Anterior interosseous nerve syndrome following infection with COVID-19: a case report.

BACKGROUND: Various neurological manifestations associated with coronavirus disease 2019 have been increasingly reported. Herein, we report a rare case of anterior interosseous nerve syndrome, which occurred 5 days after the onset of coronavirus disease 2019. CASE PRESENTATION: A 62-year-old Asian woman with a history of coronavirus disease 2019 who developed a complete motor deficit in the left flexor pollicis longus and pronator quadratus without sensory deficits. The symptoms appeared as a sudden onset fatigue and severe pain of the left arm, 5 days after the onset of coronavirus disease 2019. She noticed paralysis of the left thumb at 2 weeks after the onset of coronavirus disease 2019. Electromyography assessment of the anterior interosseous nerve-dominated muscles revealed neurogenic changes such as positive sharp wave and fibrillation in flexor pollicis longus and pronator quadratus, confirming the diagnosis of anterior interosseous nerve syndrome. There were no other diseases that could have resulted in peripheral nerve palsy. We performed a functional reconstruction surgery of the thumb by tendon transfer from the extensor carpi radialis longus to the flexor pollicis longus. The patient reported a good patient-reported outcome (2.27 points in QuickDASH Disability/Symptom scoring and 5 points in Hand20 scoring) at final follow-up (1 year after the surgery). CONCLUSION: This case highlights the need for vigilance regarding the possible development of anterior interosseous nerve syndrome in patients with coronavirus disease 2019. Tendon transfer from extensor carpi radialis longus to flexor pollicis longus can provide good functional recovery for unrecovered motor paralysis after anterior interosseous nerve syndrome.

Third cranial nerve palsy due to COVID-19 infection.

We report a case of a previously healthy man in his 40s who presented with mild SARS-CoV-2 infection (COVID-19) concomitant with acute onset of left third cranial nerve palsy with restricted supraduction, adduction and infraduction. Our patient did not present any history of hypertension, hyperlipidaemia, diabetes mellitus or smoking. The patient recovered spontaneously without any antiviral treatment. To our knowledge, this is the second report of third cranial nerve palsy spontaneously resolved without any risk factors of vascular disease, specific image findings, nor any possible causes other than COVID-19. In addition, we reviewed 10 other cases of third cranial nerve palsy associated with COVID-19, which suggested that the aetiology varies greatly. As a clinician, it is important to recognise COVID-19 as a differential diagnosis for third cranial nerve palsy. Finally, we aimed to encapsulate the aetiologies and the prognosis of the third cranial nerve palsy associated with COVID-19.

Single-cell transcriptomics identifies different immune signatures between macrophage activation-like syndrome and immune paralysis in sepsis (preprint)

Different immune phenotypes characterize sepsis patients, including hyperinflammation and/or immunosuppression, but the biological mechanisms driving this heterogeneity remain largely unknown. We used single-cell RNA sequencing to profile circulating leukocytes of healthy controls and sepsis patients classified as either hyperinflammatory (macrophage activation-like syndrome [MALS]), immune paralysis, or unclassified (when criteria for neither of these two immune subgroups were applicable). Pronounced differences were detected in the transcriptional signature of monocytes from sepsis patients, with clear distinction between MALS and immune paralysis patients. Unsupervised clustering analysis revealed the existence of MALS-specific monocyte clusters, as well as one sepsis-specific monocyte cluster that was linked to disease severity. In separate cohorts, urosepsis was characterized by heterogeneous MALS and immunosuppression monocyte signatures, while MALS-specific monocyte clusters showed overlapping transcriptional signatures with severe COVID-19. In conclusion, our findings shed light on the heterogeneous immune landscape underlying sepsis, and provide opportunities for patient stratification for future therapeutic development.

Characteristics of Delirium and Its Association with Sedation and In-Hospital Mortality in COVID-19 Patients on Veno-venous Extracorporeal Membrane Oxygenation (preprint)

Background Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been used in patients with COVID-19 acute respiratory distress syndrome (ARDS). We aim to assess the characteristics of delirium and describe its association with sedation and in-hospital mortality. Methods We retrospectively reviewed adult patients on VV-ECMO for severe COVID-19 ARDS in the Johns Hopkins Hospital ECMO registry in 2020-2021. Delirium was assessed by the Confusion Assessment Method for the ICU when patients scored -3 or above on Richmond Agitation-Sedation Scale (RASS). Primary outcomes were delirium prevalence while on VV-ECMO and categorization of VV-ECMO days based on delirium status. Results Of 47 patients (median age=51) with 6 in a persistent coma, 40 of the remaining 41 patients (98%) had ICU delirium. Delirium in the survivors (n=21) and non-survivors (n=26) was first detected at a similar time point (day 9.5[5, 14] vs. 8.5[5, 21], p=0.56) with similar total delirium days (9.5[3.3, 16.8] vs. 9.0[4.3, 28.3], p=0.43), but the RASS scores on VV-ECMO were numerically lower in non-survivors (-3.72[-4.42, -2.96] vs. -3.10[-3.91, -2.21], p=0.06). Non-survivors had significantly prolonged median delirium days (27.3[17.4, 46.4] vs. 17.0[9.9, 28], p=0.04), delirium-unassessable days on VV-ECMO with a RASS of -4/-5 (23.0[16.3, 38.3] vs. 17.0[6, 23], p=0.03), and total VV-ECMO days (44.5[20.5, 74.3] vs. 27.0[21, 38], p=0.04). The proportion of delirium-present days correlated with RASS (r=0.64, p<0.001), proportion of days with a neuromuscular blocker (r=-0.59, p=0.001) and delirium-unassessable exams (r=-0.69, p<0.001), but not with overall ECMO duration (r=0.01, p=0.96). Average daily dosage of delirium-related medications on ECMO days did not differ significantly between survivors and non-survivors. On multivariable logistic regression, proportion of delirium days was not associated with mortality. Conclusions Longer duration of delirium was associated with lighter analgosedation and shorter paralysis, but the condition did not discern in-hospital mortality. Future studies should evaluate analgosedation and paralytic strategies to optimize delirium, sedation level, and outcomes.

Crude Extracts of Talaromyces Strains (Ascomycota) Affect Honey Bee (Apis mellifera) Resistance to Chronic Bee Paralysis Virus.

Viruses contribute significantly to the global decline of honey bee populations. One way to limit the impact of such viruses is the introduction of natural antiviral compounds from fungi as a component of honey bee diets. Therefore, we examined the effect of crude organic extracts from seven strains of the fungal genus Talaromyces in honey bee diets under laboratory conditions. The strains were isolated from bee bread prepared by honey bees infected with chronic bee paralysis virus (CBPV). The antiviral effect of the extracts was also quantified in vitro using mammalian cells as a model system. We found that three extracts (from strains B13, B18 and B30) mitigated CBPV infections and increased the survival rate of bees, whereas other extracts had no effect (B11 and B49) or were independently toxic (B69 and B195). Extract B18 inhibited the replication of feline calicivirus and feline coronavirus (FCoV) in mammalian cells, whereas extracts B18 and B195 reduced the infectivity of FCoV by ~90% and 99%, respectively. Our results show that nonpathogenic fungi (and their products in food stores) offer an underexplored source of compounds that promote disease resistance in honey bees.

Neuro-ophthalmologic symptoms after coronavirus disease 2019 vaccination: a retrospective study.

BACKGROUND: There have been several studies on inflammatory ophthalmic diseases; however, few studies have reported neuro-ophthalmological symptoms, such as diplopia and ocular motor nerve palsy, after coronavirus disease 2019 (COVID-19) vaccination. Therefore, this study aimed to report neuro-ophthalmological symptoms in patients after COVID-19 vaccination. METHODS: This was a retrospective study based on the medical records of 10 patients who visited our ophthalmology clinic in 2021 with symptoms, such as diplopia (nine patients) and decreased visual acuity (one patient), and showed findings, such as ocular motor nerve palsy, after vaccination against COVID-19. RESULTS: One patient had third nerve palsy, two had sixth nerve palsy, and five had fourth nerve palsy. One patient complained of subjective binocular diplopia but all test results were normal. One patient presented with decreased visual acuity accompanied by a sudden increase in intraocular pressure and orbital cellulitis in the other eye. The symptoms improved gradually in most patients. Compared with previous studies, this study reported three cases of antiplatelet therapy that was initiated due to the older age of the patients and underlying diseases. CONCLUSION: As COVID-19 vaccines can cause neuro-ophthalmological diseases, such as ocular motor nerve palsy, patients' age and underlying diseases should be considered while administering them.

Post-COVID-19 rhinocerebral mucormycosis, a life-threatening event in the background of immunosuppressive condition: A case report (preprint)

Introduction: In patients suffering from COVID-19, immunocompromised conditions or immunosuppressive medications such as corticosteroids may predispose them to early or delayed invasive fungal infections that invade cerebral components. This study, for the first time, describes a case of COVID-19 disease diagnosed with rhinocerebral mucormycosis through cerebrospinal fluid (CSF) analysis.Case presentation: A 32-year-old woman with a history of referral and hospitalization due to COVID-19 about a month ago was being treated with immunosuppressive drugs, manifested by lower extremity plegia. In the imaging assessment, intracranial hemorrhage (thalamus zone) and mass like lesion were revealed. In cytological assessment, acute inflammations associated with fungal infection in accordance with the diagnosis of mucormycosis were definitively confirmed. Despite antifungal medication, consciousness declined one week later, and the patient developed thromboembolism and died.Conclusion In patients with a COVID-19 background of immunosuppressive therapy or clinical situations related to immunosuppression such as uncontrolled diabetes, rhinocerebral mucormycosis will always be an ambush. Therefore, screening and prevention measures should be considered.

Facial nerve palsy following the administration of COVID-19 mRNA vaccines: analysis of a self-reporting database.

OBJECTIVES: Facial nerve palsy (or Bell's palsy) has occasionally been reported following the administration of coronavirus disease 2019 (COVID-19) mRNA vaccines (BNT162b2 and mRNA-1273). Our study investigated such cases using a large self-reporting database from the USA (Vaccine Adverse Event Reporting System [VAERS]). METHODS: A disproportionality analysis, adjusted for age and sex, was conducted for VAERS reports from individuals who were vaccinated at the age of 18 years or over, between January 2010 and April 2021. RESULTS: The analysis revealed that the adverse events following immunization (AEFI) of facial nerve palsy, after administration of COVID-19 mRNA vaccines, was significantly highly reported, both for BNT162b2 (reporting odds ratio [ROR] 1.84; 95% confidence interval [CI] 1.65-2.06) and mRNA-1273 (ROR 1.54; 95% CI 1.39-1.70). These levels were comparable to that following influenza vaccination reported before the COVID-19 pandemic (ROR 2.04; 95% CI 1.76-2.36). CONCLUSIONS: Our pharmacovigilance study results suggest that the incidence of facial nerve palsy as a non-serious AEFI may be lower than, or equivalent to, that for influenza vaccines. This information might be of value in the context of promoting worldwide vaccination, but needs to be validated in future observational studies.

Venovenous Extracorporeal Membrane Oxygenation After Cardiac Arrest for Acute Respiratory Distress Syndrome Caused by Legionella: A Case Report (preprint)

Background: Legionella remains underdiagnosed in the intensive care unit and can progress to acute respiratory distress syndrome (ARDS), multiorgan failure and death. In severe cases, venovenous extracorporeal membrane oxygenation (VV-ECMO) allows time for resolution of disease with Legionella-targeted therapy. VV-ECMO outcomes for Legionella are favorable with reported survival greater than 70%. Rapid molecular polymerase chain reaction (PCR) testing of the lower respiratory tract aids in diagnosing Legionella with high sensitivity and specificity. We present a unique case of a patient with a positive COVID-19 test and ARDS who suffered a cardiac arrest. The patient was subsequently cannulated for VV-ECMO, and after lower respiratory tract PCR testing, Legionella was determined to be the cause. She was successfully treated and decannulated from VV-ECMO after 8 days.Case Presentation: A 53-year-old female presented with 1 week of dyspnea and a positive COVID-19 test. She was hypoxemic, hypotensive and had bilateral infiltrates on imaging. She received supplemental oxygen, intravenous fluids, vasopressors, broad spectrum antibiotics, and was transferred to a tertiary care center. She developed progressive hypoxemia and suffered a cardiac arrest, requiring 10 minutes of CPR and endotracheal intubation to achieve return of spontaneous circulation (ROSC). Despite mechanical ventilation and paralysis, she developed refractory hypoxemia and was cannulated for VV-ECMO. Dexamethasone and remdesivir were given for presumed COVID-19. Bronchoscopy with bronchoalveolar lavage (BAL) performed with PCR testing was positive for Legionella pneumophila and negative for COVID-19. Steroids and remdesivir were discontinued and she was treated with azithromycin. Her lung compliance improved, and she was decannulated after 8 days on VV-ECMO. She was discharged home on hospital day 16 breathing room air and neurologically intact.Conclusions: This case illustrates the utility of rapid PCR testing to diagnose Legionella in patients with respiratory failure and the early use of VV-ECMO in this patient population. Moreover, many patients encountered in the ICU may have prior COVID-19 immunity, and though a positive COVID-19 test may be present, further investigation with lower respiratory tract PCR testing may provide alternative diagnoses. Patients with ARDS should undergo Legionella-specific testing, and if positive, early VV-ECMO should be considered in patients with refractory hypoxemia.

Physicians' attitudes and perceptions of neuromuscular blocker infusions in ARDS.

PURPOSE: The perceptions and practices of ICU physicians regarding initiating neuromuscular blocker infusions (NMBI) in acute respiratory distress syndrome (ARDS) may not be evidence-based amidst the surge of severe ARDS during the SARS-CoV-2 pandemic and new practice guidelines. We identified ICU physicians' perspectives and practices regarding NMBI use in adults with moderate-severe ARDS. MATERIALS AND METHODS: After extensive development and testing, an electronic survey was distributed to 342 ICU physicians from three geographically-diverse U.S. health systems(n = 12 hospitals). RESULTS: The 173/342 (50.5%) respondents (75% medical) somewhat/strongly agreed a NMBI should be reserved until: after a trial of deep sedation (142, 82%) or proning (59, 34%) and be dose-titrated based on train-of-four monitoring (107, 62%). Of 14 potential NMBI risks, 2 were frequently reported to be of high/very high concern: prolonged muscle weakness with steroid use (135, 79%) and paralysis awareness due to inadequate sedation (114, 67%). Absence of dyssychrony (93, 56%) and use ≥48 h (87, 53%) were preferred NMBI stopping criteria. COVID-19 + ARDS patients were twice as likely to receive a NMBI (56 ± 37 vs. 28 ± 19%, p < 0.01). CONCLUSIONS: Most intensivists agreed NMBI in ARDS should be reserved until after a deep sedation trial. Stopping criteria remain poorly defined. Unique considerations exist regarding the role of paralysis in COVID-19+ ARDS.

Perspectives about COVID-19 vaccine boosters among the U.S. paralysis community.

PURPOSE/OBJECTIVE: We sought to explore perspectives of the paralysis community about COVID-19 vaccine boosters. RESEARCH METHOD/DESIGN: Data were collected through an online survey with multiple choice and open-ended questions from adult persons with paralysis (PWP), persons with other disabilities, and other members of the paralysis community (Christopher & Dana Reeve Foundation Supporters, FS). PWP and persons with other disabilities were grouped into one group (persons with disabilities, PWD) for most analyses. Multiple choice questions were analyzed using descriptive statistics and chi-square analyses were conducted to compare the PWD and FS groups; open-ended responses were coded using Hamilton's rapid assessment process. RESULTS: A total of 774 participants (740 PWD and 304 FS) responded to the survey. PWD were less likely to agree that they felt well-informed about boosters, that the boosters were safe, and that their state and federal governments provide transparent information about boosters. Of those who had not received a booster, PWP were less likely than the rest of the sample to plan to receive one. Both groups expressed similar concerns about the boosters, but distrust was a more common concern for PWD than for FS. Both groups expressed concerns about side effects and the boosters affecting a health condition, but PWP expressed concerns unique to paralysis and neurological difficulties. CONCLUSIONS: Although PWD shared concerns with the FS group, distrust is a larger issue and concerns unique to PWD that must be considered in public health efforts to ensure that the paralysis community is treated equitably. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Bundled Bispectral Index Monitoring and Sedation During Paralysis in Acute Respiratory Distress Syndrome.

BACKGROUND: Clinical assessments of depth of sedation are insufficient for patients undergoing neuromuscular blockade during treatment of acute respiratory distress syndrome (ARDS). This quality initiative was aimed to augment objective assessment and improve sedation during therapeutic paralysis using the bispectral index (BIS). METHODS: This quality improvement intervention provided education and subsequent implementation of a BIS monitoring and sedation/analgesia bundle in a large, urban, safety-net intensive care unit. After the intervention, a retrospective review of the first 70 admissions with ARDS assessed use and documented sedation changes in response to BIS. RESULTS: Therapeutic neuromuscular blockade was initiated for 58 of 70 patients (82.8%) with ARDS, of whom 43 (74%) had BIS monitoring and 29.3% had bundled BIS sedation-titration orders. Explicit documentation of sedation titration in response to BIS values occurred in 27 (62.8%) of those with BIS recordings. CONCLUSIONS: BIS sedation/analgesia bundled order sets are underused, but education and access to BIS monitoring led to high use of monitoring alone and subsequent sedation changes.

Anti-Inflammatory Activity of CIGB-258 against Acute Toxicity of Carboxymethyllysine in Paralyzed Zebrafish via Enhancement of High-Density Lipoproteins Stability and Functionality.

Background: Hyperinflammation is frequently associated with the chronic pain of autoimmune disease and the acute death of coronavirus disease (COVID-19) via a severe cytokine cascade. CIGB-258 (Jusvinza®), an altered peptide ligand with 3 kDa from heat shock protein 60 (HSP60), inhibits the systemic inflammation and cytokine storm, but the precise mechanism is still unknown. Objective: The protective effect of CIGB-258 against inflammatory stress of N-ε-carboxymethyllysine (CML) was tested to provide mechanistic insight. Methods: CIGB-258 was treated to high-density lipoproteins (HDL) and injected into zebrafish and its embryo to test a putative anti-inflammatory activity under presence of CML. Results: Treatment of CML (final 200 µM) caused remarkable glycation of HDL with severe aggregation of HDL particles to produce dysfunctional HDL, which is associated with a decrease in apolipoprotein A-I stability and lowered paraoxonase activity. Degradation of HDL3 by ferrous ions was attenuated by a co-treatment with CIGB-258 with a red-shift of the Trp fluorescence in HDL. A microinjection of CML (500 ng) into zebrafish embryos resulted in the highest embryo death rate, only 18% of survivability with developmental defects. However, co-injection of CIGB-258 (final 1 ng) caused the remarkable elevation of survivability around 58%, as well as normal developmental speed. An intraperitoneal injection of CML (final 250 µg) into adult zebrafish resulted acute paralysis, sudden death, and laying down on the bottom of the cage with no swimming ability via neurotoxicity and inflammation. However, a co-injection of CIGB-258 (1 µg) resulted in faster recovery of the swimming ability and higher survivability than CML alone injection. The CML alone group showed 49% survivability, while the CIGB-258 group showed 97% survivability (p < 0.001) with a remarkable decrease in hepatic inflammation up to 50%. A comparison of efficacy with CIGB-258, Infliximab (Remsima®), and Tocilizumab (Actemra®) showed that the CIGB-258 group exhibited faster recovery and swimming ability with higher survivability than those of the Infliximab group. The CIGB-258 group and Tocilizumab group showed the highest survivability, the lowest plasma total cholesterol and triglyceride level, and the infiltration of inflammatory cells, such as neutrophils in hepatic tissue. Conclusion: CIGB-258 ameliorated the acute neurotoxicity, paralysis, hyperinflammation, and death induced by CML, resulting in higher survivability in zebrafish and its embryos by enhancing the HDL structure and functionality.

SARS-CoV-19-associated Rhino-orbital and cerebral mucormycosis: clinical and radiological presentations.

We describe presenting clinical and imaging manifestations of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated Rhino-oculo-cerebral mucormycosis (ROCM) in a hospital setting during the second wave of SARS-CoV-2 pandemic in India. Data on the presenting manifestations were collected from 1 March to 31 May 2021. Associations between clinical and imaging findings were explored, specifically: (1) the presence or absence of orbital pain and infiltration of a superior orbital fissure on imaging; (2) the presence of unilateral facial nerve palsy and pterygopalatine fossa infiltration and geniculate ganglion signal on contrast magnetic resonance imaging, and (3) vision loss and optic nerve findings on imaging. Orbital pain was reported by 6/36 subjects. A fixed, frozen eye with proptosis and congestion was documented in 26 (72%), complete vision loss in 23 (64%), and a unilateral lower motor neuron facial nerve palsy in 18 (50%). No association was found between the presence of orbital pain and superior orbital fissure infiltration on imaging. The ipsilateral geniculate ganglion was found to enhance more profoundly in 7/11 subjects with facial palsy and available magnetic resonance (MR) imaging, and the ipsilateral pterygopalatine fossa was found infiltrated in 14. Among 23 subjects with complete loss of vision, 9 (39%) demonstrated long-segment bright signal in the posterior optic nerve on diffusion MR images. We conclude that orbital pain might be absent in SARS-CoV-2-associated ROCM. Facial nerve palsy is more common than previously appreciated and ischemic lesions of the posterior portion of the optic nerve underlie complete vision loss.

Unique clinical and radiological manifestations identified in the outbreak of Rhino-oculo-cerebral mucormycosis (ROCM) during the second epidemic wave of coronavirus disease 2019 (COVID-19) infection included the common occurrence of facial paralysis, frequent absence of ocular pain, and long segments of optic nerve damage.

Shoulder palsy following SARS-CoV-2 infection: two cases of typical Parsonage-Turner syndrome.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) is now known to cause neurological complications in both the central and the peripheral nervous system. Two new cases of typical neuralgic amyotrophy or Parsonage-Turner (PT) syndrome following coronavirus 2 infection (SARS-CoV-2) are reported here with explicit electrophysiological and imaging pathological features, underlining the possible association between COVID-19 and PT syndrome. CASE REPORTS: Case 1 was a 45-year-old schoolteacher presenting with acute pain in the right shoulder a few days after SARS-CoV-2 infection, with shoulder abduction and elbow flexion weakness. Needle electromyography showed a decrease in motor unit recruitment in the biceps brachii, and plexus magnetic resonance imaging (MRI) revealed a hyperintense signal involving the right C6 root and the superior truncus of the brachial plexus. Case 2 was a 21-year-old man hospitalized for dyspnea secondary to SARS-CoV-2 infection. Ten days after symptom onset, he presented right shoulder pain with difficulty in raising his right arm, revealing an isolated deficit of the serratus major muscle with a right scapula winging. Electrophysiological evaluation exhibited an isolated involvement of the long thoracic nerve with a neurogenic recruitment pattern in the serratus major muscle. Plexus MRI displayed a thickening and hyperintense signal involving the right long thoracic nerve. DISCUSSION: Parsonage-Turner syndrome triggered by SARS-CoV-2 seems to present clinical, electrophysiological and MRI characteristics similar to classic para-infectious PT syndrome, including the time frame between viral infection and neurological symptom onset. Conclusion SARS-CoV-2 might be a new infectious trigger of PT syndrome.

Low tidal volume ventilation is associated with mortality in COVID-19 patients-Insights from the PRoVENT-COVID study.

PURPOSE: Low tidal volume ventilation (LTVV) is associated with mortality in patients with acute respiratory distress syndrome. We investigated the association of LTVV with mortality in COVID-19 patients. METHODS: Secondary analysis of a national observational study in COVID-19 patients in the first wave of the pandemic. We compared COVID-19 patients that received LTVV, defined as controlled ventilation with a median tidal volume ≤ 6 mL/kg predicted body weight over the first 4 calendar days of ventilation, with patients that did not receive LTVV. The primary endpoint was 28-day mortality. In addition, we identified factors associated with use of LTVV. RESULTS: Of 903 patients, 294 (32.5%) received LTVV. Disease severity scores and ARDS classification was not different between the two patient groups. The primary endpoint, 28-day mortality, was met in 68 out of 294 patients (23.1%) that received LTVV versus in 193 out of 609 patients (31.7%) that did not receive LTVV (P < 0.001). LTVV was independently associated with 28-day mortality (HR, 0.68 (0.45 to 0.95); P = 0.025). Age, height, the initial tidal volume and continuous muscle paralysis was independently associated with use of LTVV. CONCLUSIONS: In this cohort of invasively ventilated COVID-19 patients, approximately a third of patients received LTVV. Use of LTVV was independently associated with reduced 28-day mortality. The initial tidal volume and continuous muscle paralysis were potentially modifiable factors associated with use of LTVV. These findings are important as they could help clinicians to recognize patients who are at risk of not receiving LTVV.

Is facial nerve palsy an early manifestation of COVID-19? A literature review.

The primary target of SARS-CoV-2 is the respiratory tract; nevertheless, the virus can invade extrapulmonary organs, such as the nervous system. Peripheral facial nerve palsy has been reported in COVID-19 cases as isolated, unilateral, or bilateral in the context of Guillain-Barré syndrome (GBS). In the present study, online databases, including PubMed and Google Scholar, were searched. Studies without focusing on isolated peripheral facial nerve palsy and SARS-CoV-2 were excluded. Finally, 36 patients with facial nerve palsy were included in our study using reverse transcriptase-polymerase chain reaction (RT-PCR) or antibody SARS-CoV-2 positive test. Interestingly, 23 (63.8%) of these patients had no typical history of COVID-19, and facial nerve palsy was their first clinical manifestation. The present study concludes that there is enough evidence to suggest that SARS-CoV-2 infection may present with facial nerve palsy as the initial clinical manifestation.