COVID-19-associated vasculitis and vasculopathy

Pediatric autoimmune diseases in the light of COVID-19 pandemic, A retrospective observational big data study

Background

The COVID-19 pandemic has raised concerns about potential links between SARS-CoV-2 infection and autoimmune diseases. This study investigated changes in the incidence rate (IR) of autoimmune diseases among children following the pandemic's onset.

Methods

A retrospective cross-sectional study analyzed data from Clalit Health Services, Israel's largest healthcare provider, examining the IR of different autoimmune diseases in children aged 0-18. The study compared pre-pandemic (2019) with pandemic/post-pandemic periods (2020-2023), encompassing a cohort of over 1.5 million children.

Results

Significant IR increases were observed across multiple autoimmune diseases. Rheumatic diseases (Juvenile Idiopathic Arthritis, Systemic Lupus Erythematosus, Henoch Schoenlein Purpura (HSP)) showed consistent increases, with HSP demonstrating the most pronounced trend. Endocrine disorders exhibited diverse patterns, with autoimmune thyroid diseases and Type 1 diabetes showing overall increases, while diabetic ketoacidosis exhibited an initial spike followed by a decline. Gastrointestinal diseases displayed heterogeneous patterns; Celiac disease and Ulcerative colitis showed general increases, Crohn's disease showed a downward trend, and autoimmune hepatitis exhibited an initial significant decrease followed by a significant increase. Dermatological conditions, including Psoriasis and Vitiligo, demonstrated consistent elevations throughout 2020-2023. Immune Thrombocytopenia Purpura showed initial decreases followed by significant increases in 2022-2023.

Conclusions

This comprehensive analysis reveals significant changes in pediatric autoimmune disease incidence following the COVID-19 pandemic, suggesting potential associations between SARS-CoV-2 infection and autoimmune dysregulation. The diverse patterns observed across different conditions highlight the complex interplay between viral infection and autoimmunity, emphasizing the need for continued surveillance and investigation of long-term immunological consequences of COVID-19 in pediatric populations.

Predictors of Unfavorable Outcomes in COVID-19-Related Sepsis: A Prospective Cohort Study

Sepsis is a leading cause of mortality in critically ill patients, arising from a dysregulated immune response to infection. While traditionally associated with bacterial pathogens, severe COVID-19 can induce a sepsis-like syndrome, characterized by systemic inflammation, endothelial dysfunction, and coagulation abnormalities. This study aimed to assess the prognostic value of age, inflammatory markers, coagulation dysfunction, comorbidity burden, and lung involvement on computer tomography (CT) scans in predicting poor outcomes. We conducted a prospective cohort study including 163 patients diagnosed with COVID-19-related sepsis. Univariate and multivariable logistic regression analyses were performed to identify the independent predictors of unfavorable outcomes. Higher D-dimer (OR: 1.417, p = 0.020) and C-reactive protein (CRP) levels (OR: 1.010, p = 0.027) were independently associated with poor outcomes. A greater than 50% lung involvement on CT (OR: 1.774, p = 0.025) was also a significant predictor. The Charleson Comorbidity Index (CCI) showed a strong trend toward significance (p = 0.065), while age lost statistical significance after adjusting for comorbidities. Our findings suggest that D-dimers, CRP, and lung involvement on CT are key independent predictors of poor outcomes in COVID-19-related sepsis. These results emphasize the importance of inflammatory and coagulation markers, alongside comorbidity burden, in early risk assessment. Further prospective studies are warranted to refine predictive models for severe COVID-19 cases complicated by sepsis.

The COVID-19 thrombus: distinguishing pathological, mechanistic, and phenotypic features and management

A heightened risk for thrombosis is a hallmark of COVID-19. Expansive clinical experience and medical literature have characterized small (micro) and large (macro) vessel involvement of the venous and arterial circulatory systems. Most events occur in patients with serious or critical illness in the hyperacute (first 1-2 weeks) or acute phases (2-4 weeks) of SARS-CoV-2 infection. However, thrombosis involving the venous, arterial, and microcirculatory systems has been reported in the subacute (4-8 weeks), convalescent (> 8-12 weeks) and chronic phases (> 12 weeks) among patients with mild-to-moderate illness. The purpose of the current focused review is to highlight the distinguishing clinical features, pathological components, and potential mechanisms of venous, arterial, and microvascular thrombosis in patients with COVID-19. The overarching objective is to better understand the proclivity for thrombosis, laying a solid foundation for screening and surveillance modalities, preventive strategies, and optimal patient management.

Polyarteritis nodosa with life-threatening intracranial aneurysms in a child, and treatment with infliximab

BACKGROUND

Polyarteritis nodosa (PAN) is a rare and serious form of systemic necrotizing vasculitis that predominantly affects medium and small-sized arteries, with central nervous system involvement being particularly uncommon. Treatment strategies are tailored according to the extent and severity of the disease. While conventional therapy includes glucocorticoids and conventional disease-modifying-rheumatic drugs (cDMARDs), biologic agents may be critical for severe and refractory cases.

CASE

We report a case of systemic PAN in a 7-year-old girl with no prior medical history, who presented with fever, abdominal pain, and altered mental status. Initial investigations with cranial MRI and echocardiography suggested encephalitis and myocarditis, respectively. Positive SARS-CoV-2 antibodies in both cerebrospinal fluid and serum oriented the diagnosis towards multisystem inflammatory syndrome in children. Despite intensive conventional therapies with glucocorticoids, cDMARDs, and intravenous immunoglobulins, the patient's condition deteriorated. Elevated von Willebrand factor levels, hypertension, and proteinuria emerged, along with stable intracranial hemorrhage and abdominal organ infarctions on imaging, leading to the diagnosis of PAN. Cyclophosphamide was added to the treatment regimen. Three cranial aneurysms were identified on selective conventional cranial angiography. Following angiography, severe intraparenchymal bleeding was detected, leading to emergency cranial surgery. Unresponsiveness to conventional therapeutics led to treatment escalation with a tumor necrosis factor inhibitor, infliximab, resulting in clinical stabilization and allowing for successful endovascular coil embolization.

CONCLUSION

This case highlights the importance of considering a tumor necrosis factor inhibitor, infliximab, in severe PAN with involvement of intracranial aneurysm.

Case Report: Atypical post-COVID Cogan's syndrome

Background

Cogan's syndrome is a rare autoimmune disorder characterized by ocular inflammation, vestibulocochlear dysfunction, and systemic vasculitis.

Case Presentation

We report a 28-year-old female who experienced decreased visual acuity and ocular redness one month after a COVID-19 infection, with ophthalmological signs linked to keratitis, uveitis and retinal vasculitis. Two weeks later, she developed vertigo, tinnitus, and sudden hearing loss, leading to a diagnosis of Cogan's disease. The patient received corticosteroid therapy, resulting in regression of ophthalmological signs, but progressed to complete deafness. One month later, she presented with lymphocytic meningitis and high intracranial pressure, which improved under treatment. The patient later received cochlear implants.

Objective

This case report aims to highlight an atypical presentation of Cogan's syndrome with neurological involvement following a COVID-19 infection. This case contributes to the limited literature on such presentations.

Conclusion

Our case is one of only two reported instances of Cogan's syndrome presenting with neurological signs post-COVID-19 infection, underscoring the rarity and complexity of this condition.

S100A7 orchestrates neutrophil chemotaxis and drives neutrophil extracellular traps (NETs) formation to facilitate lymph node metastasis in cervical cancer patients

Neutrophil extracellular traps (NETs) have been shown to promote the metastatic potential of many kinds of tumors. Our study aimed to investigate the role and mechanisms of NETs in lymph node metastasis (LNM) of cervical cancer (CCa), and evaluated the therapeutic value of targeting NETs in CCa. Immunohistochemistry demonstrated that neutrophil infiltration and NETs formation were increased in CCa patients with LNM, as well as confirming a positive correlation between S100A7 expression and neutrophil infiltration in CCa. NETs enhanced the migratory capability of CCa by activating the P38-MAPK/ERK/NFκB pathway through interaction with TLR2. Digesting NETs with deoxyribonuclease 1 (DNase 1) or inhibiting TLR2 with chloroquine eliminated the NETs-induced metastatic potential of CCa. Additionally, NETs promoted lymphangiogenesis and increased the permeability of lymphatic vessels, thus facilitating translymphatic movement of CCa. CCa-derived S100A7 exhibited a chemotactic effect on neutrophils and promoted NETs generation by elevating ROS levels rather than activating autophagy in neutrophils. The mouse model with footpad implantation illustrated that DNase 1 effectively reduced LNM in LPS-induced mice and in mice seeded with S100A7-overexpressing CCa cells. In conclusion, our study reveals a new tumor-promoting mechanism of S100A7, clarifies the crucial role and mechanism of NETs in LNM of CCa, and indicates that the NETs-targeted therapy emerges as a promising anti-metastasis therapy in CCa.

COVID-19 and COVID-19 Vaccine-Related Skin Ulcerations in the Lower Extremities: A Case Report and Literature Review

CASE

A 53-year-old male patient presented to the dermatology clinics with a three-week history of painful necrotic patches coalescent of the lateral malleolus of the right and left ankles. History goes back to when the patient reported developing pruritic papules two weeks after receiving his second shot of the Pfizer BioNTech COVID-19 vaccine (BNT162b2). Punch biopsy was consistent with leukocytoclastic vasculitis. He was prescribed a four-week course of systemic corticosteroids and antibiotics as per cultures. Vascular assessment confirmed normal peripheral arterial and venous system. Two months later, the patient re-presented with fever and worsening of his lower extremity ulcers. He underwent debridement of his wounds. Intra-operative cultures revealed multidrug resistant bacteria. He required an additional debridement session a few days later and a 14-day course of Piperacillin-Tazobactam. The patient was subsequently discharged on corticosteroids and Azathioprine and followed up in the vascular surgery and rheumatology clinics. At four months follow-up, the patient's wounds were almost completely healed.

CONCLUSION

This article highlights a case of severe new-onset COVID-19 vaccine-associated leukocytoclastic vasculitis complicated with infected ulcers that required debridement twice in addition to a prolonged course of antibiotics and immunosuppression therapy. To our knowledge, none of the cases reported in the literature were this severe in nature. In this post-pandemic era, it must remain high on the differential list, and healthcare specialists should maintain a high index of suspicion when evaluating sudden new-onset skin lesions that do not have an immediately apparent etiology.

Evaluation of the early effects of the first-dose administration of the Sinovac vaccine on the retina, choroid, and optic disc using optical coherence tomography (OCT) and OCT-angiography

AIM

To determine the effects of the first-dose administration of the Sinovac vaccine on the retina, choroid, and optic disc in healthy participants.

METHODS

This prospective design study was conducted with 27 healthy healthcare workers who received the first dose of Sinovac vaccine and 25 healthy controls who were not vaccinated. In the vaccinated group, ophthalmological examinations and measurements were performed before vaccination and one week and one month after vaccination. Subfoveal, nasal, and temporal choroidal thicknesses (CTs), retinal nerve fiber layer (RNFL) thickness, and macular thickness (MT) were determined using spectral domain-optical coherence tomography at all visits. Superficial, deep, and peripapillary radial capillary plexus (superficial capillary plexus, deep capillary plexus (DCP), and radial peripapillary capillary, respectively), choriocapillaris vascular density, and foveal avascular zone parameters were measured on optical coherence tomography-angiography (OCT-A).

RESULTS

No significant difference was detected between the two groups in terms of the parameters measured by OCT and OCT-A (p > 0.05 for all). The CT values measured in all quadrants were significantly higher at the first week after vaccination (p < 0.05 for all), and they returned to their pre-vaccination values at the first month post-vaccination measurement (p > 0.05 for all). Concerning the RNFL and MT values, there was no significant difference between the pre-vaccination and post-vaccination first-week measurements (p > 0.05 for all), but a statistically significant increase was detected in the post-vaccination first-month MT and RNFL measurements (p < 0.05 for all). Only the decreases in the foveal DCP and choriocapillaris vascular density values were significant at the first week after vaccination (p < 0.05 for all).

CONCLUSION

The early changes detected after vaccination in this study suggest the possibility that autoimmune, vascular, and inflammatory diseases may simultaneously emerge in the early post-vaccination period or may be triggered after vaccination, or that the vaccine may unmask these diseases.

Isolated Lower Limb Vasculitis Following SARS-CoV-2 Infection: A Case Report

Vasculitis is an autoimmune disease defined by inflammation within blood vessels, typically manifesting systemically with multi-organ complications and clinical features. Isolated vasculitis itself, however, is extremely rare and not characteristically based on the pathophysiology of the condition. Whilst there have been cases of isolated vasculitis in large-medium vessels (e.g. the aorta, subclavian, axillary, and/or femoral arteries) documented in the literature, vasculitis isolated to medium to smaller vessels is much more infrequent and is the primary focus of the following case report. We present a case of a 70-year-old male three weeks post-severe acute respiratory syndrome coronavirus 2, presenting with nausea, loss of appetite, eight kilograms of weight loss, and bilateral anterior knee pain resulting in significant functional decline and requiring the use of a four-wheel walking frame. After extensive screening for pathological causes, the most significant findings were elevated C-reactive protein, erythrocyte sedimentation rate, and white cell count with a predominant neutrophilia. Numerous forms of imaging were undertaken, with fluorodeoxyglucose-positron emission tomography suggestive of vasculitis in medium and small vessels within the bilateral lower limbs. The patient was commenced on prednisolone and later methotrexate, with complete resolution of symptoms three and a half months later. Symptom resolution was compared with repeat fluorodeoxyglucose-positron emission tomography, which also demonstrated the resolution of lower limb vasculitis changes. In the absence of other identified precipitants, as well as with the patient having a continuously elevated multiplex polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 during admission, it outlines a unique situation of such an infection being a potential trigger for isolated vasculitis in medium to small vessels. As this is not well expressed in the literature, it provides a basis for further research, whilst also assisting in the work-up of other patients who may present similarly.

Characterization of Neutrophil Functional Responses to SARS-CoV-2 Infection in a Translational Feline Model for COVID-19

There is a complex interplay between viral infection and host innate immune response regarding disease severity and outcomes. Neutrophil hyperactivation, including excessive release of neutrophil extracellular traps (NETs), is linked to exacerbated disease in acute COVID-19, notably in hospitalized patients. Delineating protective versus detrimental neutrophil responses is essential to developing targeted COVID-19 therapies and relies on high-quality translational animal models. In this study, we utilize a previously established feline model for COVID-19 to investigate neutrophil dysfunction in which experimentally infected cats develop clinical disease that mimics acute COVID-19. Specific pathogen-free cats were inoculated with SARS-CoV-2 (B.1.617.2; Delta variant) (n = 24) or vehicle (n = 6). Plasma, bronchoalveolar lavage fluid, and lung tissues were collected at various time points over 12 days post-inoculation. Systematic and temporal evaluation of the kinetics of neutrophil activation was conducted by measuring markers of activation including myeloperoxidase (MPO), neutrophil elastase (NE), and citrullinated histone H3 (citH3) in SARS-CoV-2-infected cats at 4 and 12 days post-inoculation (dpi) and compared to vehicle-inoculated controls. Cytokine profiling supported elevated innate inflammatory responses with specific upregulation of neutrophil activation and NET formation-related markers, namely IL-8, IL-18, CXCL1, and SDF-1, in infected cats. An increase in MPO-DNA complexes and cell-free dsDNA in infected cats compared to vehicle-inoculated was noted and supported by histopathologic severity in respiratory tissues. Immunofluorescence analyses further supported correlation of NET markers with tissue damage, especially 4 dpi. Differential gene expression analyses indicated an upregulation of genes associated with innate immune and neutrophil activation pathways. Transcripts involved in activation and NETosis pathways were upregulated by 4 dpi and downregulated by 12 dpi, suggesting peak activation of neutrophils and NET-associated markers in the early acute stages of infection. Correlation analyses conducted between NET-specific markers and clinical scores as well as histopathologic scores support association between neutrophil activation and disease severity during SARS-CoV-2 infection in this model. Overall, this study emphasizes the effect of neutrophil activation and NET release in SARS-CoV-2 infection in a feline model, prompting further investigation into therapeutic strategies aimed at mitigating excessive innate inflammatory responses in COVID-19.

COVID-19 Infection Raising Suspicions of a Connection between Vascular Damage and Thrombus Formation

Although endothelial damage has been hypothesized to be associated with coronavirus disease 2019 (COVID-19)-related cerebral infarction based on the specificity of the viral cellular invasion pathway, no case has been reported to date. We herein report a 51-year-old Japanese woman who presented with neck pain one week after COVID-19 infection. Computed tomography and magnetic resonance imaging revealed inflammation of the carotid and vertebral arteries. Ultrasonography revealed multiple flap-like structures that were assumed to be thrombi. Although the patient had no cerebral infarction, this could be an important case of vascular damage and thrombus formation in a COVID-19 patient.

Lung Involvement in Pulmonary Vasculitis: A Radiological Review

Pulmonary vasculitis identifies a heterogeneous group of diseases characterized by inflammation, damage and necrosis of the wall of pulmonary vessels. The most common approach to classify vasculitis is according to etiology, therefore dividing them into primary and secondary, with a further sub-classification of primary vasculitis based on the size of the affected vessels (large, medium, and small). Pulmonary involvement is frequently observed in patients with systemic vasculitis and radiological presentation is not pathognomonic, but may vary between diseases. The main findings using high-resolution computed tomography (HRCT) include small vessel wall thickening, nodular lesions, cavitary lesions, reticular opacities, ground-glass opacities (GGO), consolidations, interlobular septal thickening, tracheobronchial stenosis, and aneurysmal dilatation of pulmonary arteries, with or without pleural effusion. Radiological diagnosis alone is difficult since signs and symptoms of lung vessel involvement are often non-specific and might overlap with other conditions such as infections, connective tissue diseases and neoplasms. Therefore, the aim of this review is to describe the most common radiological features of lung involvement in pulmonary vasculitis so that, alongside detailed clinical history and laboratory tests, a prompt diagnosis can be performed.

Risk factors for severe COVID-19 infection and the impact of COVID-19 infection on disease progression among patients with AAV

To identify risk factors for COVID-19 infection and investigate the impact of COVID-19 infection on chronic kidney disease (CKD) progression and vasculitis flare in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). This cohort study retrospectively analyzed the prevalence and severity of COVID-19 infection in 276 patients with AAV who were followed up. Logistic regression was employed to estimate the risk of COVID-19 infection as well as CKD progression and vasculitis flare upon COVID-19 infection. During the 6-month observation period, 213 (77.2%) of 276 patients were diagnosed with COVID-19 infection. Of these 213 patients, 49 (23.0%) had a COVID-19-related inpatient admission, including 17 patients who died of COVID-19 infection. AAV patients with severe COVID-19 infection were more likely to be male (OR 1.921 [95% CI 1.020-3.619], P = 0.043), suffered from worse kidney function (serum creatinine [Scr], OR 1.901 [95% CI 1.345-2.687], P < 0.001), had higher C-reactive protein (CRP) (OR 1.054 [95% CI 1.010-1.101], P = 0.017) and less likely to have evidence of initial vaccination (OR 0.469 [95% CI 0.231-0.951], P = 0.036), and Scr and COVID-19 vaccination were proven to be significantly associated with severe COVID-19 infection even after multivariable adjustment. Severe COVID-19 infection was significantly associated with subsequent CKD progression (OR 7.929 [95% CI 2.030-30.961], P = 0.003) and vasculitis flare (OR 11.842 [95% CI 1.048-133.835], P = 0.046) among patients with AAV. AAV patients who were male, and with worse kidney function were more susceptible to severe COVID-19 infection, which subsequently increased the risk of CKD progression and vasculitis flare.

Small Molecules for the Treatment of Long-COVID-Related Vascular Damage and Abnormal Blood Clotting: A Patent-Based Appraisal

People affected by COVID-19 are exposed to, among others, abnormal clotting and endothelial dysfunction, which may result in deep vein thrombosis, cerebrovascular disorders, and ischemic and non-ischemic heart diseases, to mention a few. Treatments for COVID-19 include antiplatelet (e.g., aspirin, clopidogrel) and anticoagulant agents, but their impact on morbidity and mortality has not been proven. In addition, due to viremia-associated interconnected prothrombotic and proinflammatory events, anti-inflammatory drugs have also been investigated for their ability to mitigate against immune dysregulation due to the cytokine storm. By retrieving patent literature published in the last two years, small molecules patented for long-COVID-related blood clotting and hematological complications are herein examined, along with supporting evidence from preclinical and clinical studies. An overview of the main features and therapeutic potentials of small molecules is provided for the thromboxane receptor antagonist ramatroban, the pan-caspase inhibitor emricasan, and the sodium-hydrogen antiporter 1 (NHE-1) inhibitor rimeporide, as well as natural polyphenolic compounds.

Exploring the incidence of peripheral arterial occlusive disease following COVID-19 infection: A retrospective cohort study

Peripheral arterial occlusive disease (PAOD) is a clinical manifestation of systemic atherosclerosis and is always associated with cerebrovascular disease and various complications. The aim of our study is to evaluate the relationship between the coronavirus disease 2019 (COVID-19) infection and the subsequent PAOD development. A retrospective cohort study was conducted and individuals with COVID-19 infection were identified from the TriNetX analytics platform. A total of 2 206 065 patients with COVID-19 infection and 2 206 065 patients without COVID-19 infection were recruited after exclusion and matching. The primary outcome was the development of PAOD after the COVID-19 infection. The Cox proportional hazard regression was adopted to yield the hazard ratio (HR) and 95% confidence interval (CI) of PAOD between groups. After the whole follow-up period, the incidence of PAOD was significantly higher in the COVID-19 group at both the 3-month follow-up (HR: 1.27, 95% CI: 1.24-1.30) and the 12-month follow-up (HR: 1.33, 95% CI: 1.31-1.35) The Kaplan-Meier analysis with the log-rank test demonstrated a higher cumulative probability of PAOD in the COVID-19 group compared to the non-COVID-19 group (p < 0.001). In stratified analysis using 65 years as the threshold, both age groups in the COVID-19 group exhibited a higher risk of PAOD. Similarly, in the sex and race stratified analysis, the COVID-19 group performed a higher risk of PAOD in both subgroups. In conclusion, the COVID-19 infections are strongly associated with an increment of PAOD incidence.

Clinical and pathological findings of IgA nephropathy following SARS-CoV-2 infection

The features of IgA nephropathy (IgAN) after SARS-CoV-2 infection have not been well characterized. In this study, we compared the clinical and pathological characteristics of patients with IgAN who had experienced SARS-CoV-2 infection to those who had not. We conducted a retrospective study that enrolled 38 patients with biopsy-proven IgAN following SARS-CoV-2 infection with 4 months (post-SARS-CoV-2 infection group) and 1154 patients with IgAN prior to the pandemic (pre-SARS-CoV-2 infection group). Among the SARS-CoV-2 group cases, 61% were females. The average duration from SARS-CoV-2 infection to renal biopsy was 78.6 days. Prior to SARS-CoV-2 infection, the patients had different presentations of nephropathy. One patient had isolated hematuria, two had isolated proteinuria, twenty presented with both hematuria and proteinuria, and one patient had elevated serum creatinine. Additionally, there were eight cases with uncertain nephropathy history, and six cases did not have a history of nephropathy. Following SARS-CoV-2 infection, five patients experienced gross hematuria, one case exhibited creatinine elevation, and five cases showed an increase in proteinuria. The group of patients infected with SARS-CoV-2 after the COVID-19 pandemic exhibited older age, higher hypertension ratio and lower eGFR values compared to the pre-SARS-CoV-2 infection group. As for pathological parameters, a higher proportion of patients in the post-SARS-CoV-2 infection group exhibited a higher percentage of sclerotic glomeruli and glomerular ischemic sclerosis. There were no significant differences observed between the two groups in terms of therapy involving steroids, immunosuppressants, or RAS inhibitors. IgA nephropathy patients who were infected with SARS-CoV-2 were generally older and experienced more severe kidney damage compared to those without SARS-CoV-2 infection.

Elevated Arterial Blood Pressure as a Delayed Complication Following COVID-19-A Narrative Review

Arterial hypertension is one of the most common and significant cardiovascular risk factors. There are many well-known and identified risk factors for its development. In recent times, there has been growing concern about the potential impact of COVID-19 on the cardiovascular system and its relation to arterial hypertension. Various theories have been developed that suggest a connection between COVID-19 and elevated blood pressure. However, the precise link between SARS-CoV-2 infection and the long-term risk of developing hypertension remains insufficiently explored. Therefore, the primary objective of our study was to investigate the influence of COVID-19 infection on blood pressure elevation and the subsequent risk of developing arterial hypertension over an extended period. To accomplish this, we conducted a thorough search review of relevant papers in the PubMed and SCOPUS databases up to 3 September 2023. Our analysis encompassed a total of 30 eligible articles. Out of the 30 papers we reviewed, 19 of them provided substantial evidence showing a heightened risk of developing arterial hypertension following COVID-19 infection. Eight of the studies showed that blood pressure values increased after the infection, while three of the qualified studies did not report any notable impact of COVID-19 on blood pressure levels. The precise mechanism behind the development of hypertension after COVID-19 remains unclear, but it is suggested that endothelial injury and dysfunction of the renin-angiotensin-aldosterone system may be contributory. Additionally, changes in blood pressure following COVID-19 infection could be linked to lifestyle alterations that often occur alongside the illness. Our findings emphasize the pressing requirement for thorough research into the relationship between COVID-19 and hypertension. These insights are essential for the development of effective prevention and management approaches for individuals who have experienced COVID-19 infection.

SARS-CoV-2-Induced Vasculitic Skin Lesions Are Associated with Massive Spike Protein Depositions in Autophagosomes

In patients infected with severe acute respiratory syndrome coronavirus 2, vasculopathic changes of the skin are associated with a severe prognosis. However, the pathogenesis of this vasculopathy is not conclusively clarified. In this study, 25 prospectively collected skin samples from patients with COVID-19-related skin lesions were examined for vasculopathic changes and, in case of vasculitis, were further analyzed with electron microscopy and immunohistochemistry. Vasculopathy was observed in 76% of all COVID-19-related inflammatory skin lesions. Visual endothelial changes without manifest leukocytoclastic vasculitis were found in 60% of the COVID-19-related skin lesions, whereas leukocytoclastic vasculitis was diagnosed in 16%. In the cases of vasculitis, there were extensive spike protein depositions in microvascular endothelial cells that colocalized with the autophagosome proteins LC3B and LC3C. The autophagy protein complex LC3-associated endocytosis in microvascular endothelial cells seems to be an important pathogenic factor for severe acute respiratory syndrome coronavirus 2-related vasculitis in the skin. On ultrastructural morphology, the vasculitic process was dominated by intracellular vesicle formation and endothelial cell disruption. Direct presence of severe acute respiratory syndrome coronavirus 2 particles in the skin was not observed. Therefore, our results suggest that instead of direct viral infection, dermal vasculitic lesions in COVID-19 are caused by severe acute respiratory syndrome coronavirus 2 spike protein deposition followed by endothelial damage with activation of autophagy.

Dying at home during the SARS-CoV-2 endemic: The importance of defining the exact mechanism of death

INTRODUCTION

Coronavirus Disease 2019 (COVID-19) has become endemic in Europe thanks to the presence of less deadly and more infectious variants and to the existence of a significant portion of unvaccinated people among the general population. SARS-Cov-2 related deaths are probably going to fade in the next years, but Covid-19 should still be considered a potential cause of death in the out-of-hospital setting in the next future.

MATERIAL AND METHODS

Three (3) cases of unexpected death at home are here presented. Each case has been investigated with the same methodological approach: death scene investigation (DSI), complete autopsy with histology, immunohistochemistry, RNA in situ hybridization for SARS-CoV-2 spike protein in lung tissue, toxicology and microbiology.

RESULTS AND DISCUSSION

All three cases had a COVID + post-mortem nasopharyngeal swab. Histology and immunohistochemistry revealed a SARS-CoV-2 lung involvement in only two of the cases (Cases 2 and 3), while a septic bacterial pneumonia was found in Case 1, where RNA-in situ hybridization for viral spike protein showed no reactivity in pneumocytes. The integration of all postmortem evidence allowed to attribute a different role of SARS-Cov-2 in the determinism of the death.

CONCLUSION

In the current post-pandemic context, SARS-CoV-2 remains a possible cause of death when investigating out-of-hospital unexpected deaths. Since a positive post-mortem swab does not automatically imply a COVID-19-related death, histology and immunohistochemistry are helpful for identifying SARS-CoV-2 lung involvement and, therefore, its potential active role in the determinism of death.

Dermatologic Changes in Experimental Model of Long COVID

The coronavirus disease-19 (COVID-19) pandemic, declared in early 2020, has left an indelible mark on global health, with over 7.0 million deaths and persistent challenges. While the pharmaceutical industry raced to develop vaccines, the emergence of mutant severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) strains continues to pose a significant threat. Beyond the immediate concerns, the long-term health repercussions of COVID-19 survivors are garnering attention, particularly due to documented cases of cardiovascular issues, liver dysfunction, pulmonary complications, kidney impairments, and notable neurocognitive deficits. Recent studies have delved into the pathophysiological changes in various organs following post-acute infection with murine hepatitis virus-1 (MHV-1), a coronavirus, in mice. One aspect that stands out is the impact on the skin, a previously underexplored facet of long-term COVID-19 effects. The research reveals significant cutaneous findings during both the acute and long-term phases post-MHV-1 infection, mirroring certain alterations observed in humans post-SARS-CoV-2 infection. In the acute stages, mice exhibited destruction of the epidermal layer, increased hair follicles, extensive collagen deposition in the dermal layer, and hyperplasticity of sebaceous glands. Moreover, the thinning of the panniculus carnosus and adventitial layer was noted, consistent with human studies. A long-term investigation revealed the absence of hair follicles, destruction of adipose tissues, and further damage to the epidermal layer. Remarkably, treatment with a synthetic peptide, SPIKENET (SPK), designed to prevent Spike glycoprotein-1 binding with host receptors and elicit a potent anti-inflammatory response, showed protection against MHV-1 infection. Precisely, SPK treatment restored hair follicle loss in MHV-1 infection, re-architected the epidermal and dermal layers, and successfully overhauled fatty tissue destruction. These promising findings underscore the potential of SPK as a therapeutic intervention to prevent long-term skin alterations initiated by SARS-CoV-2, providing a glimmer of hope in the battle against the lingering effects of the pandemic.

Effects of circulating endothelial microvesicles isolated from adults with obesity on endothelial cell inflammation, apoptosis, and nitric oxide production

Circulating endothelial cell-derived microvesicles (EMVs) have been shown to be elevated with obesity and associated with endothelial dysfunction; however, their direct effect on endothelial cells is unknown. The experimental aim of this study was to determine the effect of EMVs isolated from adults with obesity on endothelial cell inflammation, apoptosis, and nitric oxide (NO) production. EMVs (CD144+ microvesicles) were identified, enumerated, and isolated from plasma by flow cytometry from 24 sedentary adults: 12 normal-weight adults [8 M/4 F; age: 55 ± 6 yr; body mass index (BMI): 24.3 ± 0.7 kg/m2; EMV: 144 ± 53 EMVs/µL] and 12 adults with obesity (6 M/6 F; 59 ± 7 yr; BMI: 31.0 ± 1.1 kg/m2; EMV: 245 ± 89 EMVs/µL). Human umbilical vein endothelial cells were cultured and treated with EMVs from either normal-weight adults or adults with obesity. EMVs from obese adults induced significantly higher release of interleukin (IL)-6 (108.2 ± 7.7 vs. 90.9 ± 10.0 pg/mL) and IL-8 (75.4 ± 9.8 vs. 59.5 ± 11.5 pg/mL) from endothelial cells vs. EMVs from normal-weight adults, concordant with greater intracellular expression of phosphorylated NF-κB p65 (Ser536; active NF-κB) [145.0 ± 34.1 vs. 114.5 ± 30.4 arbitrary units (AU)]. Expression of phosphorylated p38-MAPK (15.4 ± 5.7 vs. 9.2 ± 2.5 AU) and active caspase-3 (168.2 ± 65.5 vs. 107.8 ± 40.5 AU), markers of cell apoptosis, was higher in cells treated with obesity-related EMVs. Phosphorylated endothelial nitric oxide synthase (eNOS) (Ser1177) expression (23.5 ± 7.2 vs. 34.7 ± 9.7 AU) and NO production (6.9 ± 1.4 vs. 8.7 ± 0.7 µmol/L) were significantly lower in the cells treated with EMVs from obese adults. These data indicate that circulating EMVs from adults with obesity promote a proinflammatory, proapoptotic, and NO-compromised endothelial phenotype. Circulating EMVs are a potential mediator of obesity-related endothelial dysfunction.NEW & NOTEWORTHY In the present study, we determined the effect of circulating endothelial cell-derived microvesicles (EMVs) isolated from adults with obesity on endothelial cell inflammation, apoptosis, and nitric oxide (NO) production in vitro. Circulating EMVs harvested from adults with obesity promoted a proinflammatory, proapoptotic, and NO-compromised endothelial phenotype. Elevated circulating EMVs in adults with obesity, independent of other cardiometabolic risk factors, are a potential novel systemic mediator of obesity-related endothelial dysfunction and vascular risk.

Neuropathological findings in COVID-19 vs. non-COVID-19 acute respiratory distress syndrome-A case-control study

Acute brain injury (ABI) and neuroinflammation is reported in COVID-19 and acute respiratory distress syndrome (ARDS). It remains unclear if COVID-19 plays an independent role in development of ABI compared to those with non-COVID-19 ARDS. We aimed to evaluate if COVID-19 ARDS is associated with higher risk and specific patterns of ABI compared to non-COVID-19 ARDS. We conducted an age and sex matched case-control autopsy study at a tertiary academic center. Ten patients with COVID-19 ARDS were matched to 20 non-COVID-19 ARDS patients. Baseline demographics were comparable between the two groups including severity of ARDS (p = 0.3). The frequency of overall ABI (70 vs. 60%), infratentorial ABI (40 vs. 25%), ischemic infarct (40 vs. 25%), intracranial hemorrhage (30 vs. 35%), and hypoxic-ischemic brain injury (30 vs. 35%) was similar between COVID-19 and non-COVID-19 ARDS patients, respectively (p > 0.05). Intracapillary megakaryocytes were exclusively seen in 30% of COVID-19 patients. Overall, frequency and pattern of ABI in COVID-19 ARDS was comparable to non-COVID-19.

The Angiopoietin Signaling Pathway Is Involved in Inflammatory Processes in Hospitalized COVID-19 Patients

The viral agent SARS-CoV-2 clearly affects several organ systems, including the cardiovascular system. Angiopoietins are involved in vascular integrity and angiogenesis. Angiopoietin-1 (Ang1) promotes vessel stabilization, while angiopoietin-2 (Ang2), which is usually expressed at low levels, is significantly elevated in inflammatory and angiogenic conditions. Interleukin-6 (IL-6) is known to induce defective angiogenesis via the activation of the Ang2 pathway. Vasculitis and vasculopathy are some of the defining features of moderate to severe COVID-19-associated systemic disease. We investigated the serum levels of angiopoietins, as well as interleukin-6 levels and anti-SARS-CoV2 IgG titers, in hospitalized COVID-19 patients across disease severity and healthy controls. Ang2 levels were elevated in COVID-19 patients across all severity compared to healthy controls, while Ang1 levels were decreased. The patients with adverse outcomes (death and/or prolonged hospitalization) had relatively lower and stable Ang1 levels but continuously elevated Ang2 levels, while those who had no adverse outcomes had increasing levels of both Ang1 and Ang2, followed by a decrease in both. These results suggest that the dynamic levels of Ang1 and Ang2 during the clinical course may predict adverse outcomes in COVID-19 patients. Ang1 seems to play an important role in controlling Ang2-related inflammatory mechanisms in COVID-19 patients. IL-6 and anti-SARS-CoV2 spike protein IgG levels were significantly elevated in patients with severe disease. Our findings represent an informative pilot assessment into the role of the angiopoietin signaling pathway in the inflammatory response in COVID-19.

It's in the blood: a review of the hematological system in SARS-CoV-2-associated COVID-19

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented global healthcare crisis. While SARS-CoV-2-associated COVID-19 affects primarily the respiratory system, patients with COVID-19 frequently develop extrapulmonary manifestations. Notably, changes in the hematological system, including lymphocytopenia, neutrophilia and significant abnormalities of hemostatic markers, were observed early in the pandemic. Hematological manifestations have since been recognized as important parameters in the pathophysiology of SARS-CoV-2 and in the management of patients with COVID-19. In this narrative review, we summarize the state-of-the-art regarding the hematological and hemostatic abnormalities observed in patients with SARS-CoV-2-associated COVID-19, as well as the current understanding of the hematological system in the pathophysiology of acute and chronic SARS-CoV-2-associated COVID-19.

Pathomorphological Features of the Novel Coronavirus Disease in Patients with Systemic Amyloidosis

Amyloidosis is one of the rare systemic illnesses characterized by the deposition of amyloid fibrils in various organs and tissues. There is a common point between COVID-19 and systemic amyloidosis regarding the multiorgan involvement in the pathological process which leads to a heightened risk for severe morbidity and mortality in amyloidosis patients who contracted COVID-19. We performed a pathomorphological analysis of the autopsy records of 22 patients who had COVID-19 and pre-existing systemic amyloidosis. The premortem diagnosis of systemic amyloidosis was established in 55% of patients, and in other 45% of cases, amyloidosis was found at autopsy. Based on the results of immunohistochemical amyloid typing, amyloid A (AA) amyloidosis was detected in 23%, amyloid light chain (AL) lambda in 32%, AL kappa-in 9%, and transthyretin (ATTR) amyloidosis-in 36% of observations. Immunohistochemical staining with an antibody against SARS-CoV-2 Spike (S) protein revealed positive immune reactions in type II alveolocytes in 59% of deceased persons. The analysis of autopsy findings indicates that patients with systemic amyloidosis are more likely to experience an aggressive clinical course of COVID-19 which leads to a multiorgan failure and a higher risk of fatal outcome.

Role of SARS-COV-2 and ACE2 in the pathophysiology of peripheral vascular diseases

The occurrence of a novel coronavirus known as severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), created a serious challenge worldwide. SARS-CoV-2 has high infectivity, the ability to be transmitted even during the asymptomatic phase, and relatively low virulence, which has resulted in rapid transmission. SARS-CoV-2 can invade epithelial cells, hence, many patients infected with SARS-CoV-2 have suffered from vascular diseases (VDs) in addition to pulmonary manifestations. Accordingly, SARS-CoV-2 may can worsen the clinical condition of the patients with pre-existing VDs. Endothelial cells express angiotensin-converting enzyme 2 (ACE2). ACE2 is a biological enzyme that converts angiotensin (Ang)- 2 to Ang-(1-7). SARS-CoV-2 uses ACE2 as a cell receptor for viral entry. Thus, the SARS-CoV-2 virus promotes downregulation of ACE2, Ang-(1-7), and anti-inflammatory cytokines, as well as, an increase in Ang-2, resulting in pro-inflammatory cytokines. SARS-CoV-2 infection can cause hypertension, and endothelial damage, which can lead to intravascular thrombosis. In this review, we have concentrated on the effect of SARS-CoV-2 in peripheral vascular diseases (PVDs) and ACE2 as an enzyme in Renin-angiotensin aldosterone system (RAAS). A comprehensive search was performed on PubMed, Google Scholar, Scopus, using related keywords. Articles focusing on ("SARS-CoV-2", OR "COVID-19"), AND ("Vascular disease", OR "Peripheral vascular disease", OR interested disease name) with regard to MeSH terms, were selected. According to the studies, it is supposed that vascular diseases may increase susceptibility to severe SARS-CoV-2 infection due to increased thrombotic burden and endothelial dysfunction. Understanding SARS-CoV-2 infection mechanism and vascular system pathogenesis is crucial for effective management and treatment in pre-existing vascular diseases.

A possible mechanism of erectile dysfunction in coronavirus disease-19: Cavernosal smooth muscle damage: A pilot study

INTRODUCTION

Studies have reported that coronavirus disease 2019 (COVID-19) may cause erectile dysfunction (ED), however, its role in the pathophysiology of ED has not yet been fully elucidated. We aimed to elucidate COVID-19's effects on cavernosal smooth muscle, which has a pretty important role in erection physiology, by corpus cavernosum electromyography (cc-EMG).

MATERIALS AND METHODS

Twenty-nine male patients aged 20-50 years who applied to the urology outpatient clinic due to ED were included in the study. Nine patients that had COVID-19 and were treated as outpatients were classified as group 1, 10 patients who were hospitalized due to COVID-19 were classified as group 2, and 10 patients who did not have COVID-19 were classified as the control group (group 3). Patients underwent diagnostic evaluation including International Index of Erectile Function (IIEF)-5 form, penile color Doppler ultrasonography (CDUS), cc-EMG, and fasting serum levels of reproductive hormones (07-11am).

RESULTS

According to penile CDUS and hormonal values results, there was no significant difference between the groups. According to cc-EMG results, amplitudes and relaxation capacities of the cavernosal smooth muscle of patients in group 3 were significantly higher than those in the other groups.

CONCLUSIONS

COVID-19 can cause ED not only by psychogenic and hormonal factors but also with cavernosal smooth muscle damage.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04980508.

Rat bite fever mimicking ANCA-associated vasculitis

Rat bite fever (RBF) is a rare infectious zoonotic disease caused by two bacterial species: the Gram-negative rod Streptobacillus moniliformis and the Gram-negative coiled rod Spirillum minus. The association between RBF and skin vasculitis and arthritis has been observed. The aim of this paper was to present a case of rat-bite fever with symptoms of skin vasculitis and arthritis, associated with high titers of ANCA antibodies and anti-endothelial cell antibodies suggestive of primary vasculitis. The patient was successfully treated with antibiotics and non-steroidal anti-inflammatory drugs, leading to significant improvement. Based on the presented case, we discuss the differential diagnosis of the signs and the role of infection in the induction of ANCA antibodies. We reviewed the English language literature for cases of RBF presenting with symptoms of vasculitis and/or antibody presence. A literature review was performed in PubMed and Google using the keywords "rat bite fever" AND "vasculitis", "systemic vasculitis", "ANCA", "antiendothelial antibodies". No cases of rat-bite fever with the presence of ANCA antibodies or AECA antibodies in its course have been described thus far. Rat bite fever is a rare disease with nonspecific symptoms. In its course, general weakness, intermittent fever, leukocytoclastic vasculitis, and arthritis are reported. To our knowledge, this is the first reported case of ANCA positivity associated with RBF.

Neurological telerehabilitation in the COVID-19 era - current perspectives through a bibliometric analysis

Objective

To identify bibliometric parameters and research trends regarding to telerehabilitation of patients with stroke in the COVID-19 era.

Methodology

This is an integrative review carried out in the Scopus database, from June to July 2021, through the Biblioshiny graphical interface, provided by the Bibliometrix program. The search terms used were "Stroke," "COVID-19" and "Telerehabilitation." Results were filtered by publication date from 2019 onwards. No language restrictions were imposed.

Results

Twenty two articles were included in the study and the results were presented in the form of figures demonstrating that the journal Frontiers in Neurology was the one with the most relevant studies and the author with the highest number of citations. The Brazilian Academy of Neurology was the institution with the greatest number of studies and China ranked first as the country with the greatest scientific production. The authors used recent references in their work. A thematic map showed the centrality and density of the words presented and, finally, a three-field graph showed a strong intimacy between countries, keywords and authors.

Conclusion

A greater interest in the subject was observed in China with greater relevance of journals and institutions focused on neurology. However, despite telerehabilitation being an effective alternative in the context of the pandemic, few studies have explored this modality.

[Effect of the COVID-19 pandemic on the outcome of testicular torsion in children]

INTRODUCTION

The COVID-19 pandemic influenced not only the elective, but the acute surgeries also, all around the world. Some authors found more delayed cases and more orchiectomies performed in childhood because of testicular torsions during the pandemic.

OBJECTIVE

To examine the impact of the COVID-19 pandemic on the treatment of childhood testicular torsion and the frequency of semicastration due to torsion at the first author's institute.

METHODS

A retrospective observational cohort study was performed in a representative Hungarian centre. Boys under 18 years of age operated with testicular torsion were divided into two groups: before COVID-19 (BC; 01/07/2017-31/12/2019) and during COVID-19 (DC; 01/01/2020-30/06/2022) pandemic.

PARAMETERS

elapsed time between the first symptom and arrival at the hospital (<24 h or >24 h), elapsed time to start the surgical procedure since the arrival to the hospital and the rate of semicastration were analysed. For statistical analysis, Mann-Whitney U and chi2 tests were used.

RESULTS

During the study period, altogether, 100 patients (45 BC and 55 DC) were operated on testicular torsion. Statistically significant difference was found between the two timeframes: in the elapsed time from the first symptom and arrival at the hospital (p = 0.048). During the pandemic surgeries started earlier (1.5; 2.5 h) than before the pandemic (1.5; 3.25 h, p = 0.01). No difference was found in the frequency of semicastration between the groups (p = 0.594).

DISCUSSION

Contrary to the literature, during the COVID-19 pandemic, patients with testicular torsion arrived earlier at the hospital, and surgeries were started earlier, than before the pandemic at the investigated institute.

CONCLUSION

The reason behind this accelerated care pathway might be the absence of less severe cases during the COVID-19 period. When people are more prone to stay home, if it does not seem necessary to seek help for any kind of non-urgent medical problem. Orv Hetil. 2023; 164(35): 1367-1372.

Surgical treatment of tracheal stenosis during Covid-19 era: a single-center experience and lessons learnt on the field

SARS-CoV2 outbreak led to several healthcare system challenges, especially concerning respiratory support to Covid-19 patients. In the first 2 years of pandemic (2020-2021), we assisted to a marked increase of post-invasive mechanical ventilation (IMV) tracheal stenosis incidence, many of them requiring surgical treatment, namely resection and primary end-to-end anastomosis. Our aim is to describe our experience during the abovementioned biennium, focusing on postoperative outcomes of patients who have had Covid-19 ("post-Covid"). We retrospectively collected pre-, intra- and postoperative data on all patients who underwent tracheal surgery for benign stenosis in our Unit from May 2020 to October 2021, including previous Covid-19. Comparison between "post-Covid-19" and "non-Covid-19" groups' outcomes was then performed. Patients were 9 males and 6 females, and mean age was 57.4 ± 13.21 years. Nine patients had previous Covid-19 (60%). All patients underwent multidisciplinary preoperative evaluation. Almost every operation was conducted by cervicotomy, and the mean length of the resected specimen was 23.9 ± 6.5 mm. Postoperative complications were: dysphonia (3 cases), wound infection (1), bleeding (1), ab-ingestis pneumonia (1), anastomosis dehiscence (2), and stenosis recurrence (1). Thirty-day mortality rate was 6.7% (1 patient). No significant differences between "post-Covid-19" and "non-Covid-19" groups were identified. Pathology revealed, in 5 "post-Covid-19" patients, signs of vasculitis or perivascular inflammatory infiltrate. Tracheal stenosis' surgical treatment has always been known as a challenging procedure because of high perioperative morbidity and mortality rates. Our experience shows that previous Covid-19 and ongoing pandemic did not significantly affect perioperative outcomes of patients who underwent tracheal resection and primary end-to-end anastomosis in a high-volume Center and after multidisciplinary workup.

The spectrum of COVID-19-associated chorioretinal vasculopathy

Purpose

Although conjunctivitis represents the most common ocular manifestation of COVID-19 infection, sight-threatening retinal involvement has been reported. Herein, we report and characterize with multimodal retinal imaging 5 cases of acute vision loss secondary to presumed chorioretinal vasculopathy temporally associated with COVID-19 infection with varying severity, visual morbidity, and treatment response, and review the available literature on the association between COVID-19 infection and retinal microvascular changes.

Design

Observational case series and literature review.

Methods

Multicenter case series of 5 patients who presented to academic centers and private offices with acute vision loss temporally associated with COVID-19 infection. A review of the literature was conducted using online databases.

Results

10 eyes of 5 patients, 3 men and 2 women, with a mean age of 30.8 years (median 33, range 16-44) were described. All patients had a recently preceding episode of COVID-19, with symptomatology ranging from mild infection to life-threatening encephalopathy. Treatment for their retinal disease included topical, oral, intravitreal, and intravenous steroids, steroid-sparing immunosuppression, retinal photocoagulation, antivirals, and antiplatelet and anticoagulant agents. Treatment response and visual recovery ranged from complete recovery of baseline acuity to permanent vision loss and need for chronic immunosuppression.

Conclusions and Importance

Clinicians should be mindful of the potential for vision-threatening retinal involvement after COVID-19 infection. If found, treatment with both anti-inflammatory therapy and anticoagulation should be considered, in addition to close monitoring, as some patients with this spectrum of disease may require chronic immune suppression and/or anti-VEGF therapy.

COVID-19-Related Bilateral Avascular Necrosis of the Femoral Head

Osteonecrosis is a pathologic process that involves focal bone infarction and death of bone tissue caused by trauma, infections, autoimmune conditions, and chronic steroid use; however, most cases go undiagnosed. The link between bilateral osteonecrosis and coronavirus disease 2019 (COVID-19) infections has not been fully investigated. This is the case of a 42-year-old Caucasian woman who presented to the emergency department for bilateral hip pain, which started three months prior. Initially, the pain was mild; however, her symptoms worsened, causing her to have difficulty ambulating. Co-incidentally she tested positive for COVID-19 10 days after the onset of pain. She denied any lower-extremity numbness, weakness, and loss of bowel or bladder function. X-ray of the hips showed significant sclerosis of bilateral femoral heads and acetabula, indicating avascular necrosis. She was given ketorolac injection intramuscularly for analgesia and remained in stable condition. Upon discharge, she was given a referral to orthopedic surgery for bilateral total hip arthroplasty. Atraumatic osteonecrosis of the femoral head can be caused by multiple etiologies, including exposure to medications, post-transplantation procedures, trauma, and hypercoagulable states. This condition is likely due to poor angiogenesis after an infarct, causing a domino effect of bone demineralization, trabecular thinning, and cortical collapse. A literature search demonstrated prior cases of unilateral femoral head necrosis associated with COVID-19 infection and steroid use. There have been no cases of bilateral osteonecrosis of the femoral head reported without long-term steroid use. Considering the disease severity in both hips and limited steroid use (only five days of prednisone), other common etiologies were sought and were ruled out. In our patient, the only event that was related to her initial onset of hip pain was a COVID-19 infection. We suggest a relationship between COVID-19 infection and avascular necrosis given the rapid progression of the disease. We acknowledge that this presentation of bilateral osteonecrosis is rare and warrants further investigation. More research should be performed to establish a tenable relationship between COVID-19 infection and osteonecrosis, with and without the use of steroids.

Secondary Vasculitis Attributable to Post-COVID Syndrome

While the acute phase of the COVID-19 pandemic has largely come to pass, the chronic physiologic effects of the coronavirus continue to unfold. Specifically, the number of COVID-19-associated vasculitis cases has steadily increased since the onset of the pandemic. Data have shown that vasculitis may develop less than two weeks after COVID-19 or during a later onset of the disease. At this time, research has demonstrated that the novel coronavirus invades more than just the lungs; it can also attack the nervous system, cardiovascular system, and kidneys. In addition, there is a greater understanding of the pathogenesis regarding COVID-19-induced vasculitis via humoral immunity and immune complex disease. Recent case reports have shown an association between COVID-19 and secondary vasculitis. This review paper discusses case reports and data that suggest that COVID-19 may lead to specific vasculitis diseases such as giant cell arteritis, ophthalmic arteritis, aortitis, and Kawasaki-like disease. More research needs to be performed on this association to aid in diagnosis and treatment.

Case Report: Retinal Vasculitis in Two Adolescents After COVID-19 Vaccination

PURPOSE

To report two cases of bilateral retinal vasculitis in adolescents following COVID-19 vaccination.

STUDY DESIGN

Case report.

RESULTS

 We report the first two cases of retinal vasculitis in adolescents following COVID-19 vaccinations. Both patients received recent second-dose COVID-19 vaccinations (7 weeks and 4 weeks respectively), and presented with bilateral retinal vasculitis and vitritis. Investigations did not reveal other causes of retinal vasculitis. Both patients' retinal vasculitis settled with a short course of oral prednisolone.

CONCLUSION

Although rare, the temporal association between vaccination, bilateral eye involvement, and the absence of alternative infective or inflammatory causes, makes this a plausible etiology. mRNA vaccinations may cause an autoimmune reaction via host antigenic mimicry, and systemic vasculitis has previously been described. We believe that a short interval between COVID-19 vaccination doses might be a risk factor for the development of retinal vasculitis in adolescents, and clinicians should be aware to elicit vaccination history.

Autonomic modulation, spontaneous baroreflex sensitivity and fatigue in young men after COVID-19

Impaired autonomic modulation and baroreflex sensitivity (BRS) have been reported during and after COVID-19. Both impairments are associated with negative cardiovascular outcomes. If these impairments were to exist undetected in young men after COVID-19, they could lead to negative cardiovascular outcomes. Fatigue is associated with autonomic dysfunction during and after COVID-19. It is unclear if fatigue can be used as an indicator of impaired autonomic modulation and BRS after COVID-19. This study aims to compare parasympathetic modulation, sympathetic modulation, and BRS between young men who had COVID-19 versus controls and to determine if fatigue is associated with impaired autonomic modulation and BRS. Parasympathetic modulation as the high-frequency power of R-R intervals (lnHFR-R), sympathetic modulation as the low-frequency power of systolic blood pressure variability (LFSBP), and BRS as the -index were measured by power spectral density analysis. These variables were compared between 20 young men who had COVID-19 and 24 controls. Independent t-tests and Mann-Whitney U tests indicated no significant difference between the COVID-19 and the control group in: lnHFR-R, P=0.20; LFSBP, P=0.11, and -index, P=0.20. Fatigue was not associated with impaired autonomic modulation or BRS. There is no difference in autonomic modulations or BRS between young men who had COVID-19 compared to controls. Fatigue did not seem to be associated with impaired autonomic modulation or impaired BRS in young men after COVID-19. Findings suggest that young men might not be at increased cardiovascular risk from COVID-19-related dysautonomia and impaired BRS.

Rapid production and free distribution of a synthetic RNA material to support SARS-CoV-2 molecular diagnostic testing

In response to the COVID-19 pandemic, the National Institute of Standards and Technology released a synthetic RNA material for SARS-CoV-2 in June 2020. The goal was to rapidly produce a material to support molecular diagnostic testing applications. This material, referred to as Research Grade Test Material 10169, was shipped free of charge to laboratories across the globe to provide a non-hazardous material for assay development and assay calibration. The material consisted of two unique regions of the SARS-CoV-2 genome approximately 4 kb nucleotides in length. The concentration of each synthetic fragment was measured using RT-dPCR methods and confirmed to be compatible with RT-qPCR methods. In this report, the preparation, stability, and limitations of this material are described.

Evaluating chest pain in patients with post COVID conditions permission to think outside of the box

Chest pain is among the most common symptoms of post-COVID-19 Conditions (PCC) that prompts medical attention. Because the SARS-CoV-2 virus has proclivity for many organs and organ systems in the chest, ranging from the heart, lungs, great vessels, lymphatics, and peripheral nerves, clinicians evaluating patients with chest pain must consider a broad differential diagnosis and take a comprehensive approach to management.

Spontaneous Cervicothoracic Extradural Hematoma with Rare Presentation in Pediatric Patient with Stroke-Like Features in Association with COVID-19, Presenting as Management Dillemma

Presentation of cervico-thoracic extradural hematoma in pediatric age is rare with stroke-like features. Its association with COVID-19 in the active stage of the disease had not been reported and its management presents a management dilemma as COVID-19 with stroke-like features.

A 14-year-old boy was referred to our institute with complaints of sudden-onset upper and middle back pain, associated with loss of sensation below the middle of the back, sudden progressive weakness of both lower limbs (power 0/5) and upper limbs (power grade-2/5), and incontinence of urine, following bouts of vomiting 12 days back. There was no history of trauma, bleeding diathesis, etc. Blood investigation was suggestive of leukocytosis, and RT-PCR test for COVID-19 was positive with raised D-dimer, serum ferritin, and C-reactive protein. MRI spine was suggestive of cervicothoracic extradural hematoma extending from C5-D3 level and compressing the spinal cord. The patient refused surgical decompression and was managed conservatively, following which he improved with power grade in limbs to 4/5.

Surgical decompression is the treatment of choice but the patient can sometimes improve on medical management. Association of COVID-19 with spontaneous cervicothoracic extradural hematoma had not been reported earlier in the active stage, but its role in inducing vasculopathy and increased chances of bleeding at the uncommon site had been reported in the literature, and it may precipitate such cervical epidural hematoma.

COVID-19 Associated Vasculitis Confirmed by the Tissues RT-PCR: A Case Series Report

Background: Several cases of skin and central nervous system vasculopathy associated with COVID-19 in children have been published, but the information is rather limited. Our study aimed to describe these cases of vasculitis associated with COVID-19 in children. Methods: In the retrospective-prospective case series study we included information regarding four children with COVID-19-associated vasculitis. In every case, we had a morphological description and the etiology was confirmed via real-time polymerase chain reaction during a tissue biopsy. Results: The most involved systems were skin (4/4), respiratory (3/4), cardiovascular (2/4), nervous (1/4), eye (1/4), kidney (1/4), and inner year (1/4). All patients had increased inflammatory markers and thrombotic parameters (D-dimer). No patient met the criteria for multisystem inflammatory syndrome in children. Two patients met polyarteritis nodosa criteria, one met Henoch–Schonlein purpura criteria, and one met unclassified vasculitis criteria. All patients were treated with systemic glucocorticosteroids (two-pulse therapy). Non-biologic DMARDs were prescribed in all cases; 1/4 patients (25%) was treated with intravenous immunoglobuline, and 3/4 (75%) were treated with biologics (etanercept, tocilizumab, and adalimumab). Conclusions: Vasculitis associated with COVID-19 could be a life-threatening condition; SARS-CoV-2 might be a new trigger or etiological agent for vasculitis and other immune-mediated diseases. Further research and collection of similar cases are required.

Molecular Mechanisms of Neutrophil Extracellular Trap (NETs) Degradation

Although many studies have been exploring the mechanisms driving NETs formation, much less attention has been paid to the degradation and elimination of these structures. The NETs clearance and the effective removal of extracellular DNA, enzymatic proteins (neutrophil elastase, proteinase 3, myeloperoxidase) or histones are necessary to maintain tissue homeostasis, to prevent inflammation and to avoid the presentation of self-antigens. The persistence and overabundance of DNA fibers in the circulation and tissues may have dramatic consequences for a host leading to the development of various systemic and local damage. NETs are cleaved by a concerted action of extracellular and secreted deoxyribonucleases (DNases) followed by intracellular degradation by macrophages. NETs accumulation depends on the ability of DNase I and DNAse II to hydrolyze DNA. Furthermore, the macrophages actively engulf NETs and this event is facilitated by the preprocessing of NETs by DNase I. The purpose of this review is to present and discuss the current knowledge about the mechanisms of NETs degradation and its role in the pathogenesis of thrombosis, autoimmune diseases, cancer and severe infections, as well as to discuss the possibilities for potential therapeutic interventions. Several anti-NETs approaches had therapeutic effects in animal models of cancer and autoimmune diseases; nevertheless, the development of new drugs for patients needs further study for an effective development of clinical compounds that are able to target NETs.

The impact of the COVID-19 pandemic on patients with systemic vasculitis: a single-centre retrospective study

This study aimed to study the impact of the COVID-19 pandemic on patients living with systemic vasculitis in Kazakhstan. A single-centre retrospective study of the medical histories of 82 patients was carried out based on the regional clinical hospital of the city for all admissions with systemic vasculitis in the period from January 2019 to December 2021. The following qualitative (gender, disability, concomitant diseases) and quantitative (age, disease experience, laboratory data, etc.) variables were studied. To conduct the study, the criteria for the inclusion and exclusion of patients in the study were determined. According to the results of the study, there is a decrease in the number of hospitalized patients with vasculitis in the rheumatology department of the regional clinical hospital. Compared to 2019, in 2021, the number of hospitalized patients decreased by almost half (Table 1). Out of 82 cases, the most common was Takayasu disease (nonspecific aortoarteritis) (43.9%), IgA-vasculitis (Schenlein-Genoch disease) (31.71%), and they are typical mainly for females of rural origin, who were admitted to the hospital in a comorbid state (p < 0.001). 41.6% of patients have disabilities, and the majority of patients have a II disability group. The average body mass index is 24.2; 27 patients out of the total number of patients suffer from obesity. The most common clinical symptoms of patients with systemic vasculitis were injuries of the musculoskeletal system (75.6%). A negative average correlation was found between the indicators of the level of ESR and haemoglobin, the correlation coefficient is -0.535. The patients had concomitant diseases, such as diabetes mellitus, iron deficiency anaemia, coronary heart disease, hypertension, gastrointestinal tract diseases and hepatitis. Women of reproductive age from rural areas are often diagnosed with systemic vasculitis. A high rate of disability revealed among the patients can be explained by two main factors, the first is that the patients consulted the doctors untimely and the second is that the medical community are insufficiently informed about the management of autoimmune rheumatic diseases, in particular about systemic vasculitis, which hinders timely diagnosis and treatment, respectively. Patients, included in this survey, were mostly suffering from diseases of the musculoskeletal system, but depending on the type of vasculitis, other organs and systems may be affected. Table 1 Frequency of patients with systemic vasculitis over 3 years Year Frequency % p-value 2019 42 51.2 χ² = 12.463^a; p = 0.002 2020 23 28.0 2021 17 20.7 Total 82 100.0.

COVID-19 associated renal artery stenosis in infancy - A report of two cases

Organ-specific vasculitis is an uncommon, delayed complication of COVID-19 infection. It is usually seen in mildly symptomatic or asymptomatic patients. Underlying endothelitis is the most likely pathophysiological mechanism for such a manifestation. We report two infants with renal artery stenosis, most likely consequent to COVID-19 infection.

Facial palsy at the onset of SARS-CoV-2 infection. A case report

Introduction

SARS-CoV-2 infection has been associated with an increased number of deaths, due to severe respiratory damage, cardiovascular impairment, acute renal failure, and also neurological injury, including stroke, which is most commonly responsible for death. These are elements that determine patients to seek medical advice.

Case report

This is a case report of a female Caucasian patient, aged 65 years, with type 2 diabetes mellitus on metformin 1000 mg twice/day, and hypertension, who presented to the emergency department with one day history of left orbital hyperlacrimation and chewing and swallowing difficulty. On physical examination there was a decreased blink reflex, flattened nasolabial fold, and drooping left corner of the mouth, with left conjunctival hyperemia, and a present corneal reflex. Motion limited head CT and MRI revealed no pathological changes suggestive for the appearance of paresis. The patient was transferred to the Department of Infectious Diseases after laboratory confirmation of SARS-CoV-2 infection. Under treatment, improvement of paresis after three days was observed, with minimal asymmetry left five days after admission. A reassessment one month after discharge revealed complete recovery of the paresis, physical asthenia, and headache, in the context of long-COVID syndrome.

Conclusions

The appearance of paresis may be a consequence of the direct action of the virus on the nervous system, of hypercoagulability, or, later, of an immune mechanism. The case presented is judged as an early, direct action of the virus on the central nervous system, the respiratory symptoms were minimized by the patient at the time of presentation.

Spontaneous dissection of the superior mesenteric artery related to COVID-19

Background: Spontaneous peripheral dissections are rare, and in a substantial number of cases, the underlying aetiology remains unclear. Patients and methods: We report the case of a 63-year-old male patient with a recent asymptomatic SARS-CoV-2 infection who presented with sudden-onset intermittent abdominal pain. Imaging studies revealed a dissection of the superior mesenteric artery (SMA) and large-vessel vasculitis involving the SMA as well as the carotid, subclavian, axillary and femoropopliteal arteries. In the absence of other predisposing factors, we supposed an association with prior COVID-19 and performed a systematic review of the literature to search for similar cases with arterial dissection related to acute or recent SARS-CoV-2 infection. Results: We identified 25 cases, including ours: 13 males and 12 females, with a median age of 48 years. In 22/25 patients, arterial dissection occurred within 4 weeks after the diagnosis of COVID-19 and involved the cerebral (11/25; 44%), coronary (10/25; 40%), splanchnic (3/25; 12%) and renal (2/25; 8%) arteries. Conclusions: Although initially known for its respiratory manifestations, it has become evident that SARS-CoV-2 not only infects pneumocytes but also enters the vascular endothelium, leading to endothelial dysfunction and hypercoagulability and - as shown in our case - large-vessel vasculitis, which may predispose patients to intramural haemorrhage and arterial dissection.

A descriptive study of abdominal complications in patients with mild COVID-19 presenting to the emergency department: a single-center experience in Japan during the omicron variant phase

BACKGROUND

COVID-19 is widely known to induce a variety of extrapulmonary manifestations. Gastrointestinal symptoms have been identified as the most common extra-pulmonary manifestations of COVID-19, with an incidence reported to range from 3 to 61%. Although previous reports have addressed abdominal complications with COVID-19, these have not been adequately elucidated for the omicron variant. The aim of our study was to clarify the diagnosis of concomitant abdominal diseases in patients with mild COVID-19 who presented to hospital with abdominal symptoms during the sixth and seventh waves of the pandemic of the omicron variant in Japan.

METHODS

This study was a retrospective, single-center, descriptive study. In total, 2291 consecutive patients with COVID-19 who visited the Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, Osaka, Japan, between January 2022 and September 2022 were potentially eligible for the study. Patients delivered by ambulance or transferred from other hospitals were not included. We collected and described physical examination results, medical history, laboratory data, computed tomography findings and treatments. Data collected included diagnostic characteristics, abdominal symptoms, extra-abdominal symptoms and complicated diagnosis other than that of COVID-19 for abdominal symptoms.

RESULTS

Abdominal symptoms were present in 183 patients with COVID-19. The number of patients with each abdominal symptom were as follows: nausea and vomiting (86/183, 47%), abdominal pain (63/183, 34%), diarrhea (61/183, 33%), gastrointestinal bleeding (20/183, 11%) and anorexia (6/183, 3.3%). Of these patients, 17 were diagnosed as having acute hemorrhagic colitis, five had drug-induced adverse events, two had retroperitoneal hemorrhage, two had appendicitis, two had choledocholithiasis, two had constipation, and two had anuresis, among others. The localization of acute hemorrhagic colitis was the left-sided colon in all cases.

CONCLUSIONS

Our study showed that acute hemorrhagic colitis was characteristic in mild cases of the omicron variant of COVID-19 with gastrointestinal bleeding. When examining patients with mild COVID-19 with gastrointestinal bleeding, the potential for acute hemorrhagic colitis should be kept in mind.

Vascular Function, Systemic Inflammation, and Coagulation Activation 18 Months after COVID-19 Infection: An Observational Cohort Study

INTRODUCTION

Among its effect on virtually all other organs, COVID-19 affects the cardiovascular system, potentially jeopardizing the cardiovascular health of millions. Previous research has shown no indication of macrovascular dysfunction as reflected by carotid artery reactivity, but has shown sustained microvascular dysfunction, systemic inflammation, and coagulation activation at 3 months after acute COVID-19. The long-term effects of COVID-19 on vascular function remain unknown.

MATERIALS AND METHODS

This cohort study involved 167 patients who participated in the COVAS trial. At 3 months and 18 months after acute COVID-19, macrovascular dysfunction was evaluated by measuring the carotid artery diameter in response to cold pressor testing. Additionally, plasma endothelin-1, von Willebrand factor, Interleukin(IL)-1ra, IL-6, IL-18, and coagulation factor complexes were measured using ELISA techniques.

RESULTS

The prevalence of macrovascular dysfunction did not differ between 3 months (14.5%) and 18 months (11.7%) after COVID-19 infection (p = 0.585). However, there was a significant decrease in absolute carotid artery diameter change, 3.5% ± 4.7 vs. 2.7% ± 2.5, p-0.001, respectively. Additionally, levels of vWF:Ag were persistently high in 80% of COVID-19 survivors, reflecting endothelial cell damage and possibly attenuated endothelial function. Furthermore, while levels of the inflammatory cytokines interleukin(IL)-1RA and IL-18 were normalized and evidence of contact pathway activation was no longer present, the concentrations of IL-6 and thrombin:antithrombin complexes were further increased at 18 months versus 3 months (2.5 pg/mL ± 2.6 vs. 4.0 pg/mL ± 4.6, p = 0.006 and 4.9 μg/L ± 4.4 vs. 18.2 μg/L ± 11.4, p < 0.001, respectively).

DISCUSSION

This study shows that 18 months after COVID-19 infection, the incidence of macrovascular dysfunction as defined by a constrictive response during carotid artery reactivity testing is not increased. Nonetheless, plasma biomarkers indicate sustained endothelial cell activation (vWF), systemic inflammation (IL-6), and extrinsic/common pathway coagulation activation (FVII:AT, TAT) 18 months after COVID-19 infection.

Phylogenetic analysis of feline infectious peritonitis virus, feline enteric coronavirus, and severe acute respiratory syndrome coronavirus 2 of cats in Surabaya, Indonesia

Background and Aim

Questions about the origin of coronavirus and its introduction to human beings have persisted. The detection of a variety of coronavirus related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in bats and pangolins led to the widespread belief that SARS-CoV-2 originated from wild ani-mals and was introduced to humans through an inter-mediate animal. Thus, coronaviruses from animals, especially those in close contact with humans, have attracted particular attention. This study aimed to phylogenetically analyze feline enteric coronavirus (FECV), feline infectious peritonitis virus (FIPV), and SARS-CoV-2 found in cats in Surabaya amid the COVID-19 pandemic. The results will provide a basis for developing basic preventive and pet healthcare strategies.

Materials and Methods

Samples were collected on physical examinations of domestic and Persian cats (males and females) from March 2020 to March 2022. Samples were collected if there were clinical signs of FECV and FIP based on a veterinarian's diagnosis in several clinics in Surabaya. Laboratory examinations in this study were performed by reverse-transcription-polymerase chain reaction (RT-PCR) with primers for conserved regions of FIP and FECV, DNA sequencing was performed with Applied Biosystem Genetic Analyzer protocol, homology analysis was performed using Basic Local Alignment Search Tool NCBI, phylogenetic analysis was carried out with BioEdit 7.2 software, and sequences were compared with references from GenBank.

Results

Samples were collected from ten cats showing clinical signs of FECV and FIP, based on a veterinarian's diagnosis. On RT-PCR examinations performed with specifically designed primers for detecting FIPV in blood, peritoneal fluid, and feces, only one sample showed positivity for FIPV (1/10), namely, a peritoneal sample from a domestic cat in Surabaya. Homology analysis of the FIPV Surabaya isolate showed 98% similarity with FECV and FIPV reported in GenBank (MT444152 and DQ010921, respectively). In phylogenetic analysis, the FIPV Surabaya isolate was clustered together with SARS-CoV-2 of Clade A (MT198653) from Spain, SARS-CoV-2 Clade A (MT192765) from the USA, SARS-CoV-2 Clade D (039888) from the USA, and SARS-CoV-2 Clade F (MT020781) from Finland.

Conclusion

This study revealed a relationship between the SARS-CoV-2 viruses that infect humans and cats (FECV), which is an important finding for those keeping cats at home. However, this finding requires further comprehensive support from laboratory studies.