COVID 19-associated chilblain-like acral lesions among children and adolescents: an Italian retrospective, multicenter study.

BACKGROUND: Since the COVID-19 pandemic started, great interest has been given to this disease, especially to its possible clinical presentations. Besides classical respiratory symptoms, dermatological manifestations occur quite often among infected and non-infected patients, particularly in children. A prominent IFN-I response, that is generally higher in children compared to adults, may not only cause chilblain lesions, but it could also prevent infection and viral replication, thus justifying the negative swab results, as well as the absence of relevant systemic symptoms in positive cases. Indeed, reports have emerged describing chilblain-like acral lesions in children and adolescents with either proven or suspected infection. METHODS: Patients aged from 1 to 18 years old were enrolled in this study from 23 Italian dermatological units and were observed for an overall period of 6 months. Clinical pictures were collected along with data on the location and duration of skin lesions, their association with concomitant local and systemic symptoms, presence of nail and/or mucosal involvement, as well as histological, laboratory and imaging findings. RESULTS: One hundred thirty-seven patients were included, of whom 56.9% were females. Mean age was 11.97±3.66 years. The most commonly affected sites were the feet (77 patients, 56.2%). Lesions (48.5%) featured cyanosis, chilblains, blisters, ecchymosis, bullae, erythema, edema, and papules. Concomitant skin manifestations included maculo-papular rashes (30%), unspecified rashes (25%), vesicular rashes (20%), erythema multiforme (10%), urticaria (10%) and erythema with desquamation (5%). Forty-one patients (29.9%) reported pruritus as the main symptom associated with chilblains, and 56 out of 137 patients also reported systemic symptoms such as respiratory symptoms (33.9%), fever (28%), intestinal (27%), headache (5.5%), asthenia (3.5%), and joint pain (2%). Associated comorbid conditions were observed in 9 patients presenting with skin lesions. Nasopharyngeal swabs turned out positive in 11 patients (8%), whereas the remainder were either negative (101, 73%) or unspecified (25, 18%). CONCLUSIONS: COVID-19 has been credited as the etiology of the recent increase in acro-ischemic lesions. The present study provides a description of pediatric cutaneous manifestations deemed to be potentially associated with COVID-19, revealing a possible association between acral cyanosis and nasopharyngeal swab positivity in children and teenagers. The identification and characterization of newly recognized patterns of skin involvement may aid physicians in diagnosing cases of asymptomatic or pauci-symptomatic COVID patients.

Risk Factors for Mortality of Hospitalized Adult Patients with COVID-19 Pneumonia: A Two-Year Cohort Study in a Private Tertiary Care Center in Mexico.

During the COVID-19 pandemic, the high prevalence of comorbidities and the disparities between the public and private health subsystems in Mexico substantially contributed to the severe impact of the disease. The objective of this study was to evaluate and compare the risk factors at admission for in-hospital mortality of patients with COVID-19. A 2-year retrospective cohort study of hospitalized adult patients with COVID-19 pneumonia was conducted at a private tertiary care center. The study population consisted of 1258 patients with a median age of 56 ± 16.5 years, of whom 1093 recovered (86.8%) and 165 died (13.1%). In the univariate analysis, older age (p < 0.001), comorbidities such as hypertension (p < 0.001) and diabetes (p < 0.001), signs and symptoms of respiratory distress, and markers of acute inflammatory response were significantly more frequent in non-survivors. The multivariate analysis showed that older age (p < 0.001), the presence of cyanosis (p = 0.005), and previous myocardial infarction (p = 0.032) were independent predictors of mortality. In the studied cohort, the risk factors present at admission associated with increased mortality were older age, cyanosis, and a previous myocardial infarction, which can be used as valuable predictors for patients' outcomes. To our knowledge, this is the first study analyzing predictors of mortality in COVID-19 patients attended in a private tertiary hospital in Mexico.

Risk Factors for Mortality of Adult Patients With COVID-19: A Two-Year Cohort Study in a Private Tertiary Care Center in Mexico (preprint)

During the COVID-19 pandemic, the high prevalence of comorbidities in Mexico, as well as the disparities between public and private health subsystems, substantially contributed to the severe impact it had in the country. The objective of this study was to evaluate and compare risk factors present at admission for mortality of hospitalized patients with COVID-19. A 2-year retrospective cohort study of hospitalized adult patients with COVID-19 was conducted at a private tertiary care center. The study population consisted of 1,258 patients with a median age of 56 ± 16.5 years, of whom 1,093 recovered (86.8%) and 165 died (13.1%). In the univariate analysis, older age (p <0.001), comorbidities such as hypertension (p <0.001) and diabetes (p <0.001), signs and symptoms of respiratory distress, and markers of acute inflammatory response were significantly more frequent in non-survivors. The multivariate analysis showed that older age (p <0.001), the presence of cyanosis (p 0.005) and previous myocardial infarction (p 0.032) were independent predictors for mortality. In the studied cohort, risk factors present at admission associated with an increased risk of death were older age, cyanosis and a previous myocardial infarction, which can be used as valuable predictors for patients’ outcomes. To our knowledge, this is the first study analyzing predictors of mortality in COVID-19 patients attended on a private tertiary hospital in Mexico.

Refractory Atrial Flutter, the Only Presentation of covid-19 Infection in a Neonate: a case report and review of literature (preprint)

Background The accurate incidence of different cardiovascular consequences of COVID-19 in pediatric population have been inadequately defined due to ongoing genotype changes in the virus. Although COVID-19 is known to increase inflammatory markers associated with atrial arrhythmias, the contemporary literature has poorly described new onset arrhythmias as a complication in previously healthy neonate with COVID-19 Case presentation Twenty-day-old female term neonate, born by caesarean section with immediate cry developed labored breathing, cyanosis and tachycardia after having close contact with a confirmed case of covid-19. She developed atrial flutter, which was refractory to cardioversion and drugs namely Amiodarone, Flecainide and Propranolol. The neonate was treated with IVIG. This is the first reported case of atrial flutter in neonatal period secondary to COVID-19. Conclusion Since the starting of SARS –COV2 pandemic all attentions and concerns has been mainly on respiratory manifestations and complications. The cardiovascular complications and treatment are neglected. This case reports tachyarrhythmia (Atrial Flutter) as unusual presentation of MISC in neonatal population and show role of IvIg in treatment of refractory arrhythmias.

Histopathology of persistent long COVID toe: A case report.

During the 2020 coronavirus (SARS-CoV-2) pandemic, several cutaneous lesions were identified, including pseudo-chilblain, vesicular, urticarial, maculopapular, and livedo/necrosis. A 59-year-old obese man with probable COVID-19 developed painful cyanosis with histopathologic capillary thrombosis of toes, and the cyanosis persisted for nearly 22 months. Shortly after initial exposure to family members with documented SARS-CoV-2, he developed upper respiratory symptoms, yet his anti-SARS-CoV-2 antibody and nasal swab RT-PCR tests were repeatedly negative. Two family members were hospitalized and one of them succumbed with documented SARS-CoV-2 pneumonia within 10 days of exposure. Biopsy specimen of the distal toe 16 weeks after initial exposure showed papillary dermal capillary thrombosis with endothelial swelling, telangiectasia, and peri-eccrine lymphocytic infiltrates resembling pernio. Overall, this is the first case of biopsy specimen of "long COVID toe" following presumed SARS-CoV-2 exposure, with a demonstration of thrombotic vasculopathy, toe cyanosis, and pernio-like pathology.

BASCULE syndrome in a child with prior asymptomatic COVID-19 infection.

BASCULE syndrome, characterized by Bier anemic spots, cyanosis, and an urticaria-like eruption, has been described as a benign vasomotor dermatosis that occurs in the setting of transient tissue hypoxia. It has been postulated that dermal ischemia triggers an exaggerated vasoconstrictive arteriolar reaction, which then causes a paradoxical urticarial rash by an unknown mechanism. In patients with COVID-19, there is evidence of angiocentric inflammation leading to vasoconstriction, endothelial damage, and thrombosis. We present a case of acute-onset BASCULE syndrome appearing after asymptomatic infection with COVID-19. BASCULE syndrome should be considered in the expanding spectrum of dermatologic manifestations associated with COVID-19.

Cutaneous Manifestations of COVID-19.

Patients with coronavirus disease 2019 (COVID-19) present with multisystem signs and symptoms, including dermatologic manifestations. The recent literature has revealed that dermatologic manifestations of COVID-19 often are early onset and provide helpful cues to a timely diagnosis. We compiled the relevant emerging literature regarding the dermatologic manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) so that physicians can be aware of the various clinical cutaneous presentations in this time of high incidence of COVID-19.

Clinical efficacy of Early Administration of Convalescent Plasma among COVID-19 Cases in Egypt (preprint)

Abstract Importance: Early and effective treatment of COVID-19 is vital for control of SARS-CoV-2 infection Objectives: The primary objective of the study was to assess the degree of clinical improvement in severe and critically ill COVID-19 patients, treated early with early CPT. Designs: An interventional, single-arm, non-randomized clinical trial conducted in Egypt from April 15 to July 21, 2020. Settings: This was a multi-centre study conducted in 3 hospitals in Egypt. Participants: a total of 94 COVID-19 laboratory-confirmed patients using qRT-PCR were enrolled in the study. Intervention: All patients were administered with two plasma units (each unit is 200cc). The volume of donated plasma was 800cc. Main Outcome and Measures: Primary measure was the degree of clinical improvement among the COVID-19 patients who received CPT within seven days Results: A total of 94 patients were enrolled who received CPT either within seven days or after seven days of hospitalization. 82 were severely ill, 12 were critically ill. The average age remained 58 years (SD 15.1 years). Male were 69% and 49% patients got cured while 51% died with CFR 51%. 75% deaths were above 45years of age. The symptoms were dyspnoea (55%), fever (52%), cough (46%), and loss of taste and smell (21%), and cyanosis (15%). The most common co-morbidities among the <40 years remained Diabetes Mellitus (21%) and Asthma (14%). Among 40-60 years Hypertension (56%), Diabetes Mellitus (39%) and among >60 years age group Hypertension (57%) and Chronic Heart Disease (24%) were reported. CPT within seven days remained significant as compared with the CPT after seven days with the number of days to cure (p=0.007) and ICU stay (P=0.008) among severely ill cured cases. Conclusion and Relevance: Among patients with COVID-19 and severe or critical illness, the use of CPT along with routine standard therapy resulted in a statistically significant improvement when administered within seven days of hospital admission. However, plasma transfusion, irrespective of days to transfusion may not help treat critically ill patients. The overall mean time to cure in severely ill patients was 15 days if CPT provided within seven days with 65% cure rate. Trial Registration: Clinical Intervention identifier: MOHP_COVID-19_Ver1.1

COVID-19 in Adults With Congenital Heart Disease.

BACKGROUND: Adults with congenital heart disease (CHD) have been considered potentially high risk for novel coronavirus disease-19 (COVID-19) mortality or other complications. OBJECTIVES: This study sought to define the impact of COVID-19 in adults with CHD and to identify risk factors associated with adverse outcomes. METHODS: Adults (age 18 years or older) with CHD and with confirmed or clinically suspected COVID-19 were included from CHD centers worldwide. Data collection included anatomic diagnosis and subsequent interventions, comorbidities, medications, echocardiographic findings, presenting symptoms, course of illness, and outcomes. Predictors of death or severe infection were determined. RESULTS: From 58 adult CHD centers, the study included 1,044 infected patients (age: 35.1 ± 13.0 years; range 18 to 86 years; 51% women), 87% of whom had laboratory-confirmed coronavirus infection. The cohort included 118 (11%) patients with single ventricle and/or Fontan physiology, 87 (8%) patients with cyanosis, and 73 (7%) patients with pulmonary hypertension. There were 24 COVID-related deaths (case/fatality: 2.3%; 95% confidence interval: 1.4% to 3.2%). Factors associated with death included male sex, diabetes, cyanosis, pulmonary hypertension, renal insufficiency, and previous hospital admission for heart failure. Worse physiological stage was associated with mortality (p = 0.001), whereas anatomic complexity or defect group were not. CONCLUSIONS: COVID-19 mortality in adults with CHD is commensurate with the general population. The most vulnerable patients are those with worse physiological stage, such as cyanosis and pulmonary hypertension, whereas anatomic complexity does not appear to predict infection severity.

First reported case of unrepaired tetralogy of Fallot complicated with coronavirus disease-19 (COVID-19).

The incidence of novel coronavirus disease-19 (nCoV-19) and its associated complications is higher in high-risk groups. In this article, we explain the symptoms and course of the disease and the treatment for an adult patient with CHD who has been infected with novel nCoV-19.

A visually striking case of primary acrocyanosis: A rare cause of the blue digit.

Cold environments can trigger a variety of conditions, which, in their acute phase often present to the Emergency Department. Primary acrocyanosis is a distinct, rare condition which may be missed resulting in misdiagnosis and mismanagement. Primary acrocyanosis is a peripheral vascular disorder defined by painless, symmetrical discoloration of the distal appendages and uniquely characterized by persistence of the skin color changes after cold exposure. We present a case of a 24-year-old female who presented to the Emergency Department with peripheral cyanosis after cold exposure and was eventually diagnosed with primary acrocyanosis by Rheumatology. The prognosis for primary acrocyanosis is quite good in comparison to other acrosyndromes and once secondary causes of acrocyanosis have been ruled, out can be managed conservatively with lifestyle modifications and potential follow-up with Rheumatology.

COVID-19-associated apnea and circumoral cyanosis in a 3-week-old.

BACKGROUND: Data regarding coronavirus disease 2019 (COVID-19) cases and outcomes in infants are sparse compared to older pediatric and adult populations. CASE PRESENTATION: We present a three-week-old full-term male with a history of mild hypoxic ischemic encephalopathy (HIE) who was admitted as an inpatient twice for episodes of apnea and perioral cyanosis. The patient tested positive for COVID-19 and negative for other common respiratory viruses at both admissions. CONCLUSIONS: To our knowledge, this is the first report of apnea and perioral cyanosis associated with COVID-19 in an infant. This case highlights a previously undocumented COVID-19 presentation and suggests that even mildly symptomatic infants warrant viral diagnostic testing in an effort to prevent further spread of the disease.

AutoTriage - An Open Source Edge Computing Raspberry Pi-based Clinical Screening System (preprint)

With the recent COVID-19 pandemic, healthcare systems all over the world are struggling to manage the massive increase in emergency department (ED) visits. This has put an enormous demand on medical professionals. Increased wait times in the ED increases the risk of infection transmission. In this work we present an open-source, low cost, off-body system to assist in the automatic triage of patients in the ED based on widely available hardware. The system initially focuses on two symptoms of the infection fever and cyanosis. The use of visible and far-infrared cameras allows for rapid assessment at a 1m distance, thus reducing the load on medical staff and lowering the risk of spreading the infection within hospitals. Its utility can be extended to a general clinical setting in non-emergency times as well to reduce wait time, channel the time and effort of healthcare professionals to more critical tasks and also prioritize severe cases. Our system consists of a Raspberry Pi 4, a Google Coral USB accelerator, a Raspberry Pi Camera v2 and a FLIR Lepton 3.5 Radiometry Long-Wave Infrared Camera with an associated IO module. Algorithms running in real-time detect the presence and body parts of individual(s) in view, and segments out the forehead and lip regions using PoseNet. The temperature of the forehead-eye area is estimated from the infrared camera image and cyanosis is assessed from the image of the lips in the visible spectrum. In our preliminary experiments, an accuracy of 97% was achieved for detecting fever and 77% for the detection of cyanosis, with a sensitivity of 91% and area under the receiver operating characteristic curve of 0.91. Heart rate and respiratory effort are also estimated from the visible camera. Although preliminary results are promising, we note that the entire system needs to be optimized before use and assessed for efficacy. The use of low-cost instrumentation will not produce temperature readings and identification of cyanosis that is acceptable in many situations. For this reason, we are releasing the full code stack and system design to allow others to rapidly iterate and improve the system. This may be of particular benefit in low-resource settings, and low-to-middle income countries in particular, which are just beginning to be affected by COVID-19.