COVID-19-associated neurological sequelae: A case series on cerebral microbleeds and encephalopathy.

BACKGROUND: Critical illness-associated cerebral microbleeds and leukoencephalopathy connected to coronavirus disease 2019 (COVID-19) infection are emerging areas of concern in current medical literature. METHODS: We reviewed cases of patients with COVID-19-associated neurological manifestations to study the prevalence and outcome of such conditions. Case Series Findings: Our review yielded seven distinct patients. Six exhibited cerebral microbleeds, primarily localized in the juxtacortical white matter and the corpus callosum. In contrast, one individual presented with leukoencephalopathy. Tragically, of these patients, five succumbed to their ailments. One was discharged with mild cognitive impairments, while another underwent a tracheostomy and was subsequently moved to a long-term care establishment. CONCLUSION: Our findings underscore the significance of neuro-radiological observations in those grappling with severe manifestations of COVID-19, drawing attention to the possible neurological repercussions of the virus.

Neutrophil-to-lymphocyte ratio as a predictor of clinical outcomes in critically ill COVID-19 patients: A retrospective observational study.

Background: Timely identification of patients at risk of worse clinical outcomes is vital in managing coronavirus disease 2019 (COVID-19). The neutrophil-to-lymphocyte ratio (NLR) calculated from complete blood count can predict the degree of systemic inflammation and guide therapy accordingly. Hence, we did a study to investigate the role of NLR value on intensive care unit (ICU) admission in predicting clinical outcomes of critically ill COVID-19 patients. Methods: We conducted a retrospective analysis of electronic health records of COVID-19 patients admitted to ICUs at Hazm Mebaireek General Hospital, Qatar, from March 7, 2020 to July 18, 2020. Patients with an NLR equal to or higher than the cut-off value derived from the receiver operating characteristic curve were compared to those with an NLR value below the cut-off. The primary outcome studied was all-cause ICU mortality. The secondary outcomes evaluated were the requirement of mechanical ventilation and ICU length of stay (LOS). Results: Five hundred and nineteen patients were admitted to ICUs with severe COVID-19 infection during the study period. Overall, ICU mortality in the study population was 14.6% (76/519). NLR on ICU admission of ≥6.55 was obtained using Youden's index to predict ICU mortality, with a sensitivity of 81% and specificity of 41%. Mortality was significantly higher in patients with age ≥60 years (p < 0.001), chronic kidney disease (p = 0.03), malignancy (p < 0.002), and NLR ≥ 6.55 (p < 0.003). There was also a significant association between the requirement of mechanical ventilation (34.7% vs. 51.8%, p < 0.001) and increased ICU LOS (8 vs. 10 days, p < 0.01) in patients with ICU admission NLR ≥ 6.55. Conclusion: Higher NLR values on ICU admission are associated with worse clinical outcomes in critically ill COVID-19 patients.

Predictors of mortality and morbidity in critically ill COVID-19 patients: An experience from a low mortality country.

Background and Aims: Clinical characteristics and factors associated with mortality in patients admitted to the intensive care unit (ICU) in countries with low case fatality rates (CFR) are unknown. We sought to determine these in a large cohort of critically ill COVID-19 patients in Qatar and explore the early mortality predictors. Methods: We retrospectively studied the clinical characteristics and outcomes in patients admitted to the ICU at the national referral hospital for COVID-19 patients in Qatar. Logistic regression analysis was used to determine factors associated with mortality. Results: Between March 7 and July 16, 2020, a total of 1079 patients with COVID-19 were admitted to the ICU. The median (IQR) age of patients was 50 (41-59) years. Diabetes (47.3%) and hypertension (42.6%) were the most common comorbidities. In-hospital mortality was 12.6% overall and 25.9% among those requiring mechanical ventilation. Factors independently associated with mortality included older age ([OR]; 2.3 [95% CI; 1.92-2.75] for each 10-year increase in age, p < 0.001), chronic kidney disease (OR; 1.9 [95% CI; 1.02-3.54], p = 0.04), active malignancy (OR; 6.15 [95% CI; 1.79-21.12], p = 0.004), lower platelet count at ICU admission (OR; 1.41 [95% CI; 1.13-1.75] for each 100 × 103/µl decrease, p = 0.002), higher neutrophil-to-lymphocyte ratio at admission (OR; 1.01 [95% CI; 1-1.02] for each 1- point increase, p = 0.016), higher serum ferritin level at admission (OR; 1.05 [(95% CI; 1.02-1.08] for each 500 µg/L increase, p = 0.002), and higher serum bilirubin level at admission (OR; 1.19 [95% CI; 1.04-1.36] for each 10 µmol/L increase, p = 0.01). Conclusions: The mortality rate among critically ill COVID-19 patients is low in Qatar compared to other countries. Older age, chronic kidney disease, active malignancy, higher neutrophil-to-lymphocyte ratios, lower platelet counts, higher serum ferritin levels, and higher serum bilirubin levels are independent predictors of in-hospital mortality.

Characteristics and clinical outcomes of COVID-19 patients with pulmonary disorders: A single-center, retrospective observational study.

INTRODUCTION: Mortality rates and clinical characteristics of patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU) vary significantly. OBJECTIVES: To describe the data of patients with pulmonary comorbidities who were admitted to the ICU with COVID-19 in Qatar in terms of demographic characteristics, coexisting conditions, imaging findings, and outcomes. METHODS: We conducted a retrospective study of the outcomes with regard to mortality and requirement of invasive ventilation, demographic characteristics, coexisting conditions, secondary infections, and imaging findings for critical care patients with COVID-19 in Qatar who had pulmonary comorbidities between March and June 2020. RESULTS: A total of 923 patients were included, 29 (3.14%) were found to have pulmonary disease. All these 29 patients' respiratory disease was noted to be asthma. Among these, three patients (10.3%) died in the ICU within 28 days of ICU admission. They were all above 50 years old. Nineteen (66%) patients required intubation and mechanical ventilation. Twenty-one (72.4%) patients were males. The most common comorbidities included diabetes mellitus (55.1%) and hypertension (62%). Eighteen (62%) patients developed secondary infections in the ICU. Five (17.24%) patients developed renal impairment. Twenty (69%) patients received tocilizumab as part of their COVID-19 management, and out of these 16 (80%) patients developed a coinfection. CONCLUSION: Patients with pulmonary disorders had higher mortality rates than other patients admitted to ICU during the same time frame with similar comorbidities; these patients require extra consideration and care to avoid disease progression and death.

Prognostic tools and candidate drugs based on plasma proteomics of patients with severe COVID-19 complications.

COVID-19 complications still present a huge burden on healthcare systems and warrant predictive risk models to triage patients and inform early intervention. Here, we profile 893 plasma proteins from 50 severe and 50 mild-moderate COVID-19 patients, and 50 healthy controls, and show that 375 proteins are differentially expressed in the plasma of severe COVID-19 patients. These differentially expressed plasma proteins are implicated in the pathogenesis of COVID-19 and present targets for candidate drugs to prevent or treat severe complications. Based on the plasma proteomics and clinical lab tests, we also report a 12-plasma protein signature and a model of seven routine clinical tests that validate in an independent cohort as early risk predictors of COVID-19 severity and patient survival. The risk predictors and candidate drugs described in our study can be used and developed for personalized management of SARS-CoV-2 infected patients.

Ocular manifestations of COVID-19: facts and figures from a tertiary care center.

INTRODUCTION: COVID-19 patients presenting with ocular manifestations are from 0.8% to 32% of patients seen in the ED. The available literature is scarce regarding COVID-19 patients presenting with ocular manifestations from the Middle Eastern region. PURPOSE: This study aims to report the incidence of ocular signs and symptoms in COVID-19 patients and find any correlation between the occurrence of ocular manifestations and patients' comorbidities. METHODS: All patients having the primary diagnosis of COVID-19 infection and concurrent ocular manifestations on admission to our tertiary COVID-19 health care centre were included in the study. The patient's demographic data, comorbidities, and type of ocular manifestations were recorded from the patients' health records retrospectively. RESULTS: In our study, 39 (7.8%) patients presented with ocular manifestations. The majority of COVID-19 patients were male, and 200 (20%) patients had a history of other comorbidities. The majority of our patients had hyperaemia (13 [33.3%]), followed by eye pain (9 [23.1%]), epiphora (8 [20.5%]), burning sensation (4 [10.3%]), and photophobia (2 [5.1%]) patients. There was no statistically significant difference in the occurrence of ocular manifestations and patients' gender or comorbidities (p > .05). CONCLUSION: The occurrence of ocular manifestations was lower compared to the present literature. There was no significant association between the occurrence of ocular manifestations and the patient's gender or comorbidities.

Nebulized fentanyl for respiratory symptoms in patients with COVID-19 (ventanyl trial).

ABSTRACT: Patients with coronavirus disease (COVID-19) commonly experience distressing and challenging respiratory symptoms. Interventions such as oxygen therapy, oral opiates, and traditional nebulizers like ipratropium bromide and salbutamol are variable in their efficacy, and therapy responses in patients are difficult to predict. The purpose of this study is to investigate the efficacy of nebulized fentanyl citrate on dyspnea, cough, and throat pain in patients with COVID-19 and evaluate the safety with any potential adverse events.In COVID-19, about 59% of patients will exhibit cough, 35% generalized body ache and sore throat, and 31% dyspnea. Some methods such as nebulized lidocaine, magnesium sulfate, and systemic opioids have been used to manage the respiratory symptoms. It has been previously shown that fentanyl nebulizer has beneficial effect in improving shortness of breath in patients with chronic obstructive pulmonary disease. The proposed theory behind that was that fentanyl decreased the rate of spontaneous respiratory rate, diminished the brain stem chemoreceptor response to hypoxia and hypercarbia, in addition to exhibiting a modulating effect on the brain stem. Therefore, we hypothesize that nebulized fentanyl has superior effect in improving shortness of breath and relieving cough compared to normal saline, in addition to its advantageous throat pain relief, while exhibiting fewer side effects in patients with COVID 19 infection. Therefore, this phase-III, randomized, comparative, parallel assignment, single-blinded clinical trial aims at assessing the efficacy and safety of nebulized fentanyl to suppress cough, improve breathlessness, and relieve throat pain in patients with COVID-19.

Tension Pneumomediastinum: A life-threatening condition in patients with COVID-19.

Tension pneumomediastinum (TPM) is a rare but potentially fatal clinical entity. TPM leads to the leakage of air into the mediastinal cavity and increased pressure in thoracic vessels, respiratory tract, and the heart. Herein, this report presents a series of five cases of coronavirus disease-2019 (COVID-19) that caused acute respiratory distress syndrome (ARDS) and TPM. All patients were male who had severe ARDS with a secondary lung infection that required invasive ventilation and had moderate positive-end expiratory pressure. All patients required vasopressors to maintain hemodynamics, and two patients needed decompression with chest drains. One patient received extracorporeal membrane oxygenation therapy. Three patients had cardiac arrest, and two patients died; thus, the mortality rate was 40%. Patients with COVID-19 pneumonia with ARDS required invasive ventilation and prone positioning. Secondary lung infection can cause TPM, and TPM may cause cardiac arrest. Management should be prompt recognition and decompression with the insertion of drains, and conservative treatment is required in stable cases. Protocols for the management of pneumomediastinum and TPM may enable early detection, earlier management, and prevention of TPM.

Clinical outcomes of intravenous immunoglobulin therapy in COVID-19 related acute respiratory distress syndrome: a retrospective cohort study.

BACKGROUND: Intravenous immunoglobulin (IVIG) has been used as an immunomodulatory therapy to counteract severe systemic inflammation in coronavirus disease 2019 (COVID-19). But its use in COVID-19 related acute respiratory distress syndrome (ARDS) is not well established. METHODS: We conducted a retrospective analysis of electronic health records of COVID-19 patients admitted to intensive care units (ICUs) at Hazm Mebaireek General Hospital, Qatar, between March 7, 2020 and September 9, 2020. Patients receiving invasive mechanical ventilation for moderate-to-severe ARDS were divided into two groups based on whether they received IVIG therapy or not. The primary outcome was all-cause ICU mortality. Secondary outcomes studied were ventilator-free days and ICU-free days at day-28, and incidence of acute kidney injury (AKI). Propensity score matching was used to adjust for confounders, and the primary outcome was compared using competing-risks survival analysis. RESULTS: Among 590 patients included in the study, 400 received routine care, and 190 received IVIG therapy in addition to routine care. One hundred eighteen pairs were created after propensity score matching with no statistically significant differences between the groups. Overall ICU mortality in the study population was 27.1%, and in the matched cohort, it was 25.8%. Mortality was higher among IVIG-treated patients (36.4% vs. 15.3%; sHR 3.5; 95% CI 1.98-6.19; P < 0.001). Ventilator-free days and ICU-free days at day-28 were lower (P < 0.001 for both), and incidence of AKI was significantly higher (85.6% vs. 67.8%; P = 0.001) in the IVIG group. CONCLUSION: IVIG therapy in mechanically ventilated patients with COVID-19 related moderate-to-severe ARDS was associated with higher ICU mortality. A randomized clinical trial is needed to confirm this observation further.

Cytomegalovirus meningoencephalitis in a case of severe COVID-19 Pneumonia. A case report.

The use of steroids and other immune modulatory therapies in the treatment of severe COVID-19 pneumonia predisposes patients to the reemergence of opportunistic infections. Cytomegalovirus (CMV) reactivation can be one of them. A 55-year-old gentleman with severe COVID-19 pneumonia and hypoxic respiratory failure who was ventilated and received steroids but no other immunomodulatory drugs; had altered sensorium and multiple episodes of seizures in the later course of his illness. Brain MRI showed leptomeningeal enhancement and encephalopathy changes, electroencephalography (EEG) was suggestive of diffuse encephalopathy and his cerebrospinal fluid (CSF) analysis revealed high Cytomegalovirus PCR DNA titers (103,614). The patient made a complete recovery after treatment with Ganciclovir. Altered sensorium in cases of COVID-19 can be multifactorial. High index of suspicion for reactivation of dormant infections is warranted. CMV meningoencephalitis is one of the differential diagnoses. We believe this is the first case reported of CMV meningoencephalitis in the setting of severe COVID-19 infection.

Spontaneous pneumomediastinum and pneumothorax in COVID-19 patients: A tertiary care experience.

INTRODUCTION: COVID-19 can occasionally complicate into spontaneous pneumothorax (SP) and/or spontaneous pneumomediastinum (SM). This study aims at exploring the occurrence of SP and or SM, risk factors, and outcomes in COVID-19 patients. MATERIALS AND METHODS: All patients with COVID-19, which complicated into SP and/or SM at Hamad Medical Corporation (the principal public healthcare provider in Qatar) from March to September 2020, were retrospectively enrolled. The clinical diagnosis was confirmed by CXR and CT. Between-group comparisons were performed by using Chi-square and t-test. Differences were considered statistically significant at P ≤ .05. RESULTS: A total of 1100 patients were admitted, and 43 patients developed SP, SP + SM, or SM. Most patients were males (42/97.9%), and the most common comorbidity was diabetes mellitus (13/30.2%). All patients had acute respiratory distress syndrome (ARDS), and most patients had low lung compliance at the time of developing SP or SM. Twenty-two of the patients developed SP (51.2%), 11 patients had both SP and SM (25.6%), and 10 patients had SM only (23.3%). There was no significant difference in the development of SP or SM and patients' gender or blood group or whether patients were on invasive or noninvasive ventilation or even the mortality (P > .05). Lung compliance was significantly (P < .05) lower in patients complicated with SP and or SM. Patients with SP required significantly higher (P < .001) chest drain insertion. CONCLUSION: Patients with severe COVID-19 pneumonia can complicate into SP and SM. These complications are more common in male diabetic patients. Patients with ARDS and having low lung compliance are at a higher risk of developing SP, SP + SM, or SM.

Clinical outcomes of post-renal transplant patients with COVID-19 infection in the ICU: A single-center case series.

Most of the post-renal transplant patients are taking immunosuppressive medications, including calcineurin inhibitors, anti-proliferative agents, and steroids. This case series highlights the clinical characteristics and outcomes of eight post-renal transplant patients with severe COVID-19 infection admitted to the intensive care unit.

Managing a patient with bipolar disorder associated with COVID-19: A case report from Qatar.

This case highlights an atypical presentation of a patient with unknown history of mental disease who has been diagnosed with a bipolar disorder associated with severe COVID-19 symptoms. Neuroimaging was only positive for subtle white matter changes; he was treated with antipsychotics and mood-stabilizing agents until he reached partial remission. The authors urge clinicians to consider the impact of the COVID-19 pandemic on patients with mental illness and the urgent need for vigilant monitoring of presenting signs and symptoms.

Right atrial mass in a patient with COVID-19 pneumonia: A case report.

Lipomatous hypertrophy of the interatrial septum can have an atypical appearance by transthoracic echocardiography. The authors emphasize on the importance of the multimodality imaging approach to reach the appropriate diagnosis in such cases.

Management considerations for a critically ill 26-gestational week patient with COVID-19: A case report.

Pregnant women are potentially more susceptible to respiratory tract infections making them a high-risk group. We describe the successful management of a 35-year-old pregnant woman, G3, P1, with a history of a cesarean section who tested positive for COVID-19 at 26 weeks and required critical care support.

Comparison of the clinical outcomes of non-invasive ventilation by helmet vs facemask in patients with acute respiratory distress syndrome.

ABSTRACT: The main aim of this study is to compare the use of non-invasive ventilation (NIV) via helmet versus face mask where different interfaces and masks can apply NIV. However, some of the limitations of the NIV face mask were air leak, face mask intolerance, and requirement of high positive end expiratory pressure, which could be resolved with the use of the helmet NIV. NIV facemask will be applied as per the facial contour of the patient. NIV helmet is a transparent hood and size will be measured as per the head size. Both groups will have a standard protocol for titration of NIV.Patients aged more than 18 years old and diagnosed with acute respiratory distress syndrome as per Berlin definition will be enrolled in the study after signing the informed consent. Subjects who met the inclusion criteria will receive 1 of the 2 interventions; blood gases, oxygenation status [Po2/Fio2] will be monitored in both groups. The time of intubation will be the main comparison factor among the 2 groups. The primary and secondary outcomes will be measured by the number of patients requiring endotracheal intubation after application of helmet device, Improvement of oxygenation defined as PaO2/FiO2 ≥ 200 or increase from baseline by 100, duration of mechanical ventilation via an endotracheal tube, intensive care unit length of stay, death from any cause during hospitalization at the time of enrolment, need for proning during the hospital stay, intensive care unit mortality, and the degree to which overt adverse effects of a drug can be tolerated by a patient including feeding tolerance. TRIAL REGISTRATION NUMBER: NCT04507802. PROTOCOL VERSION: May 2020.

Serum sickness following rituximab therapy in a patient with pemphigus vulgaris: A case report.

Serum sickness, a reaction presenting with a classic triad (fever, rash, myalgia/arthralgia), is considered as a rare adverse event following monoclonal antibodies and specifically following treatment with rituximab. This report describes a case of serum sickness in a newly treated young male patient with rituximab for pemphigus vulgaris.

Cryptococcemia in a patient with COVID-19: A case report.

The authors urge clinicians to balance the use of Immunosuppressant drugs and tocilizumab for COVID-19 patients to avoid the development of infections like Cryptococcemia, leading to death within 30 days.

Tocilizumab-induced cytomegalovirus colitis in a patient with COVID-19.

The authors urge clinicians to observe for early signs of CMV reactivation in patients presenting with gastrointestinal bleeding and intestinal perforation after receiving tocilizumab or other immunosuppressive therapy as a treatment for COVID 19. Early recognition of CMV infection and treatment will prevent life-threatening bleeding and mortality.

Arnold-Chiari malformation type 1 as an unusual cause of acute respiratory failure: A case report.

The authors urge clinicians to consider the possibility of Arnold-Chiari Malformation type 1 with other central causes especially in cases where acute respiratory failure is unexplainable.