Acute Neurological Manifestations of COVID-19 Patients From Three Tertiary Care Hospitals in Qatar.

Introduction Worldwide, there are more than 424 million confirmed cases of COVID-19. Most of the hospitalized critical COVID-19 patients manifested neurological signs and symptoms and higher mortality. The majority of COVID-19 fatalities occurred mostly in patients with advanced age and underlying medical comorbidities. This is the first local retrospective study in Qatar, which reported neurologic manifestations (48.5%) of hospitalized COVID-19 patients. The primary objective of this study is to evaluate acute neurological manifestations in COVID-19 hospitalized patients in the country. Methods This is a retrospective, observational study of 413 hospitalized COVID-19 patients. They were admitted to three different COVID-19 designated hospitals (Hazm Mebaireek, Ras Laffan, and Cuban tertiary care Hospitals) under the Hamad Medical Corporation, Qatar from 1st January 2020, to 31 January 2021. We evaluated electronic medical records of these patients and data were collected while their neurological manifestations were confirmed by two trained neurologists. These neurologic manifestations were categorized into three major groups: central nervous system (CNS), peripheral nervous system (PNS), and neuromuscular system. Results Of 413 patients, 94% (389) were male and 6% (24) were female; the mean age was 52 years. Among all different nationalities of COVID-19 patients, 20.3% (84) were Indian, 12.5% (52) were Bangladeshi, 10.1% (42) were Qatari and 9.2% (38) were Nepali. The most common symptoms at the onset of COVID-19 illness were as follows: 77.5% (321) had a fever, 67.4% (279) experienced cough, 58.7% (243) experienced shortness of breath and 26.1% (108) developed a sore throat. Overall 48.5% (201) patients developed different neurologic manifestations. The most common neurologic symptoms were myalgia (28%; 116), headache (10.4%; 43), dizziness (5.8%; 24) and hemiparesis due to strokes (5.3%; 22). In this study, the most common risk factors were hypertension (47.6%), diabetes (46.9%), obesity (21%), chronic kidney disease (10%), ischemic heart disease (9.7%), and smoking (6.8%). About 45.2% (187) patients were admitted to MICU and 8.5% (35) died due to COVID-19 complications. Significant other extrapulmonary multiorgan system involvement were skeletal muscle injury (39.4%), kidney injury (36.7%), liver injury (27.5%), myocardial injury (23.9%), rhabdomyolysis (15.7%) heart failure (11.4%) and acute pancreatitis (11.1%). Discussion The most common neurologic signs and symptoms were myalgia, headache, dizziness, and strokes, mainly due to large vessel thrombosis, lacunar, and posterior circulation strokes. Conclusions Patients with COVID-19 are at high risk of developing neurological manifestations. The most common COVID-19-related acute neurological manifestations were myalgia, headache, dizziness, and acute ischemic stroke. Prompt recognition, early diagnosis, and appropriate management of these manifestations could potentially lead to better patient outcomes in COVID-19 patients.

Acute Myocardial Injury and Rhabdomyolysis in COVID-19 Patients: Incidence and Mortality.

Background Myocardial injury has been defined as an elevated troponin level. The frequency of acute myocardial injury of hospitalized coronavirus disease 2019 (COVID-19) patients ranges from 7% to 36%. COVID-19 patients with cardiovascular disease (CVD) have a four-fold higher risk of mortality (odds ratio, 4.33; CI 95%, 3.16-5.94). In COVID-19 hospitalized patients' study showed mortality rate was 18.5%. Rhabdomyolysis is considered as muscle necrosis and the release of intracellular muscles elements and enzymes into blood. In one of retrospective cohort study of COVID-19 hospitalized patients, incidence of rhabdomyolysis was 16.7%. Materials and methods This retrospective observational study consisted of 413 COVID-19 hospitalized patients. Patients with rhabdomyolysis was defined as creatine kinase level greater than 1,000 U/L and acute myocardial injury was defined as serum high-sensitivity troponin-T for males greater than 30 ng/l and for female greater than 20 ng/l. The primary outcome was in-hospital mortality of COVID-19 patients with acute myocardial injury and rhabdomyolysis.  Results The incidence of acute myocardial injury and rhabdomyolysis in hospitalized COVID-19 patients was 23.9% (99) and 15.7% (65), respectively. The mortality rate of in hospitalized COVID-19 patients who developed acute myocardial injury (28.3%) was significantly higher in comparison to patients who developed rhabdomyolysis (13.8%). Discussion The binding of SARS-CoV-2 virus to the angiotensin-converting enzyme 2 (ACE2) is a critical step in the pathophysiology in patients with COVID-19. There may be diverse direct and indirect mechanisms of acute myocardial injury in COVID-19 including ischemic injury, hypoxic injury (MI type 2), direct viral myocarditis, stress cardiomyopathy and systemic cytokine storm. Musculoskeletal injury may be caused by direct viral myositis or indirectly by host immune hyperinflammatory cytokine storm response that leads to skeletal muscle fiber proteolysis and fibrosis. Conclusions Acute myocardial injury and rhabdomyolysis were underreported in COVID-19 patients. The incidence and mortality of acute myocardial injury are higher than that of rhabdomyolysis in COVID-19 hospitalized patients. The outcome was worse in COVID-19 patients with severe acute myocardial injury. Patients with acute myocardial injury and rhabdomyolysis may get benefits from rehabilitation programs.

Severe Hypothyroidism Presenting With Rhabdomyolysis in a Young Patient.

Rhabdomyolysis is an uncommon but potentially life-threatening medical condition. The acute muscle breakdown leads to the release of toxic muscle contents which can damage the kidneys and can cause the development of acute kidney injury (AKI) and fatal electrolyte imbalances associated with high morbidity and mortality. There are a variety of causes including exposure to extremely hot weather, toxins, trauma, certain drugs, and rarely endocrine disorders in particular thyroid dysfunction. It is more common among a certain group of people, for example, enthusiastic athletes, physical laborers, military and police personnel working in hot and humid weather. Moreover, it is also seen in patients using certain medications, and in the elderly following a fall and prolonged laying on the floor. The majority of the patients develop acute kidney failure and treatment with intravenous hydration and the underlying cause remains the mainstay of management. Our case demonstrates the rare occurrence of AKI induced by rhabdomyolysis in patients with severe hypothyroidism. A 36-years-old male presented with generalized body pains, arthralgias, weight gain, and ankle edema of three months duration. On investigations, he was found to have severe hypothyroidism, AKI along with raised creatinine kinase (CK) and myoglobin indicating severe muscle damage. He was treated with intravenous (IV) fluids and oral levothyroxine in accordance with endocrine team advice. This case highlights the significance of investigating acute rhabdomyolysis with thyroid function tests if no other cause is apparent from history like hyperthermia/drugs/toxins as in our case. Timely diagnosis and treatment of underlying pathology improve patient outcomes.

Dapagliflozin, as Add-on Therapy in Type 2 Diabetes Patients, Is Associated With a Reduction in Albuminuria and Serum Transaminase Levels.

Introduction: SGLT-2 inhibitors are shown to be nephroprotective, slowing progression of nonalcoholic steatohepatitis (NASH) in addition to improving glycemic control in patients with type 2 diabetes (T2D). To date, no real-life clinical data is available on the effect of SGLT-2 inhibitors on urine albumin-creatinine ratio (ACR) and liver enzymes in a Middle Eastern population. Therefore, we evaluated the effect of dapagliflozin (DAPA) on urine ACR, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) when added to standard therapy for T2D. Methods: This is an observational study of 40 patients with T2D in whom DAPA was added to their existing anti-diabetic regimen to improve glycemic control. The primary outcomes were changes in serum transaminase level and urine albumin-to-creatinine ratio (ACR). Secondary outcomes include changes in glycosylated hemoglobin (HbA1C), body mass index (BMI), oral hypoglycemic agents and insulin dose. Results: Whole group analysis showed a reduction in ALT (p<0.0001), (AST) (p=0.009), ACR (p=0.009) and BMI (p<0.0001) following DAPA treatment. Further sub-group analysis showed that patients on insulin and DAPA combination had a reduction in ACR (p=0.0090), ALT (p=0.0312), BMI (p=0.0007) and HbA1c (p<0.0001) compared to the sulfonylurea and DAPA combination group. In the sulfonylurea and DAPA combination group, there was a reduction in the sulfonylurea requirement following DAPA therapy (p=0.0116), with reductions in ALT (p=0.0122), AST (p=0.0362), BMI (p=0.0026) and HbA1c (p<0.0001) but with no change in ACR (p=0.814). Conclusion: In routine clinical practice, the addition of DAPA to standard medical therapy is well tolerated and beneficial for T2D patients and is associated with a reduction of ALT and ACR.