Predictive Factors for the Diagnosis of Coronavirus Disease 2019

Objective: We evaluated patients suspected or confirmed to have coronavirus disease 2019 (COVID- 19) to determine predictive factors for the diagnosis of COVID- 19. Method(s): We conducted a retrospective cohort study at The Jikei University Hospital, Tokyo, Japan. This study included adult patients who underwent medical examination for suspected or confirmed COVID- 19 in April and May 2020. We analyzed the clinical characteristics, blood test results, and findings of computed tomography of the chest from the medical record system of the hospital. Result(s): Of the 267 patients included in this study, 27 were found to be positive for COVID- 19 on reverse transcription polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 (SARS- CoV- 2). Of the patients, 128 (47.9%) were men, and the median age was 47 years (interquartile range, 34.5- 65). Twenty- two (8.2%) patients had a history of close contact with a COVID- 19 patient. The most common symptoms were fever, general malaise, and cough. Multivariate analysis with the logistic regression model revealed that close contact, fever for 4 or more days, dysgeusia, and dysosmia were independent predictive factors for reverse transcription polymerase chain reaction test results being positive for SARS- CoV- 2. Conclusion(s): Patients who have had close contact with a COVID- 19 patient, fever for 4 days or more, dysgeusia, or dysosmia should undergo diagnostic testing for SARS- CoV- 2.Copyright © 2021 Jikei University School of Medicine. All rights reserved.

Persistent Fever and Positive PCR 90 Days Post-SARS-CoV-2 Infection in a Rituximab-Treated Patient: A Case of Late Antiviral Treatment.

Background: Persistent fever after SARS-CoV-2 infection in rituximab-treated patients has been reported. Due to reduced sensitivity in conventional sampling methods and unspecific symptoms in these patients, distinguishing between low-grade viral replication or hyperinflammation is challenging. Antiviral treatment is recommended as prophylactic or early treatment in the at-risk population; however, no defined treatment approaches for protracted SARS-CoV-2 infection exist. Results: We present a case of 96 days of persistent fever and SARS-CoV-2 infection in a patient receiving B cell depletion therapy for multiple sclerosis. Migratory lung infiltrates and positive PCR tests from serum (day-58 post infection) and lower airways (day-90 post infection) confirmed continuous viral replication. The dominant symptoms were continuous high fever, dyspnea and mild to moderate hypoxemia, which never developed into severe respiratory failure. The patient was hospitalized three times, with transient improvement after late antiviral treatment and full recovery 6 months post-rituximab infusion. Conclusions: A strategy for securing samples from lower airways and serum should be a prioritization to strengthen diagnostic certainty in immunocompromised patients. B-cell-deprived patients could benefit from late treatment with SARS-CoV-2-specific monoclonal antibodies and antivirals. Importantly, increased intervals between immunosuppressive therapy should be considered where feasible.

A Mysterious Fever and Retropharyngeal Edema on a Previously Healthy 10-Year-Old Boy Without Known Exposure to COVID-19.

Multisystem inflammatory syndrome in children (MIS-C) is considered a late manifestation of COVID-19 infection, and it is a diagnosis of exclusion after ruling out other causes of systemic inflammations. We present a case of MIS-C to highlight the importance of cardiac workup in MIS-C due to frequent cardiac involvement and discuss the possible association between retropharyngeal edema and MIS-C. The case patient is a 10-year-old previously healthy boy who presented with persistent fever, right-side neck pain, and a new rash. The rash was attributed to recent amoxicillin use by his parents. Pertinent workups included elevated inflammatory markers, a benign electrocardiogram test, a negative urine analysis, blood culture, and retropharyngeal edema by computerized tomography. On day four of hospitalization, the patient failed to improve with broad-spectrum antibiotics and became tachycardic. A repeat echocardiogram revealed a decreased ejection fraction with mitral valve regurgitation. The cardiac finding, the skin finding, the persistent fever, and the initial negative workups fulfilled the case criteria for MIS-C. A positive test for anti-SARS-CoV-2 spike protein receptor-binding domain antibodies confirmed the diagnosis, and the patient improved with intravenous immune globulin (IVIG) and steroids. The retropharyngeal edema was thought to be coincidental; however, there seem to be frequent associations between MIS-C and retropharyngeal edema, suggesting that the retropharyngeal edema could be one of the initial manifestations of MIS-C. More study is needed to study the association between retropharyngeal edema and MIS-C and shed light on the diagnosis and medical management of MIS-C.

Acute Appendicitis Associated With Kawasaki Disease: Case Report and Review of the Literature.

Acute appendicitis is a rare complication of Kawasaki disease in the setting of the absence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We experienced a rare case of acute appendicitis associated with Kawasaki disease. The patient is a six-year-old male who was brought to the emergency department by his mother with a pruritic rash, nausea, vomiting, and abdominal pain. Given fever, tenderness in the right lower quadrant on physical examination, leukocytosis with bandemia, and a non-compressible and dilated appendix on ultrasound, he was diagnosed with acute appendicitis and was treated with a laparoscopic appendectomy. He developed persistent fevers after surgery with new lip swelling, mucositis, and bilateral conjunctival injection. Kawasaki disease was suspected and intravenous gammaglobulin and aspirin were administrated. He made a full recovery. This case suggests that careful examination is needed for accurate diagnosis, especially in patients with postoperative persistent fever without signs of intra-abdominal complications. We performed a PubMed literature search and reviewed eight cases of appendicitis associated with Kawasaki disease. Of note, this case was seen in 2018 before the SARS-CoV-2 pandemic and the description of multisystem inflammatory syndrome in children (MIS-C).