Right-to-Left Intra-cardiac Shunt in a COVID-19 Patient Leading to Stroke and Poor Prognosis: A Case Report and Review of the Literature

Coronavirus disease 2019 (COVID-19) often presents with a wide range of complications, including respiratory distress, acute respiratory distress syndrome (ARDS), and hypercoagulable states with resultant cerebrovascular incidents. Intra- and extra-pulmonological shunts can further complicate patient courses, leading to persistent hypoxemia and paradoxical emboli, resulting in potentially life-threatening consequences, necessitating a comprehensive, multidisciplinary approach to patient care. Here we present the case of a 73-year-old male who experienced severe persistent hypoxemic respiratory failure, superimposed methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, and stroke with a previously undiagnosed patent foramen ovale (PFO) contributing to his clinical presentation.

Tenecteplase With Concomitant Anticoagulation for Acute Respiratory Failure in Patients With COVID-19: A Randomized Controlled Trial

Background Pulmonary thrombosis and thromboembolism play a significant role in the physiologic derangements seen in COVID-19 acute respiratory failure. The effect of thrombolysis with tenecteplase on patient outcomes is unknown. Methods We conducted a randomized, controlled, double-blind, phase II trial comparing tenecteplase versus placebo in patients with COVID-19 acute respiratory failure (NCT04505592). Patients with COVID-19 acute respiratory failure were randomized to tenecteplase 0.25 mg/kg or placebo in a 2:1 proportion. Both groups received therapeutic heparin for at least 72 hours. Results Thirteen patients were included in the trial. Eight patients were randomized to tenecteplase and five were randomized to placebo. At 28 days, 63% (n = 5) of patients assigned to the treatment group were alive and free from respiratory failure compared to 40% (n = 2) in the placebo arm (p = 0.43). Mortality at 28 days was 25% (n = 2) in the treatment arm and 20% (n = 1) in the control arm (p = 1.0). No patients in the treatment arm developed renal failure by 28 days compared to 60% (n = 3) in the placebo arm (p = 0.07). Major bleeding occurred in 25% (n = 2) of the treatment arm and 20% (n = 1) in the placebo arm; however, no patients in either arm experienced intracranial hemorrhage. Conclusions Tenecteplase with concomitant heparin may improve patient outcomes in patients with COVID-19 respiratory failure. As this study was limited by a small sample size, larger confirmatory studies are needed.

A Systematic Review of Mortality Rates Among Adult Acute Respiratory Distress Syndrome Patients Undergoing Extracorporeal Membrane Oxygenation Therapy

Acute respiratory distress syndrome (ARDS) is a severe lung disease associated with a high mortality rate. Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe ARDS patients who do not respond to conventional treatments. Nevertheless, the optimal management of ARDS patients undergoing ECMO and their mortality rates remain subjects of controversy. Thus, this systematic review aims to assess mortality rates in ARDS patients on ECMO and identify associated factors. The review adhered to the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA) 2020 guidelines. A comprehensive literature search was conducted on PubMed, PubMed Central (PMC), Medline, and Embase. In accordance with our inclusion and exclusion criteria, filters, and key terms, we proceeded to screen the articles. After assessing the relevance of each article to our topic, further screening was carried out. Quality assessment of the articles was conducted, resulting in the inclusion of a total of 12 articles for the review. The primary outcome focused on mortality rates among ARDS patients undergoing ECMO. Secondary outcomes explored potential contributors to mortality, including patient age, underlying cause of ARDS, and Sequential Organ Failure Assessment (SOFA) scores at the initiation of ECMO. Mortality rates exhibited significant variation, ranging from 22% to 62.6%. Several factors emerged as potential predictors of mortality, encompassing patient age, comorbidities, complications during ECMO therapy, and treatment-related variables. This systematic review offers valuable insights into the intricate factors influencing mortality rates among ARDS patients on ECMO. A comprehension of these factors is essential to steer clinical practice and enhance patient outcomes. While ECMO serves as a restorative avenue for ARDS patients, future research is warranted to further elucidate these complex interactions and refine ECMO therapy protocols.

In silico transcriptional analysis of asymptomatic and severe COVID-19 patients reveals the susceptibility of severe patients to other comorbidities and non-viral pathological conditions

COVID-19 is a severe respiratory disease caused by SARS-CoV-2, a novel human coronavirus. Patients infected with SARS-CoV-2 exhibit heterogeneous symptoms that pose pragmatic hurdles for implementing appropriate therapy and management of the COVID-19 patients and their post-COVID complications. Thus, understanding the impact of infection severity at the molecular level in the host is vital to understand the host response and accordingly it's precise management. In the current study, we performed a comparative transcriptomics analysis of publicly available seven asymptomatic and eight severe COVID-19 patients. Exploratory data analysis employing Principal Component Analysis (PCA) showed the distinct clusters of asymptomatic and severe patients. Subsequently, the differential gene expression analysis using DESeq2 identified 1224 significantly upregulated genes (logFC≥ 1.5, p-adjusted value <0.05) and 268 significantly downregulated genes (logFC≤ −1.5, p-adjusted value <0.05) in severe samples in comparison to asymptomatic samples. Eventually, Gene Set Enrichment Analysis (GSEA) revealed the upregulation of anti-viral and anti-inflammatory pathways, secondary infections, Iron homeostasis, anemia, cardiac-related, etc.; while, downregulation of lipid metabolism, adaptive immune response, translation, recurrent respiratory infections, heme-biosynthetic pathways, etc. Conclusively, these findings provide insight into the enhanced susceptibility of severe COVID-19 patients to other health comorbidities including non-viral pathogenic infections, atherosclerosis, autoinflammatory diseases, anemia, male infertility, etc. owing to the activation of biological processes, pathways and molecular functions associated with them. We anticipate this study will facilitate the researchers in finding efficient therapeutic targets and eventually the clinicians in management of COVID-19 patients and post-COVID-19 effects in them.

Is the Use of Dialysis Associated With an Increased Risk of Death in COVID-19-Related Acute Kidney Injury?

INTRODUCTION

Acute kidney injury (AKI) is frequently reported in the setting of severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) infection. The aim of our work is to evaluate the impact of acute dialysis use on mortality in patients with AKI during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This is a retrospective study conducted in the Hassan II University Hospital of Fez, Morocco. From July 2020 to December 2021, we included all patients admitted to a COVID-19 unit with acute kidney injury defined according to Kidney Disease Improvement Global Outcomes 2012 (KDIGO 2012) criteria. Our patients were older than 18 years, and SARS-CoV-2 infection was confirmed by a positive RT-PCR test or thoracic CT scan imaging. Patients with end-stage renal disease (ESRD) and pregnant women were excluded from our study.

RESULTS

The total number of patients hospitalized in the COVID-19 unit during the study period was 2560, including 206 in an intensive care setting. We included 61 patients with AKI, with an incidence in the intensive care unit (ICU) setting of 15.5%. Eighty percent of patients had respiratory distress on admission, which was the main reason for consultation. Stage 1 AKI was found in 1.6% of patients, 25.8% had stage II AKI, and 72.6% had KDIGO stage 3 AKI. The main etiology of AKI was acute tubular necrosis. Lung involvement secondary to infection was severe in 18 patients; 21 had moderate involvement. In our study, twenty-one of our patients (34.4%) were hospitalized in an ICU. Thirteen of our patients were intubated (21.1%). Twenty-one (34.4%) patients were hemodynamically unstable and were put on vasoactive drugs. Twenty-three (37.7%) of our patients received at least one session of conventional acute hemodialysis with an average duration of 2.1 hours ± 0.9 (1-3.5). The indication was overload (27%), severe metabolic acidosis (1.6%), threatening hyperkalemia (1.6%), and symptomatic hyperuremia (62%). The evolution was marked by a return to baseline renal function in two patients, partial improvement in 35 of them at discharge, and no improvement in 24 patients. We recorded a death rate of 34.4% (n=21). In a univariate analysis, we compared the demographic, clinical, paraclinical, and dialytic characteristics of the dialysis and non-dialysis groups. There was a significant difference between unstable, intubated patients and those hospitalized in the ICU in the dialysis group, with respective p-values of p=0.0001, p=0.0001, and p=0.01. We noticed there were more deaths in the dialysis group than in the non-dialysis group; this difference was statistically significant with a p-value of 0.005. In multivariate analysis, a logistic regression model was performed to test the relationship between dialysis and COVID-19 mortality while adjusting for other co-factors. The final model did not show a significant association between dialysis and mortality (p = 0.150, OR: 2.578 [0.710-9.364]). The only factor that remained independently significant was admission to the intensive care unit (p = 0.004, OR: 6.732 [1.847-24.540]).

CONCLUSION

AKI is a frequently encountered complication in patients with COVID-19, especially those hospitalized in the ICU. In the context of the SARS-CoV-2 infection, the use of at least one dialysis session seems to represent an excess risk of mortality related to AKI.

Methamphetamine Intoxication and Perioperative Complications Following Orthopaedic Surgical Procedures

Background Methamphetamine use is increasing in prevalence. There is a theoretical increased risk of complication postoperative due to catecholamine depletion. When presented with an urgent surgical problem, there are little data to help counsel the patient on the risks of undergoing surgery in the setting of a positive methamphetamine test result. Aims and objectives The aim of this study was to examine the perioperative complication rate for patients who underwent emergent orthopaedic procedures in the setting of a positive methamphetamine drug screen. Additional data were collected in an attempt to further stratify risk factors for perioperative complications in this patient population. Design and methods A retrospective case series of 110 patients. Patients were identified by querying the medical record for patients with a positive methamphetamine result within 24 hours of the surgery start time. Data were collected on each patient, including the nature of the surgery, the type of injury sustained, disposition from the operating room, among other data points. The primary outcome was the presence of a perioperative cardiopulmonary complication, as determined by a new diagnosis made in the chart. The secondary outcome was whether the patient needed an increased level of care postoperatively. Results Of the 110 charts reviewed, three patients sustained complications during their hospitalization; an overall complication rate of 2.7%. One patient developed acute respiratory distress syndrome (ARDS), while two others developed surgical site infections. Of the 19 patients who went to the intensive care unit (ICU) postoperatively, none were because the patient required a higher level of care than the preoperative level. Conclusions Patients who underwent emergent surgical intervention in the setting of a positive methamphetamine drug test had a low complication rate. While the dogma is to delay surgery in the setting of methamphetamine use, the true risk of undergoing surgery in this setting is not fully understood. We advocate for continued research in this poorly studied group of patients. Larger studies will need to be done in order to fully understand the risks associated with operating in the setting of a positive methamphetamine drug screen.

Human Metapneumovirus Pneumonia Precipitating Acute Respiratory Distress Syndrome in an Adult Patient

Acute respiratory distress syndrome (ARDS) is often due to direct lung injury, trauma, surgery, or infection. Making a definitive diagnosis may be difficult initially, as clinical manifestations are nonspecific until the disease progresses. We present a case of human metapneumovirus (hMPV) pulmonary infection precipitating ARDS.

A 51-year-old woman presented with one week of pleuritic chest pain, dyspnea, wheezing, subjective fever, and productive cough prior to presentation. Her medical history was significant for human immunodeficiency virus (HIV) with an unknown CD4 count and viral load, pulmonary sarcoidosis, asthma, and being an active smoker. On admission, the patient was dyspneic and using accessory muscles to breathe. She was afebrile and hypotensive. Physical examination revealed bilateral diffuse crackles. Her white blood cell (WBC) count was 7.7 K/mcL. A chest radiograph demonstrated bilateral lung opacifications suggestive of pneumonia, possibly Pneumocystis jiroveci pneumonia (PJP). Broad-spectrum antibiotics, including PJP treatment, corticosteroids, and fluids, were started. The patient received approximately 4 liters of intravenous fluids; yet, she remained hypotensive and required norepinephrine. Chest computed tomography (CT) demonstrated bilateral consolidations. Arterial blood gas (ABG) showed a partial pressure of oxygen (PaO₂) of 55 mmHg. The patient was intubated for acute hypoxemic respiratory failure and had a PaO₂/fraction of inspired oxygen (FiO₂) < 100. Repeat ABG within 12 hours showed a potential of hydrogen (pH) of 7.34, partial pressure of carbon dioxide (pCO₂) of 42 mmHg, and a PaO₂ of 130 mmHg. Bronchoalveolar lavage revealed only hMPV. The patient was managed supportively and extubated three days later. She was discharged home without oxygen requirement.

hMPV causes respiratory infections, most commonly in the extremes of age and immunocompromised patients. The treatment is supportive. Our patient developed acute hypoxemic respiratory failure secondary to an hMPV infection. hMPV pneumonia should be considered as a differential diagnosis in patients with severe respiratory illness and ARDS in order to promote antibiotic stewardship.

Functional and Radiological Improvement in a COVID-19 Pneumonia Patient Treated With Steroids

Like its predecessors, coronavirus disease 2019 (COVID-19) can lead to long-term health-related consequences in a significant segment of the afflicted population. Although the medical community has developed multiple vaccines by now, COVID-19 has affected over 100 million individuals worldwide and will infect millions more before vaccines can be effectively distributed on a global scale. Additionally, it seems probable that another outbreak caused by a coronavirus may occur in the future, given that this is the third outbreak caused by a coronavirus in recent history. In light of this, the medical community must develop reliable methods of curtailing long-term sequelae of coronaviruses, and the use of corticosteroids in affected patients may be vital for this purpose. In this report, we present a case of progressive dyspnea caused by COVID-19 pneumonia; the patient was treated with a short course of oral corticosteroids, and subsequently showed marked improvement of the dyspnea with corresponding improvements on chest CT.

Use of Dexmedetomidine in Early Prone Positioning Combined With High-Flow Nasal Cannula and Non-Invasive Positive Pressure Ventilation in a COVID-19 Positive Patient

As the COVID-19 pandemic continues to manifest in our society, we still lack evidence-based treatment guidelines. Current treatment for COVID-19 pneumonia has been modeled from currently established guidelines such as that of acute respiratory distress syndrome (ARDS). COVID-19 pneumonia, also known as SARS-CoV-2, is characterized by severe hypoxia and near-normal respiratory system compliance with a time-related presentation. Dexmedetomidine is a centrally acting alpha-2 receptor agonist that promotes sedative and anxiolytic effects without the risk of respiratory depression and can provide cooperative or semi-rousable sedation. Patients who are developing ARDS secondary to COVID-19 pneumonia have been treated with self-proning intervals in combination with supplementation of oxygenation via high-flow nasal cannula (HFNC) or non-invasive positive pressure ventilation (NIPPV); however, a few patients have poor tolerance to the devices, leading to poor compliance and eventual worsening respiratory symptoms leading to intubation. In the current case report, we detail how a patient was able to successfully be self-proned with proper tolerance to HFNC and NIPPV while using dexmedetomidine, leading to discharge without the need for further oxygen supplementation at home.

Icosapent Ethyl - A Successful Treatment for Symptomatic COVID-19 Infection

COVID-19 is a fatal, universal pandemic caused by the SARS-CoV-2 virus that has directly caused at least 95,235 deaths in the US by May 2020. It has a poor prognosis with a mortality rate as high as 21% in the general population at the height of the pandemic, a rate that is much higher in elderly patients, as well as those requiring intensive care unit (ICU) care. The role of inflammation in symptomatic COVID-19 is being studied, and it is hypothesized that hyper-inflammation is a causative factor in severe COVID-19 disease. Treatment options are limited and mostly rely on supportive care.

Icosapent ethyl (IPE) is an Omega-3 fatty acid derivative that has been shown to significantly reduce cardiovascular mortality and is used as an adjunct to statin therapy. Though it has been shown to act as an anti-inflammatory, it is not currently indicated for that purpose. Here, we describe, for the first time, the successful treatment of a COVID-19 patient with IPE.

Early Initiation of Awake Veno-Venous Extracorporeal Membrane Oxygenation Can Attenuate Muscle Atrophy and Weakness in Acute Respiratory Distress Syndrome

Patients with acute respiratory distress syndrome (ARDS) exhibit prominent muscle atrophy and weakness. Although these patients often require deep sedation to perform lung-protective ventilation, extracorporeal membrane oxygenation (ECMO) can keep patients awake and make mobilization possible. A 60-year-old man was treated with ECMO due to ARDS. A multidisciplinary team conducted mobilization with standing on day 3. During intensive care unit (ICU) stay, catabolism was ongoing (urinary titin: 24.1-38.4 pmol/mg Cr), but the rectus femoris muscle, measured by ultrasound, moderately decreased by 5.3%, 10.8%, and 13.0% on days 3, 5, and 7, respectively, with maintained Medical Research Council score of 58-60. Diaphragm thickness remained unchanged. On day 5, he was separated from ECMO. After ambulation training, he was discharged from ICU on day 7. He returned home without prominent physical dysfunction. Our experience indicates early initiation of awake ECMO can accompany mobilization and attenuate muscle atrophy and weakness in ARDS.

Varied Presentation of Fulminant Blastomycosis with Prostatitis and Acute Respiratory Distress Syndrome in a Patient With High Inoculum Inhalation: A Review of Diagnosis and Management

Blastomycosis is an uncommon granulomatous disease caused by infection with thermally dimorphic fungi of the genus Blastomyces. Although pulmonary infections from Blastomyces dermatitidis are uncommon, it is important to understand the geographical distribution, presentation, diagnosis, and management of treating this condition. We report a case of fulminant blastomycosis after high inoculum inhalation, with involvement of the prostate on presentation, which progressed to acute respiratory distress syndrome.

The addition of a membrane oxygenator to a ventricular assist device in a patient with acute respiratory distress syndrome

A 12-year-old boy with Marfan's syndrome required a biventricular assist device (VAD) after an aortic root replacement. The patient developed acute respiratory distress syndrome and required escalating ventilator support. We hypothesized that the addition of a membrane oxygenator in series with the assist device would improve gas exchange and allow for a more lung-protective ventilator approach. A membrane oxygenator was placed in series with the right VAD resulting in a blood path of right atrium to VAD to oxygenator to pulmonary artery. Circuit function was gauged by monitoring flow and oxygenator pressures and periodic circuit inspections and oxygenator blood gases. Heparin was titrated to maintain unfractionated antifactor Xa levels of .3-.7 IU/mL and partial thromboplastin time of 60-80 seconds. The initial sweep gas supplying the oxygenator was 5 L/min at an F1O2 of 1.0, which achieved a pH > 7.40 and a PF ratio > 250. The pre- and post-oxygenator pressures were 55-60 mmHg and 45-50 mmHg, respectively, and the measured flow at the oxygenator outlet was 2.0-2.2 L/min. The patient was changed from high-frequency oscillatory ventilation to pressure-controlled synchronized intermittent ventilation with pH maintained at 7.35-7.40 and PF ratio > 250. Paralytics were discontinued and the patient's neurologic condition was deemed intact. The patient hemorrhaged after a sternal closure and required transfusions and antifibrinolytics that led to thrombus in the membrane and membrane circuitry, which were replaced without incident. The patient's respiratory status remained stable; however, his overall condition worsened as a result of additional organ dysfunction and septicemia, and he did not survive. The addition of a membrane oxygenator to a VAD is feasible and supplements gas exchange permitting the use of more lung protective ventilation.