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Purpose of study COVID-19 primarily affects the respiratory system from flu-like syndrome to acute hypoxic respiratory failure. Neurological manifestations are uncommon and can result in serious complications. We report a unique case of sudden onset of rapidly progressive encephalopathy in the setting of COVID-19. Methods used Reviewed the manifestations, clinical course, and outcome for a patient presenting with altered mental status secondary to COVID-19. Summary of results A 48-year-old with no significant past medical history presented to the emergency department complaining of severe headache for four days. His vital signs on presentation showed a blood pressure of 154/90, pulse of 114 bpm, temperature of 99.6 degreeF, and oxygen saturation of 97% on room air. Physical exam was unremarkable. Lab work showed elevated D-dimer 8,500 ng/L, Elevated ESR:42, LDH:340 and Ferritin:692. White blood count: 7.59 uL, Platelets 50 x 103 uL. Computer tomography angiography (CTA) of the chest showed bilateral multifocal pneumonia. CT Head was performed and was negative for an acute hemorrhage, hydrocephalus or territorial infarcts. Patient spiked a fever shortly after admission 103degreeF. Patient was started on Ceftriaxone and Azithromycin. Blood and urine cultures were positive for Klebsiella pneumonia. Patient was re-evaluated in the morning and was found altered with associated neck stiffness. Antibiotics were switched to cover for suspected meningitis. Neurology was consulted and recommended lumbar puncture. Within a few hours, the patient's mental status deteriorated and was found to be hypertensive with a blood pressure of 220/110. Repeat CT Head was negative. The patient was tested and found to be positive for COVID-19. Patient further decompensated within a few hours and became unresponsive, pulseless. ACLS was performed and the patient was transferred to the intensive care unit. Conclusions This case report highlights the heterogenous presentation in patients with COVID-19 and the importance of recognizing a new onset, severe headache as the only initial presentation. Headaches in some cases may precede the respiratory symptoms or may be the only manifestations in COVID-19 patients and it is crucial to be aware of the neurological complications and the rapid decompensation these patients may undergo if not recognized early.
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Background: The COVID 19 pandemic outbreak caused 143427 cases and more than 28000 deaths in France. To contain this highly contagious and potentially deadly disease, the French government decided an unprecedented nationwide lockdown. We investigated in a large cohort of cancer patients from Hauts-de-France, the third French region most stricken by COVID-19, the frequency of symptoms, how cancer navigated the health care system during these very difficult circumstances, and their feelings. Method(s): We made a flash survey among 6900 patients treated at our cancer center within March 2019 and March 2020. Respondents were asked by email to fill in a short web-based survey sent on April 30 and closed on May 14. Result(s): We received reports from 2224 cancer patients. Mean age was 63 years, 72% were women, only 9% were smokers, 26% had hypertension, 9% diabetes, and 5% asthma. The most represented cancers were breast (45%), gynecologic cancers (12%), digestive (8%), and head and neck cancer (6%). Most patients were in follow up, 13% were receiving chemotherapy. The majority did not develop symptoms associated with COVID during the COVID wave;one third experienced symptoms. The main symptoms reported were headache (38%), myalgia and arthralgia (31%), cough (25%), digestive signs (20%), intense fatigue (19%), or fever (13%). Among patients with symptoms, 58% did not seek medical advice during the COVID wave and 95% of them were not tested. For those receiving chemotherapy, 80% had their treatment as planned. Among patients with a planned surgery, 30% of them were delayed. 32% of the patients reported anxiety, 35% felt unsecure and 16% reported an increased consumption of antistress medication, tobacco or alcohol. We also discuss the pattern of symptoms and feelings according to the cancer type and the treatment received. Conclusion(s): This study showed that most of our cancer patients were probably not infected during the COVID wave, which highlights the need to maintain barrier measures to protect them and perform validated tests. An appropriate supportive care is also necessary to manage patients' distress due to COVID 19 in many of them. Legal entity responsible for the study: Centre Oscar Lambret. Funding(s): Has not received any funding. Disclosure: All authors have declared no conflicts of interest.Copyright © 2020
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INTRODUCTION: Coronavirus Disease 2019 (COVID-19) can lead to rapid respiratory decompensation requiring mechanical ventilation. There is limited evidence regarding the efficacy of existing treatment for severe COVID-19 infection. The purpose of this study was to assess the efficacy and safety of tocilizumab (TCZ) alone or with the combination of corticosteroids and therapeutic anticoagulation in intensive care unit (ICU) patients on mechanical ventilation with COVID-19 infection. METHODS: A single-center observational cohort study was conducted at an urban community teaching hospital in the New York City area between March 9, 2020 and April 28, 2020. The primary outcome of this study was in-hospital mortality. Secondary outcomes included 30-day mortality, duration of mechanical ventilation, ICU length of stay, and hospital length of stay. RESULTS: A total of 152 COVID-19 positive ICU patients were included in this study, of which 40 (26.7%) patients received one dose of TCZ 400 mg IV and three patients received an additional 400 mg dose. There were no statistically significant differences noted between the treatment and control group in regards to in-hospital mortality [31 (77.5%) vs. 94 (83.9%), P = 0.35], 30-day mortality [28 (70%) vs. 90 (80.4%), P = 0.18], or duration of mechanical ventilation (13 days ± 15.4 vs. 9.7 days ± 10.6, P = 0.22). Patients receiving TCZ had a significantly longer ICU and hospital length of stay [(15.1 days ± 16.1 vs. 9.6 days ± 9.8, P = 0.05) and (25.5 ± 29.9 vs. 14.1 ± 16.9, P = 0.03), respectively]. There was no difference in the incidence of thromboembolic complications [7 (17.5%) vs. 9 (8%), P = 0.13] or atrial fibrillation [4 (10%) vs. 13 (11.6%), P = 1.0] between the two groups. No anaphylactic or injective site reactions were noted. Results of multivariate linear and logistic regression analyses demonstrated that corticosteroids and anticoagulants were not independent predictors of duration of mechanical ventilation or in hospital mortality. CONCLUSIONS: The use of TCZ alone or in combination with corticosteroids and therapeutic anticoagulation was not associated with a decreased risk of mortality or shorter duration of mechanical ventilation in critically ill patients with COVID-19 infection. Additional studies are needed to evaluate the efficacy of TCZ for COVID-19.
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INTRODUCTION: Right heart thrombi (RVT) are uncommon, usually found concurrent with pulmonary embolism and associated with significantly increased mortality. We describe a rare etiology of RVT formation ?in situ? complicating acute pulmonary embolism of a patient with COVID-19 infection already on anticoagulation with direct oral anticoagulants (DOACs). METHODS: A 43 yo obese male was diagnosed with presumptive COVID-19 infection based on clinical, inflammatory markers, and radiographic evidence. PCR was negative, which is encountered in 38% of tests. D-dimer was elevated 12499 ng/L however, CT angiogram (CTA), lower extremity duplex, and transthoracic echocardiogram (TTE) were unremarkable for thrombus. He received therapeutic enoxaparin for 3 days and was discharged on apixaban 5 mg twice daily. 5 days later, he developed worsening shortness of breath and hypoxemic respiratory failure. Repeat CTA revealed bilateral pulmonary emboli and TTE showed a 1.4 x 1.2 cm mobile thrombus in the right ventricle. Hypercoagulable workup was negative. Catheterdirected thrombolysis and salvage extracorporeal membrane oxygenation (ECMO) were considered however, the patient was unstable for transfer and ultimately expired after a sudden cardiac arrest. RESULTS: The existing consensus favors enoxaparin as the preferred anticoagulation for COVID-19 patients. It promotes anti-inflammatory properties by reducing IL-6 and lung edema. Other benefits include reducing the exposure of personnel by the absence of activated partial thromboplastin monitoring. There is a lack of anti-inflammatory properties with the use of DOACs as well as an understanding of the appropriate dose requirements. Therefore, the decision to discharge patients on prophylactic anticoagulation with enoxaparin as compared to DOACs is essential given the increased propensity of thromboembolic disease. We highlight the unique challenges in the evaluation and treatment of patients with COVID-19 and an elevated D-dimer. The increased risk of microthrombi warrants the initiation of therapeutic anticoagulation. We recommend the use of enoxaparin upon discharge of patients with elevated D-dimer. Further studies are required to understand the best choice, role, dosage, and duration of anticoagulation therapy in patients with COVID-19 infection.