Neuromyelitis Optica Spectrum Disorder After BIBP COVID-19 Vaccine: A Case Report (preprint)

Background: With the availability of the COVID-19 vaccine, post-vaccination neurological complications have occasionally been reported. Case presentation: We present a case of neuromyelitis optica spectrum disorder (NMOSD) that developed 1 month after the second dose of BIBP COVID-19 vaccine (SARS-CoV-2-Vaccine [Vero Cell] Inactived). The patient presented itching, numbness of the hand and right side of the face, associated with nausea, vomiting and hiccups. Brain MRI showed lesions in the area postrema, medulla, and bilateral hypothalamus, typical of NMOSD. Serum antibodies to anti-AQP4 and anti-MOG were negative. Conclusions: The pathogenesis of NMOSD development and the vaccine is still unknown. The presentation of NMOSD is generally aggressive and disabling, it is important for the neurologist to be attentive to the highly variable clinical presentation after vaccination against COVID-9 for early diagnosis and effective treatment.

Persistent Hiccups as an Atypical Initial Presentation of COVID-19: A Case Report.

INTRODUCTION: SARS-CoV-2 is a novel coronavirus that causes acute respiratory syndrome in humans. It is also known as COVID-19 and was first discovered in Wuhan, Hubei Province in China in December 2019 and soon became a global pandemic. The common symptoms of COVID-19 include fever, fatigue, and dry cough; however, there are some atypical symptoms that remain either unreported or underreported. CASE SUMMARY: In this case report, we described a 48-year-old diabetic man who presented with the chief complaint of persistent hiccups (<48h) to the emergency room with no history of malignancy, GI, cardiovascular, or neurological diseases. The patient also mentioned intermittent cough and mild dyspnea initiated the morning of admission day. On physical examination, other than mild tachycardia and tachypnea, there were no notable findings. Following an abnormal chest X-Ray, a chest CT scan was carried out, and peripheral ground-glass opacities along with scattered round opacities were identified in both lungs' fields. Given the strong suspicion of COVID-19, an RT-PCR test was performed, and the symptomatic treatment was initiated. The patient was diagnosed with COVID-19 following the PCR result release. The treatment was initiated per the protocol, and the patient was transferred to the isolated room and discharged after four days following the relief of the symptoms. CONCLUSION: It is critical for medical practitioners to seriously consider the possibility of COVID-19 in a patient with similar presentations and isolate the patient at the asymptomatic stages to eliminate the possibility of virus transmission.

COVID-19 presenting as persistent hiccups: a case report.

Hiccups are involuntary, spasmodic contractions of the diaphragm and intercostal muscles and can be classified as acute (< 48 h), persistent (48 h to a month) or intractable (> 1 month). A previously healthy 29-year-old man sought the Emergency Department with flu-like symptoms and a two-day history of persistent hiccups. His physical examination was otherwise unremarkable and vital signs were within normal limits. An unenhanced computed tomography scan of the chest showed small focal ground-glass opacities scattered throughout 25% of the lungs. A COVID-19 test was positive. Chlorpromazine was prescribed for the hiccups with improvement over 10 h. The patient was discharged home on the same day without hiccups and no other complications.

Levosulpiride Relieved Persistent Hiccups in a Patient With COVID-19 and Vascular Cognitive Impairment.

BACKGROUND: The coronavirus disease 2019 (COVID-19) is a systemic illness that implies neurological features and complications. Persistent (>48 hours) hiccups (ie, singultus or hiccoughs) have been recently described as a rare presentation of COVID-19. Even when considered benign, the frequency and duration of hiccup spells can be burdensome and sometimes difficult to treat. CASE PRESENTATION: We report the case of a 62-year-old man known by the treating physicians for vascular cognitive impairment, who consulted for progressive persistent hiccups that commenced 5 days earlier, about 24 hours after testing positive for the severe acute respiratory syndrome coronavirus 2 by real-time reverse transcription polymerase chain reaction. The patient could barely sleep because the hiccups reached the highest rate of 47 per minute in a spell lasting almost 72 hours. The patient initially received levomepromazine 25 mg by mouth, but sedation and delirium impeded the continuation of treatment, which only reduced the frequency of the hiccup spells by about 25%. Afterward, the patient was offered levosulpiride 25 mg thrice a day by mouth, resulting in a steady reduction in the hiccups rate, as well as the duration and daily frequency of spells, which disappeared after 3 days of levosulpiride treatment. COVID-19 pneumonia was moderate by chest computed tomography scan imaging and biomarkers, meriting continuous oxygen therapy, dexamethasone 6 mg once a day by mouth for 10 days, and enoxaparin 40 mg once a day, subcutaneously, for 7 days (due to elevated D-dimer serum concentration). Oxygen therapy was gradually withdrawn after 12 days. CONCLUSIONS: Oral levosulpiride is a suitable option in persistent hiccups that occur in patients with COVID-19 pneumonia. To our knowledge, this is the fourth published case of persistent hiccups as a clinical feature of COVID-19.

Case Report: Two Cases of Persistent Hiccups Complicating COVID-19.

Two cases are presented with coronavirus disease 19 (COVID-19)-related hiccups: one during initial presentation and one 10 days after COVID-19 diagnosis. Hiccups in both patients were resistant to treatment and responded only to chlorpromazine. COVID-19 patients may present with hiccups and also may have hiccups after treatment. Resistant hiccups without any underlying disease other than COVID-19 should be considered in association with COVID-19 and may respond well to chlorpromazine.

Posterior circulation stroke presenting as a new continuous cough: not always COVID-19.

A 19-year-old man was admitted with a 2-week history of continuous cough along with a day history of acute onset unsteadiness and hiccups. Given the current pandemic, he was initially suspected to have COVID-19, however he tested negative on two occasions. Subsequent brain magnetic resonance imaging (MRI)confirmed a small left acute and subacute lateral medullary infarction with chest X-ray suggesting aspiration pneumonia with right lower lobe collapse. This is a distinctive case of posterior circulation stroke presenting with a new continuous cough in this era of COVID-19 pandemic. We anticipate based on MRI findings that his persistent cough was likely due to silent aspiration from dysphagia because of the subacute medullary infarction. It is therefore imperative that healthcare workers evaluate people who present with new continuous cough thoroughly to exclude any other sinister pathology. We should also be familiar with the possible presentations of posterior circulation stroke in this pandemic era.

Persistent hiccup: A rare presentation of COVID-19.

BACKGROUND: Hiccups are involuntary diaphragmatic muscle contractions with early glottis closure terminating inspiration. They are classified into two types: acute (<48 hours) and persistent (>48 hours). COVID-19 is the defining health crisis of our generation. Although there are common symptoms of the disease (e.g. fever, cough), several atypical presentations have appeared as the pandemic has evolved. Here, we present a patient with COVID-19 presenting with fever, sore throat, and persistent hiccups. METHODS AND RESULTS: A 48-year-old man presented to the hospital with a seven-day history of persistent hiccups, fever, and sore throat. Physical examination was unremarkable and abdominal ultrasound showed gaseous abdominal distension. Laboratory values were remarkable for elevated C-reactive protein, ferritin, and lactate dehydrogenase levels. Computed tomography of the chest showed bilateral subpleural areas of ground-glass attenuation and crazy-paving pattern. A COVID-19 test was positive, and hydroxychloroquine, oseltamivir, baclofen, and symptomatic treatment were initiated. The hiccups improved, and the patient was discharged home after ten days. CONCLUSION: Physicians should maintain a high level of suspicion and be aware of atypical presentations of COVID-19.

Detection of SARS-CoV-2 nucleic acid in CSF by ultrahigh depth sequencing in a patient with COVID-19 and neurological dysfunction: a case report (preprint)

Background: SARS-Coronavirus-2 (SARS-CoV-2), the pathogen of coronavirus disease 2019 (COVID-19), not only infects the respiratory tract, but also other organs. About a third of the inpatients of COVID-19 have neurological symptoms and in vitro experiments revealed that SARS-CoV-2 could infect human neural progenitor cells and brain organoids. However, the traditional test often reports negative owing to the low number of virus in the cerebrospinal fluid. To date, timely diagnosis of central nervous system infection of SARS-CoV-2 remains a challenge.Case presentation: On day 14 of COVID-19, seizures, maxillofacial convulsions, intractable hiccups and significant increase in intracranial pressure developed in a 56-year-old man. The RT-PCR of SARS-CoV-2 was negative. SARS-CoV-2 nucleic acid were detected in cerebrospinal fluid (CSF) by ultrahigh depth sequencing. The patient was successfully treated after 14 days of mechanical ventilation and treatment of pneumonia and neurological dysfunction.Conclusions: This case suggests SARS-CoV-2 can invade the central nervous system and relevant examinations with CSF including ultrahigh depth sequencing of SARS-CoV-2 are needed among COVID-19 patients with neurological dysfunction.

Neurological manifestations associated with COVID-19: a nationwide registry (preprint)

Background: The clinical description of the neurological manifestations in COVID-19 patients is still underway. This study aims to provide an overview of the spectrum, characteristics and outcomes of neurological manifestations associated with SARS-CoV-2 infection. Methods: We conducted a nationwide, multicentric, retrospective study during the French COVID-19 epidemic in March-April 2020. All COVID-19 patients with de novo neurological manifestations were eligible. Results: We included 222 COVID-19 patients with neurological manifestations from 46 centers throughout the country. Median age was 65 years (IQR 53-72), and 136 patients (61.3%) were male. COVID-19 was severe or critical in almost half of the patients (102, 45.2%). The most common neurological diseases were COVID-19 associated encephalopathy (67/222, 30.2%), acute ischemic cerebrovascular syndrome (57/222, 25.7%), encephalitis (21/222, 9.5%), and Guillain-Barre Syndrome (15/222, 6.8%). Neurological manifestations appeared after first COVID-19 symptoms with a median (IQR) delay of 6 (3-8) days in COVID-19 associated encephalopathy, 7 (5-10) days in encephalitis, 12 (7-18) days in acute ischemic cerebrovascular syndrome and 18 (15-28) days in Guillain-Barre Syndrome. Brain imaging was performed in 192 patients (86.5%), including 157 MRI (70.7%). Brain MRI of encephalitis patients showed heterogeneous acute non vascular lesion in 14/21 patients (66.7%) with associated small ischemic lesion or microhemorrhages in 4 patients. Among patients with acute ischemic cerebrovascular syndrome, 13/57 (22.8%) had multi territory ischemic strokes, with large vessel thrombosis in 16/57 (28.1%). Cerebrospinal fluid was analyzed in 97 patients (43.7%), with pleocytosis in 18 patients (18.6%). A SARS-CoV-2 PCR was performed in 75 patients and was positive only in 2 encephalitis patients. Among patients with encephalitis, ten out of 21 (47.6%) fully recovered, 3 of whom received corticosteroids (CS). Less common neurological manifestations included isolated seizure (8/222, 3.6%), critical illness neuropathy (8/222, 3.6%), transient alteration of consciousness (5/222, 2.3%), intracranial hemorrhage (5/222, 2.3%), acute benign lymphocytic meningitis (3/222, 1.4%), cranial neuropathy (3/222, 1.4%), single acute demyelinating lesion (2/222, 0.9%), Tapia syndrome (2/222, 0.9%), cerebral venous thrombosis (1/222, 0.5%), sudden paraparesis (1/222, 0.5%), generalized myoclonus and cerebellar ataxia (1/222, 0.5%), bilateral fibular palsy (1/222, 0.5%) and isolated neurological symptoms (headache, anosmia, dizziness, sensitive or auditive symptoms, hiccups, 15/222, 6.8%). The median (IQR) follow-up of the 222 patients was 24 (17-34) days with a high short-term mortality rate (28/222, 12.6%). Conclusion: Neurological manifestations associated with COVID-19 mainly included CAE, AICS, encephalitis and GBS. Clinical spectrum and outcomes were broad and heterogeneous, suggesting different underlying pathogenic processes.

Persistent Hiccups as atypical presentation of COVID-19: a Case Report (preprint)

The recent  outbreak of SARS-CoV-2 has become pandemic since it began in late 2019. Typical symptoms include cough, shortness of breath or difficulty breathing, fever, myalgia and sore throat. There are other unusual or atypical presentations of COVID-19 in ORL practice.  We report a 64-year-old male patient presenting with hiccups as the only symptom. Chest x-ray ray revealed new ground-glass opacities in both lung fields and he was found to be COVID-19 positive by RT-PCR. Early recognition of the COVID-19 atypical presentations by the Otolaryngologist facilitates subsequent management and case isolation to eliminate the risk of viral transmission. 

Knowledge, Attitude and Practice Towards Novel Corona Virus among Bangladeshi People: Implications for mitigation measures (preprint)

The current novel coronavirus (nCoV) outbreak, COVID-19, was first reported in December 2019 in Wuhan, China has spread all over the world causing startling loss of lives, stalling the global economy and disrupting the social life. One of the challenges to contain the COVID-19 is making people adopt personal hygiene, social distancing and self-quarantine practices which are all related to knowledge, attitude and practice (KAP) of the people in respective countries. Bangladesh, the most densely populated countries with a fast-growing economy and moderate literacy rate, has shown many hiccups in its efforts to implement COVID-19 policies. Understanding KAP may give the policy makers to make informed decisions. Hence, this study aimed to make a quick assessment of KAP of people in relation to COVID-19 in Bangladesh. An online survey using a pre-tested questionnaire conducted in late March 2020 attained 1837 responses across Bangladesh. However, 1589 completed responses were included in statistical analysis to calculate KAP scores, their interrelations with socio-demographic variables. The overall KAP is poor with only 10% of the respondents showed good knowledge with parallel attitudes and practices. Socio-demographic factors have strong bearings on the KAP scores. Significantly higher KAP score is evident in female over male respondents, among aged (45 years and above) over younger respondents and among retired and homemakers above students and public service holders. The study indicated a panic fuelled by poor understanding of COVID-19 associated facts and the need for the government to ensure more granular and targeted awareness campaigns in a transparent and factual manner to gain public confidence and arrest more meaningful public participation in mitigation measures. The study provides a baseline of KAP among people in Bangladesh on COVID-19.

Persistent hiccups as an atypical presenting complaint of COVID-19.

Hiccups (singultus) are reflex inspiratory movements that involve the swallowing reflex arc and can be classified as acute (<48 h) or persistent (>48 h). A 62-year-old man with no history of malignancy or pulmonary disease presented to the Emergency Department with a four-day history of persistent hiccups. Other than episodic hiccupping, his physical examination was otherwise unremarkable. An abnormal chest X-ray led to a CT scan of the chest with IV contrast, which demonstrated regional, peripheral groundglass opacities of the upper lobes with small focal groundglass opacities scattered throughout the lungs. He was tested for COVID-19 per admission protocol, started on hydroxychloroquine, his hiccups improved, and he was discharged to home after 3 days. An emergency medicine physician should keep COVID-19 on the differential and be vigilant of exposure in atypical presentations.