Category: Case Study

Fatigue Doesn’t Always have to be caused by SARS-CoV-2: Case Report

Abstract:

We report on a 17-year-old female adolescent who presented with marked fatigue. The cause of this was found to be Epstein-Barr virus (EBV) infection. Even during the COVID-19 pandemic, fatigue doesn’t always have to be caused by SARS-CoV‑2 but can also be induced by other adolescent-onset diseases (EBV), Up to 13.5 % of EBV sufferers develop chronic fatigue syndrome, which is why it makes sense to determine the exact cause. Diagnosis, therapy and prognosis of infectious mononucleosis are addressed.

Source: Howanietz H, Graf U, Kainz T. Fatigue muss nicht immer SARS-CoV-2-bedingt sein – eine Kasuistik [Fatigue Doesn’t Always have to be caused by SARS-CoV-2: Case Report]. Padiatr Padol. 2022 May 19:1-4. German. doi: 10.1007/s00608-022-00989-8. Epub ahead of print. PMID: 35611157; PMCID: PMC9118809. https://pubmed.ncbi.nlm.nih.gov/35611157/ [Full article in German]

Improvement in Long-COVID Symptoms Using Acupuncture: A Case Study

Abstract:

Background: The long-COVID syndrome (LCS), defined by residual symptoms from acute COVID-19 for <60 days, affects about one-third of all COVID survivors and is an emerging public health challenge. Empirical data about the range of symptoms or the utility of acupuncture alone for the LCS are very limited.

Case: This observational case study of a 46-year-old male with LCS was conducted to preliminarily define the range of symptoms, a Traditional Chinese Medicine (TCM) diagnostic structure, and evaluate the potential utility of prescribed acupuncture for LCS.

Results: The primary TCM diagnostic patterns from this patient’s LCS presentation included Lung Qi and Yin Deficiency, Qi and Blood Stagnation, and Spleen Qi Deficiency with dampness. Acupuncture for this patient was associated with reduced symptoms and signs of LCS.

Conclusion: A preliminary TCM diagnostic structure for LCS was defined. Acupuncture appears to have been helpful for a patient with LCS. Further research is needed to demonstrate the efficacy of acupuncture and/or other TCM modalities for LCS.

Source: Michael Hollifield, Karen Cocozza, Teresa Calloway, Jennifer Lai, Brianna Caicedo, Kala Carrick, Ruth Alpert, and An-Fu Hsiao. Medical Acupuncture (ahead of print). http://doi.org/10.1089/acu.2021.0088 https://www.liebertpub.com/doi/full/10.1089/acu.2021.0088  (Full text)

Cardiac tamponade – an unexpected “long COVID-19” complication

Abstract:

Introduction: Year 2020 has been a cornerstone in medical research due to the COVID-19 pandemic
outbreak. The process of understanding the condition brought to light certain organ involvement like
pulmonary or kidney damage or endocrine disbalances, while connection to other types of organ
impairment remain unclear. SARS-CoV-2 has previously been incriminated in cardiac involvement,
ranging from mild symptoms to more severe occurrences such as myocarditis, arrythmias or heart
failure, thus complicating the acute-phase management and worsening patients’ prognosis. Despite being
reported as an acute manifestation in critical COVID-19, cardiac tamponade seems to also occur as a
“long- COVID19” complication. The latter is a distinct yet unclear entity associated with remanent
fatigue or cough, but more severe sequelae like vasculitis or polyneuropathy can occur.

Case report: We report the case of a 42-year-old patient admitted in the intensive care unit for severe
respiratory and renal dysfunction one month after an initial mild episode of COVID-19. RT-PCR for
SARS-CoV-2 on admission was negative. Initial imaging through CT and heart ultrasound revealed the
presence of pericardial effusion but no signs of tamponade were initially obvious. Twelve hours later, the
patient’s state deteriorated with cardiocirculatory failure and signs of obstructive shock. Agents
responsible for severe acute respiratory infection (SARI) such as influenza A and B, adenovirus,
Bordetella pertussis, Mycoplasma pneumoniae, coxsackie virus, Chlamydia pneumoniae or parainfluenza
viruses were ruled out. Surprisingly, RT-PCR testing for SARS-CoV-2 came back positive, although the
initial test was negative. Repeated imaging confirmed massive circumferential pericardial effusion for
which emergency pericardiocentesis was performed. Fluid was an exudate and histopathology reported
chronic inflammation. RT-PCR testing for Mycoplasma tuberculosis in the pericardial tissue came back
negative.

Conclusions: The case is to our knowledge among the first to report cardiac tamponade one month
after mild COVID-19 infection. The aim of this case report is to raise awareness in the medical
community on the possibility of severe complications targeting major organs in the long-COVID-19
phase.

Source: Cobilinschi, Cristian; Melente, Oana Maria; Bologa, Cristina; Cotae, Ana-Maria; Constantinescu, Laura; et al. Cardiac tamponade – an unexpected “long COVID-19” complication. Germs; Bucharest Vol. 12, Iss. 1, (Mar 2022): 112-117. https://www.proquest.com/openview/4b836e7b0259b3a7fe1c40199f4b9c4c/1?pq-origsite=gscholar&cbl=2032454 (Full text)

Histopathology of Persistent Long COVID Toe: A Case Report

Abstract:

During the 2020 coronavirus (SARS-CoV-2) pandemic, several cutaneous lesions were identified, including: pseudo-chilblain, vesicular, urticarial, maculopapular, and livedo/necrosis. A 59-year-old obese man with probable COVID-19 developed painful cyanosis with histopathologic capillary thrombosis of toes, and the cyanosis persisted for nearly 22 months. Shortly after initial exposure to family members with documented SARS-CoV-2, he developed upper respiratory symptoms, yet his anti-SARS-CoV-2 antibody and nasal swab RT-PCR tests were repeatedly negative. Two family members were hospitalized and one of them succumbed with documented SARS-CoV-2 pneumonia within ten days of exposure. Biopsy of the distal toe 16 weeks after initial exposure demonstrated papillary dermal capillary thrombosis with endothelial swelling, telangiectasia, and peri-eccrine lymphocytic infiltrates resembling pernio. Overall, this is the first case of biopsy of “long COVID toe” following presumed SARS-Cov-2 exposure, with demonstration of thrombotic vasculopathy, toe cyanosis, and pernio-like pathology.

Source: Nirenberg MS, Requena L, Santonja C, Smith GT, McClain SA. Histopathology of Persistent Long COVID Toe: A Case Report. J Cutan Pathol. 2022 Apr 2. doi: 10.1111/cup.14240. Epub ahead of print. PMID: 35366017.  https://pubmed.ncbi.nlm.nih.gov/35366017/

New Clinical Phenotype of the Post-Covid Syndrome: Fibromyalgia and Joint Hypermobility Condition

Abstract:

Fibromyalgia can be defined as a chronic pain condition, affecting the musculoskeletal system, etiology and pathophysiology of which is sufficiently understudied. Despite the fact that many authors consider this entity to be a manifestation of central sensitization, and not an autoimmune disease, the high prevalence of fibromyalgia in patients with post-COVID-19 conditions requires taking a fresh look at the causes of the disease development.

During the patient examination, the authors identified a combination of symptoms that occurs so often, that they can be carefully described as a clinical pattern. These manifestations include young age, female gender, joint hypermobility, the onset of pain after COVID-19, physical traumatization of one particular tendon and the development of the fibromyalgia pain syndrome during the next several weeks. As well as an increase in the titer of antinuclear antibodies and some other systemic inflammation factors. It can be assumed with great caution that local damage to the connective tissue in patients with joint hypermobility, having COVID-19 as a trigger factor can lead to the development of fibromyalgia syndrome. This article presents three clinical cases that illustrated this hypothesis.

Source: Gavrilova N, Soprun L, Lukashenko M, Ryabkova V, Fedotkina TV, Churilov LP, Shoenfeld Y. New Clinical Phenotype of the Post-Covid Syndrome: Fibromyalgia and Joint Hypermobility Condition. Pathophysiology. 2022 Jan 19;29(1):24-29. doi: 10.3390/pathophysiology29010003. PMID: 35366287. https://www.mdpi.com/1873-149X/29/1/3/htm (Full text)

Antihistamines for Postacute Sequelae of SARS-CoV-2 Infection

Abstract:

Postacute sequelae of SARS-CoV2 (PASC) infection is an emerging global health crisis, variably affecting millions worldwide. PASC has no established treatment. We describe 2 cases of PASC in response to opportune administration of over-the-counter antihistamines, with significant improvement in symptoms and ability to perform activities of daily living. Future studies are warranted to understand the potential role of histamine in the pathogenesis of PASC and explore the clinical benefits of antihistamines in the treatment of PASC.

Source: Melissa D. Pinto, Natalie Lambert, Charles A. Downs, Heather Abrahim, Thomas D. Hughes, Amir M. Rahmani, Candace W. Burton, Rana Chakraborty. Antihistamines for Postacute Sequelae of SARS-CoV-2 Infection. The Journal for Nurse Practitioners, 2022, ISSN 1555-4155, https://doi.org/10.1016/j.nurpra.2021.12.016.
https://www.sciencedirect.com/science/article/pii/S155541552100547X  (Full text)

Myalgic encephalomyelitis/chronic fatigue syndrome post coronavirus disease 2019

Coronavirus disease 2019 (COVID-19), an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been the most impactful infectious disease in the 21st century. The SARS-CoV-2 pandemic significantly increased the number of patients and deaths worldwide. Long-course diseases related to COVID-19, which present with persistent reparatory distress or fatigue (so-called long COVID) have been reported in adult and pediatric patients since the latter half of 2020. Long-COVID is observed as a persistent symptom after the acute phase of the disease.1 Recent research suggested that it can present with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).2 We report a case of long COVID to contribute to the body of knowledge regarding this disease, which has not been well investigated in children.

A 14-year-old boy with well controlled asthma, controlled by a long-acting muscarinic antagonist, long-acting beta-agonist, and corticosteroid inhaler, was admitted to our hospital for severe fatigue and appetite loss. He suffered from COVID-19 diagnosed using reverse transcription polymerase chain reaction 90 days prior to hospitalization. He presented with a low-grade fever, mild cough, dysgeusia, and dysosmia. He was placed under quarantine in a hotel room for 6 days. His low-grade fever and mild cough resolved after 10 days, while the dysgeusia and dysosmia disappeared within a month. He presented with gradually progressive upper limb muscle weakness, severe fatigue, and difficulty concentrating (so-called “brain fog”) 20 days before hospitalization (70 days after the onset of COVID-19). He was unable to commute to attend junior high school. Three days before hospitalization, the patient did not eat due to appetite loss. He received oral prednisolone (20 mg/day) and Kanpō medicine (Rikkun-shito and Hotyu-ekkito). However, his symptoms were not relieved, and the patient was hospitalized. At the time of hospitalization, he did not present with fever, dyspnea, or desaturation. Physical examination revealed an upper limb strength of grade 4 on manual muscle testing, but the tendon reflexes or sensory/motor nerve abnormalities were not noted in the extremities. Blood tests revealed normal white blood cell and C-reactive protein levels. Epstein–Barr virus and human immunodeficiency virus antibodies and antinuclear antibodies were not detected. The 10 min standing test revealed an increase of 52 heartbeats after standing at an upright position (from 81 to 133 beats/min). The patient was diagnosed with postural orthostatic tachycardia syndrome (POTS). After the test, the patient complained of worsening fatigue, suggesting post-exertional malaise (PEM), a specific characteristic of ME/CFS. Based on the clinical course and physical examination, the patient was diagnosed with ME/CFS due to long-COVID. Oral prednisolone was discontinued, while the Kanpō medicine was continued. The patient then developed alopecia. Meanwhile, his muscle weakness and fatigue were alleviated by activity restriction due to hospitalization. On the 14th day of admission, he was discharged because his appetite improved, and he was referred to a hospital that specifically tended to chronic fatigue syndrome patients. Neither brain imaging nor electroencephalography were performed throughout the patient’s hospitalization.

The National Institute for Health Research in England classified long-COVID into four categories, namely, post-ICU syndrome, long-term organ damage, post-viral syndrome, and an entirely novel syndrome.3 Myalgic encephalomyelitis/chronic fatigue syndrome is typical of post-viral syndromes in adults, and similar cases have also been reported in children.4 Females are more likely to suffer from the disease, but males could also be affected. The exacerbation of symptoms upon exertion is known as PEM; avoiding extensive work is the essential aspect of ME/CFS management.5 In this case, the patient’s muscle fatigue and weakness dramatically improved with activity restriction due to hospitalization. This strategy may be useful for treating the severe exacerbation of ME/CFS. Chronic fatigue syndrome is diagnosed based on the persistence of symptoms for more than 6 months.2 This implies that patients have to wait for 6 months to be diagnosed with ME/CFS. Thus, new diagnostic criteria, specifically for ME/CFS due to COVID, are required to allow early intervention. Petracek et al. reported that POTS might be an early sign of COVID-induced ME/CFS,4 POTS is considered to be a viable diagnostic criterion. To prepare for a surge of pediatric ME/CFS, the diagnostic and treatment algorithm for the disease should be standardized, and physicians need to know about or recognize the disease.

Read more HERE.

Source: Kusama Y, Fukui S, Maruyama M, Kamimura K, Maihara T. Myalgic encephalomyelitis/chronic fatigue syndrome post coronavirus disease 2019. Pediatr Int. 2022 Jan;64(1):e14976. doi: 10.1111/ped.14976. PMID: 35143110. https://onlinelibrary.wiley.com/doi/10.1111/ped.14976 (Full text)

Improvement of a Long Covid patient after vaccinations, a case report in family practice

Abstract:

Since 2019, primary care has been under great pressure from Covid-19 patients and now from those affected by Long Covid. The issue of this new condition, its diagnosis and available treatments, were investigated on the occasion of an anecdotal and unexpected recovery of a patient with Long Covid.

A 48-year-old woman, a single mother of two and patient in our family practice for several years, became sick from Covid-19 in October 2020. She never recovered, and 9 months later was still showing signs of severe Long Covid with somatic, behavioral, cognitive and memory disorders.

After her two vaccinations by Comirnaty – Pfizer/BioNTech, she reported severe side effects, followed at day 12 after the first vaccine by an unexpected improvement still present at day 30 and 44 of the Long Covid symptoms from which she had suffered for several months. SARSCoV-2 antibodies were very high and although Magnetic Resonance Imaging were not very contributory, cerebral tomoscintigraphic examination was compatible with a cerebral pathology of vascular type.

While no conclusions can be drawn from an isolated case, this case allows us to show that post Covid patients, who may already be highly comorbid, should be accompanied on a long-term basis. The disease is not yet precisely defined and symptoms may be non-specific family practice or may vary depending on the organs affected. Diagnostic procedures are not always helpful. A post Covid heartsink patient with medically unexplained symptoms may well be a Covid long hauler. This makes listening to the patient‘s words and narrative medicine very powerful.

Source: Jamoulle M, Kazeneza-Mugisha G, Zayane A. Improvement of a Long Covid patient after vaccinations, a case report in The Permanente Journal. Accepted. Oct. 2021. In press. https://orbi.uliege.be/bitstream/2268/267459/1/in_press_Long_Covid_revised_full_final_draft_20212610.pdf (Full text)

Small heart and single coronary artery in a young patient with chronic fatigue syndrome: a case report

Abstract:

Aims: Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a clinically defined condition reported mostly in adults, characterized by fatigue and unexplained aspecifical symptoms. Patients with CFS/ME frequently have reduced stroke volume with an inverse relation between cardiac output and post-exertional malaise severity. We describe a rare case of a young man affected by CFS/ME, small heart, and anomalous anatomy of left main coronary artery (LMCA).

Methods and results: A 19-year-old Caucasian male referred to our clinic complaining weakness, lack of concentration, and sleepiness. He suffered by CFS/ME, D hypovitaminosis, inflammatory bowel disease, and exocrine pancreas insufficiency.

Blood tests revealed no pathological findings. Faecal exams documented intestinal dysbiosis and low pancreatic elastase.

He was treated with oxygen-ozone rectal insufflations and probiotics. Physical examination was unremarkable.

Electrocardiogram showed normal sinus rhythm. Echocardiogram revealed reduced diameters of the left ventricle (LV), normal aortic root dimensions and, in a five-chamber apical view, a binary structure that seemed to cross the aorta perpendicularly. Cardiac magnetic resonance (CMR) found reduced LV stroke volume (34 ml/m2) and end-diastolic volume (57 ml/m2) together with reduced end-diastolic wall mass (51 g/m2). Right ventricle volumes were reduced too.

In addition, the exam confirmed the anomalous origin of LMCA stemming from the proximal segment of right coronary artery and following a retro-aortic course.

Mechanism of CFS/ME remains unknown, although various factors have been implicated, including immune activation, chronic viral infection, and emotional disorders.

A considerable number of patients affected by CFS has an anatomically small heart. Small heart syndrome, in fact, may contribute to the onset of CFS/ME.

Previous studies hypothesized that clinical manifestations of CMS/ME were caused by reduced venous return, cardiac output, and heart mass, together with decreased arterial oxygen saturation. Single coronary artery is an uncommon congenital anatomic abnormality identified by a single coronary ostium giving rise to all arteries supplying the heart.

Thus, we reported a rare case of a very young man affected by chronic fatigue syndrome and small heart, investigated not only with echocardiogram but also with CMR, not often used in this clinical setting. More, we found an anomalous origin of LMCA. From literature, it’s not reported any cases of a patient including these three rare conditions (CFS/ME, small heart, and single coronary artery).

Conclusions: This case highlights that CFS/ME together with small heart is a condition possible also in young people. More studies and reports could be necessary to better define the association between cardiac congenital anomalies and CFS/ME.

Source: Cristina Poleggi, Silvia Perfetti, Davide Restelli, Alessia Perna, Rocco Donato, Gianluca Di Bella, 770 Small heart and single coronary artery in a young patient with chronic fatigue syndrome: a case report, European Heart Journal Supplements, Volume 23, Issue Supplement_G, December 2021, suab133.018, https://doi.org/10.1093/eurheartj/suab133.018

Case Report: Neutralization of Autoantibodies Targeting G-Protein-Coupled Receptors Improves Capillary Impairment and Fatigue Symptoms After COVID-19 Infection

Abstract:

Clinical features of Coronavirus disease 2019 (COVID-19) are caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Acute infection management is a substantial healthcare issue, and the development of long-Covid syndrome (LCS) is extremely challenging for patients and physicians. It is associated with a variety of characteristics as impaired capillary microcirculation, chronic fatigue syndrome (CFS), proinflammatory cytokines, and functional autoantibodies targeting G-protein-coupled receptors (GPCR-AAbs). Here, we present a case report of successful healing of LCS with BC 007 (Berlin Cures, Berlin, Germany), a DNA aptamer drug with a high affinity to GPCR-AAbs that neutralizes these AAbs.

A patient with a documented history of glaucoma, recovered from mild COVID-19, but still suffered from CFS, loss of taste, and impaired capillary microcirculation in the macula and peripapillary region. He was positively tested for various targeting GPCR-AAbs. Within 48 h after a single BC 007 treatment, GPCR-AAbs were functionally inactivated and remained inactive during the observation period of 4 weeks. This observation was accompanied by constant improvement of the fatigue symptoms of the patient, taste, and retinal capillary microcirculation. Therefore, the removal of GPCR-AAb might ameliorate the characteristics of the LCD, such as capillary impairment, loss of taste, and CFS.

Source: Hohberger B, Harrer T, Mardin C, Kruse F, Hoffmanns J, Rogge L, Heltmann F, Moritz M, Szewczykowski C, Schottenhamml J, Kräter M, Bergua A, Zenkel M, Gießl A, Schlötzer-Schrehardt U, Lämmer R, Herrmann M, Haberland A, Göttel P, Müller J, Wallukat G. Case Report: Neutralization of Autoantibodies Targeting G-Protein-Coupled Receptors Improves Capillary Impairment and Fatigue Symptoms After COVID-19 Infection. Front Med (Lausanne). 2021 Nov 18;8:754667. doi: 10.3389/fmed.2021.754667. PMID: 34869451; PMCID: PMC8637609. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8637609/ (Full text)