (without ophthalmoplegia).

Modifiable Contextual Factors and Implementation Processes Associated with Improved Outcomes in the Multisite Spread of a Safety Intervention (preprint)

Background: The national spread of safety interventions has been slow and difficult. While it is widely known that hospital contextual features and implementation factors impact spread of evidence-based interventions, there is little prospective research on modifiable factors that impact implementation at multiple sites. Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) is a system-level patient safety intervention that led to a sustained reduction in nephrotoxic medication–associated acute kidney injury (NTMx-AKI) at one hospital. Our objective was to prospectively characterize the association between context and implementation factors and reduction of NTMx-AKI at nine hospitals implementing NINJA, using mixed methods. Methods: Grounded in i-PARIHS, we used qualitative comparative analysis (QCA) to assess the association between context and implementation factors, measured quarterly by survey, and reduction of NTMx-AKI, measured using statistical process control and ARIMA modeling. Interviews provided an understanding of causal processes underlying associations identified in QCA. Qualitative and quantitative data were collected and analyzed concurrently and then merged. Results: Five hospitals reduced AKI, four did not. Overall, the collaborative reduced NTMx- AKI by 8 cases per 1000 patient-days per month (95% CI: 14.6-1.4; p=0.018). QCA analysis revealed that hospitals needed to have a baseline AKI rate > 1.0 to reduce NTMx-AKI (Ncon 1.0, Ncov 0.83). In addition, hospitals that reduced NTMx-AKI had either (a) a pharmacist champion and > 2 pharmacists working on NINJA (Scon 1.0, Scov 0.8) or (b) No other organizational priorities causing implementation delays (Scon 1.0, Scov 0.2). Involving quality improvement coordinators or data analysts did not influence success. Qualitative interviews supported these findings and underscored the importance of how the NINJA implementation team integrated with frontline staff. Conclusions: We identified two different pathways to successful reduction in NTMx-AKI when implementing NINJA. These findings have implications for the future spread of NINJA and suggest an approach to study spread and scale of safety interventions more broadly.

HSV-2 induced Cerebellitis; A reactivatation of HSV-2 by SARS Covid -2 infection, A case Presentation (preprint)

Background: Herpes simplex virus type-2 could hardly lead to encephalitis in human-being. Some DNA viruses could be reactivated by COVID-19 infection such as HSV-1 and HSV-2 viruses. An uncommon presentation of HSV-2 was detected as cerebellitis in this patient. It could be concluded that SARS COVID-2 can reactivate DNA viruses such as HSV-2.   Case Presentation: Here we report a one-year-old girl infant with cerebellum involvement secondary to herpes simplex virus type 2 infection. Conclusion: The patient was treated for three weeks with intravenous acyclovir and oral prednisolone. Finally, during her neurological follow-ups in a 9 months period of time, she was able to walk with minimal ataxia.

Mechanisms of COVID-19-induced cerebellitis.

The COVID-19 pandemic caused by SARS-CoV2 has raised several important health concerns, not least increased mortality and morbidity. SARS-CoV2 can infect the central nervous system via hematogenous or transneuronal routes, acting through different receptors including ACE2, DPP4, and neuropilin 1 and cause several issues, including the focus here, cerebellitis. The cerebellum is an essential part of the CNS located adjacent to the brainstem with a complex micro and macroscopic structure. The cerebellum plays several physiological roles, such as coordination, cognition, and executive functioning. Damage to the cerebellum can lead to incoordination and ataxia. In our narrative review, we searched different databases from 2021 to 2022 with the keywords cerebellum and COVID-19; 247 studies were identified and reviewed, focusing on clinical studies and excluding non-clinical studies; 56 studies were finally included for analysis. SARS-CoV2 infection of the cerebellum can be seen to be assessed through many methods such as MRI, PET, CT, postmortem studies, and histological findings. These methodological studies have demonstrated that cerebellar infection with COVID-19 can bring about several sequelae: thrombosis, microbleed, hemorrhage, stroke, autoantibody production, ataxia, and widespread inflammation in the cerebellum. Such central effects are likely to exacerbate the known multiorgan effects of SARS-CoV2 and should also be considered as part of disease prognosis.

Optic ataxia in a patient with HaNDL syndrome.

We present a woman in her 40s who arrived at the emergency room with hypertension and optic ataxia. Her medical history is only relevant for obesity. Her lumbar puncture revealed high intracranial pressure and lymphocytic pleocytosis, and her neuroimaging tests, including angiography and venography, were normal. The patient improved after a cerebrospinal fluid drainage with a lumbar puncture, and her clinical manifestations resolved in parallel to the lymphocytic pleocytosis.The patient was diagnosed with a syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis and fully recovered 21 days after her discharge.