Consider differentials before diagnosing COVID-19 associated polyradiculitis

Evidence is accumulating that SARS-CoV-2 infections and SARS-CoV-2 vaccinations can induce Guillain-Barre syndrome (GBS). More than 400 GBS cases after SARS-CoV-2 infection respectively vaccination have been reported as per the end of 2021. GBS is usually diagnosed according to the Brighton criteria, but also the Besta criteria or Hadden criteria are applied. The diagnosis can be supported by MRI with contrast medium of the cranial or spinal nerves showing enhancing nerve roots. As GBS can be complicated by autonomic dysfunction such as pupillary abnormalities, salivatory dysfunction, reduced heart rate variability, bowel disturbance (constipation, diarrhea), urinary hesitancy, urinary retention, or impotence, it is crucial to investigate GBS patients for autonomic involvement. Before diagnosing GBS various differentials need to be excluded, including neuropathy as a side effect of the anti-SARS-CoV-2 medication, critical ill neuropathy in COVID-19 patients treated on the ICU, and compression neuropathy in COVID-19 patients requiring long-term ventilation.

An evaluation of Mucormycosis, Outburst

Black fungus is also known as Mucormycosis, and it is occasional but threatening infection. Black fungus is caused by getting into exposure with fungus spores in the surroundings. It can also form in the skin after the fungus enters through a cut, scrape, burn, or another type of skin trauma. Fungi live in the environment, particularly in soil and decaying organic matter such as leaves, compost piles, rotten wood, particularly in soil, compost, and animal dung. This fungal infection is caused by a type of mould known as 'mucromycetes’. It should be noted that this rare fungal infection affects persons who have health issues or who use drugs that weaken the body's ability to fight the infections. There are different types of mucormycosis Trusted Source, including rhino cerebral (sinus and brain), pulmonary (lung), gastrointestinal, and cutaneous (skin) mucormycosis. The COVID-19 generates a sudden change in the interior environment of the host for the fungus, and the medical treatment administered unknowingly promotes fungal development. COVID-19 causes harm to the airway mucosa and blood vessels. It also causes a rise in serum iron, which is required for the fungus to grow. Broad-spectrum antibiotics not only kill potentially harmful bacteria but also beneficial commensals. Although antifungals such as Voriconazole prevent Aspergillosis, Mucor survives and grows due to a lack of resistance. Long-term ventilation decreases immunity, and there is conjecture that the humidifier water that is delivered along with the oxygen transfers the fungus. It is ubiquitous and found in soil and air and even in the nose and mucus of healthy people. It affects the sinuses, the brain and the lungs and can be life-threatening in diabetic or severely immunocompromised individuals, such as cancer patients or people with HIV/AIDS. Doctors believe mucormycosis, which has an overall mortality rate of 50%, may be being triggered by the use of steroids, a life-saving treatment for severe and critically ill Covid-19 patients. Steroids reduce inflammation in the lungs for Covid-19 and appear to help stop some of the damage that can happen when the body's immune system goes into overdrive to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid-19 patients. It’s thought that this drop in immunity could be triggering these cases of mucormycosis.

Emergency management plan for paediatric patients with tracheostomies during the COVID-19 pandemic

Objectives: Paediatric patients living with tracheostomies are a medically vulnerable group. During the COVID-19 pandemic, there may be apprehension about their susceptibility to SARS-CoV-2 infection with unknown consequences. Healthcare workers managing this cohort can be anxious about viral transmission from respiratory secretions and aerosols emerging from the open airway. Our objective is to share a systematic approach to minimise incidental mismanagement, avoid iatrogenic airway injury, reduce aerosolisation and decrease staff exposure when treating these patients. Methods: A COVID-19 emergency management plan was created for paediatric patients with tracheostomies in the event of presentation with unknown, suspected or proven SARS-CoV-2 infection. Three documents were developed: a generic tracheostomy management plan detailing troubleshooting measures to reduce air leak from around the tube; a personalised management plan with customised recommendations; a guide for tracheostomy tube change with emphasis on minimising aerosol production. Results: Our plan was distributed to 31 patients (age range 11 months - 17 years) including 23 (74.2%) with uncuffed tubes and 9 (29%) on long term ventilation. There have been 10 occasions in which the plan was utilised and influenced care, including 4 situations where successful troubleshooting avoided tube manipulation and 6 situations where an uncuffed tube was safely replaced with a pre-selected cuffed tube to reduce air leak. Conclusions: A structured approach to emergency presentations during the COVID-19 pandemic may safeguard paediatric patients from unnecessary manipulation of their tracheostomy tube and airway trauma, as well as provide guidance to minimise viral exposure and allow provision of expeditious care.

Corona again? SSC after a severe COVID-disease

Secondary sclerosing cholangitis (SSC) is a severe complication of intensive care treatment in critically ill patients. It is characterized by rapid onset and severe chlolestasis with elevation of gGT. In contrast to primary sclerosing cholangitis, SSC-CIP has a distinct and timely well defined trigger and can have a rapid progress to cirrhosis and liver failure. In context of the COVID-19-pandemic, there are reports about patients, who developed SSC after a severe COVID-infection and intensive care treatment.We report on a 62-year old patient without any relevant pre-existing illnesses, who suffered from severe COVID-19 pneumonia with the need for long term ventilation. In the course of the disease he developed a critical-illness-polyneuropathy a pronounced cholestasis. After recovery from COVID-pneumonia, the PNP regressed but the cholestasis progressed. MRCP showed only irregular intrahepatic bile ducts, while EUS showed echogenic intraductal longitudinal structures characteristic for intraductal casts and for SSC-CIP. This was confirmed with ERC, where the complete necrotic bile ducts could be extracted and retrieved for histological and molecular analysis.The patient was included in a scheduled ERC-program to prevent a progress of SSC and the concomitant cirrhosis.SSC is an often missed diagnosis, which obviously can also occur in COVID-patients. In case of elevated liver function tests with cholestasis, EUS might be the key diagnostic method to characterize intraductal casts and identify those patients who should undergo ERC.