Can COVID-19 cause myalgia with a completely different mechanism? A hypothesis

Neurological Complications of COVID-19 Infection: A Comprehensive Review

The COVID-19 pandemic is well on its way to reaching endemic status across the globe. While the medical community's understanding of the respiratory complications induced by COVID-19 is improving, there is still much to be learned about the neurological manifestations associated with COVID-19 infection. This review aimed to compile relevant, available evidence of COVID-19-induced neurological complications and to provide information for each complication regarding symptomology, progression patterns, demographic risk factors, treatment, and causative mechanism of action when available. Data for this review was collected using a confined search on PubMed using the keywords ["COVID-19" OR "SARS-CoV-2"] AND ["neurological complications" OR "olfactory symptoms" OR "gustatory symptoms" OR "myalgia" OR "headache" OR "dizziness" OR "stroke" OR "seizures" OR "meningoencephalitis" OR "cerebellar ataxia" OR "acute myelitis" OR "Guillain Barré Syndrome" OR "Miller Fisher Syndrome" OR "Posterior Reversible Encephalopathy Syndrome"] between 2019 and 2023. A wide range of neurological manifestations impact a significant percentage of COVID-19 patients, and a deeper understanding of these manifestations is necessary to ensure adequate management. The most common neurological complications identified consist of olfactory and gustatory dysfunctions, myalgia, headache, and dizziness, while the most severe complications include stroke, seizures, meningoencephalitis, Guillain-Barré syndrome, Miller Fisher syndrome, acute myelitis, and posterior reversible encephalopathy syndrome. While this review effectively provides a roadmap of the neurological risks posed to COVID-19 patients, further research is needed to clarify the precise incidence of these complications and to elucidate the mechanisms responsible for their manifestation.

SARS-CoV-2 PCR cycle threshold value at admission might not be a good predictor of in-hospital COVID-19-associated AKI

Background

Acute kidney injury (AKI) is a prevalent complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and a predictor of disease severity and mortality; furthermore, a prompt diagnosis and treatment of this complication may enhance COVID-19 prognosis. Therefore, we aim to investigate potential risk factors for SARS-CoV-2-associated AKI, including SARS-CoV-2 PCR cycle threshold value (CT value), which correlation with AKI is conflicting.

Methods

This case-control study included 110 hospitalized patients with SARS-CoV-2-associated AKI as cases and 110 random SARS-CoV-2 hospitalized patients as controls. Reverse transcription real-time PCR of admission nasopharyngeal swabs evaluated E gene cycle thresholds. Additional clinical and paraclinical information extracted from medical records. The patient's status at discharge, and 14 and 30 days after discharge. Therefore, after adjusting for age and gender, the correlation between variables was assessed.

Results

SARS-CoV-2 AKI is significantly associated with age above 60, hypertension, diabetes mellitus, ischemic heart disease, and underlying kidney diseases. Abnormal admission hemoglobin or alkaline phosphatase, proteinuria or hematuria in urine sediment, and abnormal creatinine during hospitalization were the paraclinical features correlated to SARS-CoV-2 AKI. AKI group demonstrated greater in-hospital, 14- and 30-day mortality. Nevertheless, this study did not evidence a correlation between the admission CT value and mortality or AKI.

Conclusion

Admission CT values provide limited information regarding the dynamic viral load and varying hospitalization time points; thus, they may not be reliable for predicting the prognosis and complications of COVID-19 in all populations. Further studies with serial CT measurements or symptom onset time adjustment are recommended.

Respiratory SARS-CoV-2 Infection Causes Skeletal Muscle Atrophy and Long-Lasting Energy Metabolism Suppression

Muscle fatigue represents the most prevalent symptom of long-term COVID, with elusive pathogenic mechanisms. We performed a longitudinal study to characterize histopathological and transcriptional changes in skeletal muscle in a hamster model of respiratory SARS-CoV-2 infection and compared them with influenza A virus (IAV) and mock infections. Histopathological and bulk RNA sequencing analyses of leg muscles derived from infected animals at days 3, 30, and 60 post-infection showed no direct viral invasion but myofiber atrophy in the SARS-CoV-2 group, which was accompanied by persistent downregulation of the genes related to myofibers, ribosomal proteins, fatty acid β-oxidation, tricarboxylic acid cycle, and mitochondrial oxidative phosphorylation complexes. While both SARS-CoV-2 and IAV infections induced acute and transient type I and II interferon responses in muscle, only the SARS-CoV-2 infection upregulated TNF-α/NF-κB but not IL-6 signaling in muscle. Treatment of C2C12 myotubes, a skeletal muscle cell line, with combined IFN-γ and TNF-α but not with IFN-γ or TNF-α alone markedly impaired mitochondrial function. We conclude that a respiratory SARS-CoV-2 infection can cause myofiber atrophy and persistent energy metabolism suppression without direct viral invasion. The effects may be induced by the combined systemic interferon and TNF-α responses at the acute phase and may contribute to post-COVID-19 persistent muscle fatigue.

Developing effective strategies to optimize physical activity and cardiorespiratory fitness in the long Covid population- The need for caution and objective assessment

The Post Covid-19 Condition (commonly known as Long Covid) has been defined by the World Health Organisation as occurring in individuals with a history of probable or confirmed SARS CoV 2 infection, usually within 3 months from the onset of acute Covid-19 infection with symptoms that last for at least two months which cannot be explained by an alternative diagnosis. Long Covid is associated with over two hundred recognised symptoms and affects tens of millions of people worldwide. Widely reported reductions in quality of life(QoL) and functional status are caused by extremely sensitive and cyclical symptom profiles that are augmented following exposure to physical, emotional, orthostatic, and cognitive stimuli. This manifestation prevents millions of people from engaging in routine activities of daily living (ADLs) and has important health and well-being, social and economic impacts. Post-exertional symptom exacerbation (PESE) (also known as post-exertional malaise) is an exacerbation in the severity of fatigue and other symptoms following physical, emotional, orthostatic and cognitive tasks. Typically, this will occur 24-72 h after "over-exertion" and can persist for several days and even weeks. It is a hallmark symptom of Long Covid with a reported prevalence of 86%. The debilitating nature of PESE prevents patients from engaging in physical activity which impacts functional status and QoL. In this review, the authors present an update to the literature relating to PESE in Long Covid and make the case for evidence-based guidelines that support the design and implementation of safe rehabilitation approaches for people with Long Covid. This review also considers the role of objective monitoring to quantify a patient's response to external stimuli which can be used to support the safe management of Long Covid and inform decisions relating to engagement with any stimuli that could prompt an exacerbation of symptoms.

Could the fibromyalgia syndrome be triggered or enhanced by COVID-19?

Fibromyalgia (FM) is a complex disease with an uncertain aetiology and intricate pathophysiology. Although its genesis is not fully explained, potential environmental factors, such as viral infections might trigger FM or worsen patients' clinical outcomes. The SARS-CoV-2 virus may affect central and peripheral nervous systems, leading to musculoskeletal, neurological, and psychological disturbances. These symptoms might persist at least 12 months beyond the recovery, often referred to as post-COVID syndrome, which resembles FM syndrome. In this sense, we argued the potential consequences of COVID-19 exclusively on FM syndrome. First, we have described post-COVID syndrome and its painful symptoms. Afterwards, we argued whether FM syndrome could be triggered or enhanced by COVID-19 infection or by numerous and persistent stressors imposed daily by the pandemic setting (isolation, uncertainty, depression, mental stress, generalized anxiety, and fear of the virus). In addition, we have demonstrated similarities between pathophysiological mechanisms and cardinal symptoms of FM and COVID-19, speculating that SARS-CoV-2 might represent a critical mediator of FM or an exacerbator of its symptoms once both syndromes share similar mechanisms and complaints. Therefore, pharmacologic and non-pharmacological approaches commonly used to treat FM could serve as strategic therapies to attenuate painful and neurological manifestations of post-COVID syndrome. Although it is still theoretical, clinicians and researchers should be alert of patients who develop symptoms similar to FM or those who had their FM symptoms increased post-COVID to manage them better.

Clinical Characteristics in the Acute Phase of COVID-19 That Predict Long COVID: Tachycardia, Myalgias, Severity, and Use of Antibiotics as Main Risk Factors, While Education and Blood Group B Are Protective

BACKGROUND

Risk factors for developing long COVID are not clearly established. The present study was designed to determine if any sign, symptom, or treatment of the acute phase, or personal characteristics of the patient, is associated with the development of long COVID.

METHODS

A cohort study was carried out, randomly selecting symptomatic COVID-19 patients and not vaccinated. The severity of the acute illness was assessed through the number of compatible COVID-19 symptoms, hospitalizations, and the symptom severity score using a 10-point visual analog scale.

RESULTS

After multivariate analysis, a severity score ≥8 (RR 2.0, 95%CI 1.1-3.5, p = 0.022), hospitalization (RR 2.1, 95%CI 1.0-4.4, p = 0.039), myalgia (RR 1.9, 95%CI 1.08-3.6, p = 0.027), tachycardia (RR 10.4, 95%CI 2.2-47.7, p = 0.003), and use of antibiotics (RR 2.0, 95%CI 1.1-3.5, p = 0.022), was positively associated with the risk of having long COVID. Higher levels of education (RR 0.6, 95%CI 0.4-0.9, p = 0.029) and type positive B blood group (B + AB, RR 0.44, 95%CI 0.2-0.9, p = 0.044) were protective factors. The most important population attributable fractions (PAFs) for long COVID were myalgia (37%), severity score ≥8 (31%), and use of antibiotics (27%).

CONCLUSIONS

Further studies in diverse populations over time are needed to expand the knowledge that could lead us to prevent and/or treat long COVID.

Long COVID active case detection initiative among COVID-19 patients in Port Dickson, Malaysia: a retrospective study on the positive outcomes, the proportion of patients with long COVID and its associated factors

Background

Long COVID is new or ongoing symptoms at four weeks or more after the start of acute COVID-19. However, the prevalence and factors associated with long COVID are largely unknown in Malaysia. We aim to determine the proportion and factors associated with long COVID among COVID-19 patients in Port Dickson, Malaysia. The positive outcomes of our long COVID active detection initiative were also described.

Methods

This was a retrospective analysis of long COVID data collected by the Port Dickson District Health Office between 1 September 2021 to 31 October 2021. Monitoring long COVID symptoms was our quality improvement initiative to safeguard residents' health in the district. The study population was patients previously diagnosed with COVID-19 who resided in Port Dickson. The inclusion criteria were adults aged 18 years and above and were in the fifth week (day 29 to 35) post-COVID-19 diagnosis during the data collection period. We called all consecutive eligible patients to inquire regarding long COVID symptoms. Long COVID was defined as new or ongoing symptoms lasting more than 28 days from the date of positive SARS-CoV-2 by polymerase chain reaction test. Binary multivariate logistic regression was conducted to determine factors associated with long COVID.

Results

Among 452 patients, they were predominantly male (54.2%), Malays (68.8%) and aged 18-29 years (58.6%). A total of 27.4% (95% CI [23.4-31.8]) of patients experienced long COVID symptoms and were referred to government clinics. The most frequent long COVID symptoms experienced were fatigue (54.0%), cough (20.2%), muscle pain (18.5%), headache (17.7%) and sleep disturbance (16.1%). Females, patients with underlying cardiovascular disease, asthma and chronic obstructive airway disease, those who received symptomatic care, and patients with myalgia and headaches at COVID-19 diagnosis were more likely to have long COVID. Three patients with suspected severe mental health problems were referred to the district psychologist, and ten patients with no/incomplete vaccination were referred for vaccination.

Conclusion

Long COVID is highly prevalent among COVID-19 patients in Port Dickson, Malaysia. Long-term surveillance and management of long COVID, especially among the high-risk groups, are needed as we transition to living with COVID-19.

Post-acute COVID-19 symptom risk in hospitalized and non-hospitalized COVID-19 survivors: A systematic review and meta-analysis

Background

Post-acute coronavirus disease 2019 (COVID-19) symptoms occurred in most of the COVID-19 survivors. However, few studies have examined the issue of whether hospitalization results in different post-acute COVID-19 symptom risks. This study aimed to compare potential COVID-19 long-term effects in hospitalized and non-hospitalized COVID-19 survivors.

Methods

This study is designed as a systematic review and meta-analysis of observational studies. A systematic search of six databases was performed for identifying articles published from inception until April 20th, 2022, which compared post-acute COVID-19 symptom risk in hospitalized and non-hospitalized COVID-19 survivors using a predesigned search strategy included terms for SARS-CoV-2 (eg, COVID, coronavirus, and 2019-nCoV), post-acute COVID-19 Syndrome (eg, post-COVID, post COVID conditions, chronic COVID symptom, long COVID, long COVID symptom, long-haul COVID, COVID sequelae, convalescence, and persistent COVID symptom), and hospitalization (hospitalized, in hospital, and home-isolated). The present meta-analysis was conducted according to The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement using R software 4.1.3 to create forest plots. Q statistics and the I ² index were used to evaluate heterogeneity in this meta-analysis.

Results

Six observational studies conducted in Spain, Austria, Switzerland, Canada, and the USA involving 419 hospitalized and 742 non-hospitalized COVID-19 survivors were included. The number of COVID-19 survivors in included studies ranged from 63 to 431, and follow-up data were collected through visits in four studies and another two used an electronic questionnaire, visit and telephone, respectively. Significant increase in the risks of long dyspnea (OR = 3.18, 95% CI = 1.90-5.32), anxiety (OR = 3.09, 95% CI = 1.47-6.47), myalgia (OR = 2.33, 95% CI = 1.02-5.33), and hair loss (OR = 2.76, 95% CI = 1.07-7.12) risk were found in hospitalized COVID-19 survivors compared with outpatients. Conversely, persisting ageusia risk was significantly reduced in hospitalized COVID-19 survivors than in non-hospitalized patients.

Conclusion

The findings suggested that special attention and patient-centered rehabilitation service based on a needs survey should be provided for hospitalized COVID-19 survivors who experienced high post-acute COVID-19 symptoms risk.

Suicide Risk in Post-COVID-19 Syndrome

Post-acute sequelae of COVID-19 include several neuropsychiatric disorders. Little is known about the relationship between post-COVID-19 syndrome and suicidality. The aim of the study was to investigate the risk of suicide in subjects with persistent post-COVID-19 syndrome. One-thousand five-hundred eighty-eight subjects were assessed in the Post-Acute Care Service at the Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS of Rome. Assessment included: (a) sociodemographic characteristics; (b) symptoms during and after COVID-19; (c) psychopathological evaluation. Participants were divided in those with (SUI) or without (NON SUI) suicide risk according to the Mini International Neuropsychiatric Interview. Additionally, subjects with SUI were split into those with high (HIGH SUI) and low (LOW SUI) suicide risk. Between-group comparisons were made with t-tests for continuous variables and χ² tests for categorical variables. SUI showed greater percentages of physical complaints during and after COVID-19, greater percentages of psychiatric history and presence of psychiatric history in relatives, greater percentages of subjects previously undergoing psychopharmacotherapy, and greater levels of anxiety, mixed depressive symptoms, general psychopathology than NON SUI. HIGH SUI showed greater number of symptoms during and after COVID-19 and higher levels of mixed depressive symptoms than LOW SUI. Percentages of subjects undergoing psychotherapy was higher in LOW SUI than HIGH SUI. Greater levels of physical complaints and psychopathology during post-COVID-syndrome might enhance the risk of committing suicide. Treatment of physical complaints and psychotherapy might reduce suicide risk.

Impaired pulmonary and muscle function during moderate exercise in female patients recovered from SARS-CoV-2

This study aimed to assess pulmonary and muscle dysfunction by analyzing the slow component of oxygen uptake (VO2SC), and mechanical and ventilatory efficiency in adult women recovered from the severe acute respiratory syndrome coronavirus type II (SARS-CoV-2) during a constant load test. 32 women (N = 17 patients with SARS-CoV-2; N = 15 control group) performed two cardiopulmonary exercise tests (CPX) on a cycle ergometer. In the first test, the participants performed incremental CPX until extenuation. In the second test the participants performed a 10-min CPX at a constant load intensity (watts) corresponding to the first ventilatory threshold. There was a 48-72 h rest period between the two tests. There was a significant increase in the VO2SC in the patients recovered from SARS-CoV-2 (160.4 ± 60 mL min-1) in comparison with the healthy participants (59.6 ± 65 mL min-1) (P < 0.001). Mechanical efficiency significantly decreased in patients recovered from SARS-CoV-2 compared to the control group (P = 0.04). Ventilatory inefficiency significantly increased in the patients recovered from SARS-CoV-2 compared with the control group (P < 0.001). Adult women recovered from SARS-CoV-2 infection have important pulmonary and muscular dysfunction and fatigue which contributes to increasing the VO2SC and reducing mechanical and ventilatory efficiency during mild-moderate exercise at a constant load.

Lifting the Mask on Musculoskeletal Manifestations of COVID-19: Results of an Interview-Based Study

Background

Coronavirus disease of 2019 (COVID-19) is considered a multi-system disease that might present with or develop complications during the acute phase of illness. The aim of this study was to describe the characteristics of musculoskeletal (MSK) manifestations in patients with COVID-19 infection and investigate their clinical correlations.

Methods

This study was carried out on 110 patients with a history of RT-PCR confirmed COVID-19 infection. They completed a questionnaire that covered detailed information on their sociodemographic characteristics, clinical data of COVID-19 infection in addition to MSK discomfort form based on the Nordic MSK Questionnaire.

Results

The mean age of the patients was 37.7 years (SD 12.9), 72.7% were females. The majority of patients (90.9%) reported MSK symptoms that occur during or shortly after the acute attack of COVID-19 infection. The median duration of onset of MSK symptoms was 2 days from the first day of COVID-19 infection (min-max: 0–45 days) with a median duration of MSK symptoms of 7 days. Myalgia was the main complaint (85.5%) followed by arthralgia 90 (81.8%). However, swollen joints were reported in only 9 patients (8.2%). According to the body areas, maximum number of patients felt pain at the lower back (60%), followed by neck (39.1%), and upper back (32.5%) followed by right and left shoulder (20.9%). Patients with MSK manifestations were associated higher severity of COVID-19 infection (p < 0.001), prolonged duration of COVID-19 symptoms (p < 0.001) and higher prevalence of fatigue (p < 0.001).

Conclusion

MSK manifestations are common in COVID-19 patients and related to disease severity, duration and fatigue.

Gut Microbiota Dynamics in Relation to Long-COVID-19 Syndrome: Role of Probiotics to Combat Psychiatric Complications

Increasing numbers of patients who recover from COVID-19 report lasting symptoms, such as fatigue, muscle weakness, dementia, and insomnia, known collectively as post-acute COVID syndrome or long COVID. These lasting symptoms have been examined in different studies and found to influence multiple organs, sometimes resulting in life-threating conditions. In this review, these symptoms are discussed in connection to the COVID-19 and long-COVID-19 immune changes, highlighting oral and psychiatric health, as this work focuses on the gut microbiota’s link to long-COVID-19 manifestations in the liver, heart, kidney, brain, and spleen. A model of this is presented to show the biological and clinical implications of gut microbiota in SARS-CoV-2 infection and how they could possibly affect the therapeutic aspects of the disease. Probiotics can support the body’s systems in fighting viral infections. This review focuses on current knowledge about the use of probiotics as adjuvant therapies for COVID-19 patients that might help to prevent long-COVID-19 complications.

Role of Nuclear Factor Erythroid 2 (Nrf2) in the Recovery of Long COVID-19 Using Natural Antioxidants: A Systematic Review

Coronavirus disease 2019 (COVID-19) is an infectious disease with approximately 517 million confirmed cases, with the average number of cases revealing that patients recover immediately without hospitalization. However, several other cases found that patients still experience various symptoms after 3–12 weeks, which is known as a long COVID syndrome. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can activate nuclear factor kappa beta (NF-κβ) and unbind the nuclear factor erythroid 2-related factor 2 (Nrf2) with Kelch-like ECH-associated protein 1 (Keap1), causing inhibition of Nrf2, which has an important role in antioxidant response and redox homeostasis. Disrupting the Keap1–Nrf2 pathway enhances Nrf2 activity, and has been identified as a vital approach for the prevention of oxidative stress and inflammation. Hence, natural antioxidants from various sources have been identified as a promising strategy to prevent oxidative stress, which plays a role in reducing the long COVID-19 symptoms. Oxygen-rich natural antioxidant compounds provide an effective Nrf2 activation effect that interact with the conserved amino acid residues in the Keap1-binding pocket, such as Ser602, Ser363, Ser508, and Ser555. In this review, the benefits of various natural antioxidant compounds that can modulate the Nrf2 signaling pathway, which is critical in reducing and curing long COVID-19, are highlighted and discussed.

Speculation on the pathophysiology of musculoskeletal injury with COVID-19 infection

Coronavirus disease 2019 (COVID-19) primarily affects the respiratory tract, but also many other organs and tissues, leading to different pathological pictures, such as those of the musculoskeletal tissues. The present study should be considered as a speculation on the relationship between COVID-19 infection and some frequent musculoskeletal pathologies, in particular sarcopenia, bone loss/osteoporosis (OP) and fracture risk and osteoarthritis (OA), to hypothesize how the virus acts on these pathologies and consequently on the tissue regeneration/healing potential. The study focuses in particular on the modalities of interaction of COVID-19 with Angiotensin-Converting Enzyme 2 (ACE2) and on the “cytokine storm.” Knowing the effects of COVID-19 on musculoskeletal tissues could be important also to understand if tissue regenerative/reparative capacity is compromised, especially in elderly and frail patients. We speculate that ACE2 and serine proteases together with an intense inflammation, immobilization and malnutrition could be the responsible for muscle weakness, altered bone remodeling, increase in bone fracture risk and inflammatory joint pathologies. Future preclinical and clinical studies may focus on the regenerative/reparative properties of the musculoskeletal tissues after COVID-19 infection, toward a personalized treatment usually based on scaffolds, cells, and growth factors.

Perspectives post-COVID-19 : le point de vue des pneumologues

Plus de 5 millions de personnes en France ont présenté une infection par le SARS-CoV-2. Lors des précédentes épidémies de coronavirus (SARS-CoV, Mers-CoV), les patients ont développé des séquelles pulmonaires avec une dyspnée, une diminution de la capacité de diffusion du monoxyde de carbone et/ou des lésions de fibrose. Le but de cette revue était d’évaluer les séquelles respiratoires et de faire une synthèse des principaux symptômes respiratoires après une infection au COVID-19 et de leurs étiologies. Les quatre principales causes de dyspnée sont les séquelles respiratoires, le déconditionnement, l’hyperventilation et les causes classiques de dyspnée. Les principales séquelles respiratoires étaient l’altération de la capacité de diffusion du monoxyde de carbone et le schéma de fibrose. La prévalence de ces séquelles respiratoires est actuellement inconnue.

Tranilast as an Adjunctive Therapy in Hospitalized Patients with Severe COVID- 19: A Randomized Controlled Trial

Background

Tranilast is a potential NLRP3 inflammasome inhibitor that may relieve progressive inflammation due to COVID-19.

Aim of the study

To evaluate the therapeutic effects of Tranilast in combination with antiviral drugs in non-ICU-admitted hospitalized patients with COVID-19.

Methods

This study was an open-label clinical trial that included 72 hospitals admitted patients with severe COVID-19 at Razi Hospital, Ahvaz, Iran, from July 2020–August 2020. These patients were randomly assigned in a 1:1 ratio to control (30) and intervention groups (30). Patients in the control group received antiviral therapy, while patients in the intervention group received Tranilast (300 mg daily) in addition to the antiviral drugs for Seven days. The collected data, including the expression of inflammatory cytokine, laboratory tests, and clinical findings, was used for intragroup comparisons.

Results

The intervention group showed significantly lower levels of NLR (p = 0.001), q-CRP (p = 0.002), IL-1 (p = 0.001), TNF (p = 0.001), and LDH (p = 0.046) in comparison with the control group. The effect of intervention was significant in increasing the o2 saturation (F = 7.72, p = 0.007). Long hospitalization (four days or above) was 36.6% in the Tranilast and 66.6% in the control group (RR = 0.58; 95% CI: 0.38–1.06, p = 0.045). In the Tranilst and control groups, one and four deaths or hospitalization in ICU were observed respectively (RR = 0.31; 95% CI: 0.03–2.88, p = 0.20).

Conclusions

Tranilast might be used as an effective and safe adjuvant therapy and enhance the antiviral therapy's efficacy for managing patients with COVID-19.

Unraveling Muscle Impairment Associated With COVID-19 and the Role of 3D Culture in Its Investigation

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been considered a public health emergency, extensively investigated by researchers. Accordingly, the respiratory tract has been the main research focus, with some other studies outlining the effects on the neurological, cardiovascular, and renal systems. However, concerning SARS-CoV-2 outcomes on skeletal muscle, scientific evidence is still not sufficiently strong to trace, treat and prevent possible muscle impairment due to the COVID-19. Simultaneously, there has been a considerable amount of studies reporting skeletal muscle damage in the context of COVID-19. Among the detrimental musculoskeletal conditions associated with the viral infection, the most commonly described are sarcopenia, cachexia, myalgia, myositis, rhabdomyolysis, atrophy, peripheral neuropathy, and Guillain-Barré Syndrome. Of note, the risk of developing sarcopenia during or after COVID-19 is relatively high, which poses special importance to the condition amid the SARS-CoV-2 infection. The yet uncovered mechanisms by which musculoskeletal injury takes place in COVID-19 and the lack of published methods tailored to study the correlation between COVID-19 and skeletal muscle hinder the ability of healthcare professionals to provide SARS-CoV-2 infected patients with an adequate treatment plan. The present review aims to minimize this burden by both thoroughly exploring the interaction between COVID-19 and the musculoskeletal system and examining the cutting-edge 3D cell culture techniques capable of revolutionizing the study of muscle dynamics.

Dexamethasone and Nutraceutical Therapy Can Reduce the Myalgia Due to COVID-19 - a Systemic Review of the Active Substances that Can Reduce the Expression of Interlukin-6

Background

Myalgia reflects generalized inflammation and cytokine response and can be the onset symptom of 36% of patients with COVID-19. Interleukin-6 (IL-6) and tumor necrosis factor-α (TNF- α) levels in plasma and upper respiratory secretions directly correlate with the magnitude of viral replication, fever, and respiratory and systemic symptoms, including musculoskeletal clinical manifestations.

Objective

The aim of our work is to report literature scientific investigation clinical protocol to reduce the immunomodulation and inflammatory response nutraceutical therapy associated with dexamethasone and how can reduce the expression of Interlukina-6(IL-6) and myalgia due to COVID-19.

Methods

We searched in Pubmed and Cochrane the nautriceutical drugs to treat the immune modulation of organism to COVID-19. We put these keywords: immune inflammation, desease descriptions, epidemiology COVID-19; immunomodulations; IL-6; Rheumatic Symptoms; Joint; Musculoskeletal Disorders; dexamethasone; Polydatin; Zinc; Melatonin; N- Acetyl Cysteine; Colostrum; L- Glutamine; Vitamin D3.

Results

We found 61 papers. All the authors analyze them. After the Analyze we suggest the use of response nutraceutical therapy associated with dexamethasone can reduce the expression of Interlukina-6(IL-6) and myalgia due to COVID-19.

Conclusion

According the scientific literature nutraceutical therapy associated with dexamethasone can reduce the expression of Interlukina-6(IL-6) and myalgia due to COVID-19.

Management of musculoskeletal pain in patients with idiopathic pulmonary fibrosis: a review

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrotic, and fatal interstitial lung disease (ILD) of unknown etiology that primarily affects the elderly. Patients with IPF suffer from a heavy symptom burden and usually have a poor quality of life. Dyspnea and dry cough are predominant symptoms of IPF. Although pain is not considered one of the main symptoms of IPF, it can occur for a variety of reasons, such as hypoxia, coughing, muscle and nerve damage, deconditioning, and steroid use. The prevalence of pain in IPF patients varies greatly, ranging from around 30 to 80%, with the prevalence being estimated mostly among patients in the end-of-life period. It manifests itself in the form of muscle pain, joint discomfort, or back and chest pain. Approaches to the treatment of chronic musculoskeletal pain in patients with IPF include pharmacological and non-pharmacological measures that are also important to optimize the treatment of other symptoms (dyspnea and cough) and the optimal treatment of comorbidities. Given the scarcity of data on this symptom in the literature, this article summarizes what is currently known about the etiology and treatment of musculoskeletal pain in IPF.

Research Progress in the Treatment of Complications and Sequelae of COVID-19

With the improvement in the understanding of COVID-19 and the widespread vaccination of COVID-19 vaccines in various countries, the epidemic will be brought under control soon. However, multiple viruses could result in the post-viral syndrome, which is also common among patients with COVID-19. Therefore, the long-term consequences and the corresponding treatment of COVID-19 should be the focus in the post-epidemic era. In this review, we summarize the therapeutic strategies for the complications and sequelae of eight major systems caused by COVID-19, including respiratory system, cardiovascular system, neurological system, digestive system, urinary system, endocrine system, reproductive system and skeletal complication. In addition, we also sorted out the side effects reported in the vaccine trials. The purpose of this article is to remind people of possible complications and sequelae of COVID-19 and provide robust guidance on the treatment. It is extremely important to conduct long-term observational prognosis research on a larger scale, so as to have a comprehensive understanding of the impact of the SARS-CoV-2 on the human body and reduce complications to the greatest extent.

[Thoracolumbar back pain as the leading symptom of a marked COVID-19 pneumonia]

HISTORY

 A 49-year-old male patient visited the surgical outpatient clinic with new onset low back pain. The pain was increasing for nine days and he did not have any signs of a respiratory infection, in particular neither fever nor cough.

INVESTIGATIONS

 During the further examination and unclothing, mild dyspnea was apparent. According to the patient, the dyspnea was also progressive in the last days but would not affect everyday life. Furthermore, the patient reported a significant and unintended weight loss. Outpatient chest X-ray revealed bilateral, peripheral, fine-speckled infiltrates that became increasingly confluent. Polymerase chain reaction analysis of the nasopharyngeal swab was positive for SARS-CoV-2 (wild type).

TREATMENT AND COURSE

 Due to progressive dyspnea, the patient was referred to inpatient treatment within the day, where he rapidly developed severe acute respiratory failure. To provide respiratory support, a combined intermittent non-invasive ventilation and nasal high flow-therapy was started. Moreover, a probatory antiviral therapy with remdesivir was initiated. Since a bacterial superinfection was suspected, additional antibiotic therapy was ordered. After 13 days of inpatient treatment, the patient was discharged. The low back pain receded completely during inpatient treatment without any specific therapy.

CONCLUSIONS

 Low back pain can be a symptom of COVID-19. In our case report, it was the only complain that led to the outpatient consultation. Even though back pain is a very common symptom in everyday practice, one should keep unusual causes in mind.

Insight into pain syndromes in acute phase of mild-to-moderate COVID-19: Frequency, clinical characteristics, and associated factors

Background

Pain has been frequently described as a clinical feature of COVID‐19, and the main pain syndromes that have been associated with the acute phase of this disease so far are headache, myalgia, arthralgia, and neuropathic pain. Understanding the characteristics of pain symptoms is crucial for a better clinical approach.

Methods

Patients who were diagnosed as having COVID‐19 using reverse transcription‐polymerase chain reaction were included in the study. Patients were asked to complete a 51‐item questionnaire via a phone interview, which included questions on demographics, acute COVID‐19 symptoms, the presence of pain symptoms, and their characteristics in the acute phase of COVID‐19.

Results

A total of 222 out of 266 patients with COVID‐19 participated in the study, yielding a response rate of 83.5%. A total of 159 patients reported at least one kind of pain syndrome with a prevalence of 71.6%. Myalgia was reported in 110 (49.6%) patients, headache in 109 (49.1%), neuropathic pain symptoms in 55 (24.8%), and polyarthralgia in 30 (13.5%) patients. A total of 66 patients reported only one type of pain, 46 reported two types, 42 reported three types, and five patients reported all four types of pain. Logistic regression analysis showed that there were significant associations between these pain syndromes and a strong association was found between neuropathic pain and headache.

Conclusion

Pain is a frequently observed symptom of mild‐to‐moderate COVID‐19. There are significant relationships between pain syndromes in COVID‐19, which may be due to a sequence of common etiologic factors.

Significance

This study described the main pain syndromes associated acute phase of mild‐to‐moderate COVID‐19 and its associated features. Headaches and pain of neuropathic characteristics were prevalent in this sample.

Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments

Long COVID or post-COVID-19 syndrome first gained widespread recognition among social support groups and later in scientific and medical communities. This illness is poorly understood as it affects COVID-19 survivors at all levels of disease severity, even younger adults, children, and those not hospitalized. While the precise definition of long COVID may be lacking, the most common symptoms reported in many studies are fatigue and dyspnoea that last for months after acute COVID-19. Other persistent symptoms may include cognitive and mental impairments, chest and joint pains, palpitations, myalgia, smell and taste dysfunctions, cough, headache, and gastrointestinal and cardiac issues. Presently, there is limited literature discussing the possible pathophysiology, risk factors, and treatments in long COVID, which the current review aims to address. In brief, long COVID may be driven by long-term tissue damage (e.g. lung, brain, and heart) and pathological inflammation (e.g. from viral persistence, immune dysregulation, and autoimmunity). The associated risk factors may include female sex, more than five early symptoms, early dyspnoea, prior psychiatric disorders, and specific biomarkers (e.g. D-dimer, CRP, and lymphocyte count), although more research is required to substantiate such risk factors. While preliminary evidence suggests that personalized rehabilitation training may help certain long COVID cases, therapeutic drugs repurposed from other similar conditions, such as myalgic encephalomyelitis or chronic fatigue syndrome, postural orthostatic tachycardia syndrome, and mast cell activation syndrome, also hold potential. In sum, this review hopes to provide the current understanding of what is known about long COVID.

Deconditioning as main mechanism of impaired exercise response in COVID-19 survivors

SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) and the related coronavirus disease 2019 (COVID-19) hit Europe in February 2020 [1], raising issues on acute phase management and, later on, the management of its long-term sequelae. Cardiopulmonary exercise testing (CPET), which is the gold standard for the evaluation of exercise capacity, is included in the list of examinations of the European Respiratory Society/American Thoracic Society task force for the follow-up of COVID-19 patients [2]. However, it is not performed in every clinical centre, as it requires specific technical skills. The objective of this observational, prospective study was to evaluate the sequelae of COVID-19 by assessing exercise performance during incremental CPET.

CPET reveals only a mild impairment of exercise capacity, with preserved ventilatory and gas exchange response at 3 months follow-up in COVID-19 survivors, due to deconditioninghttps://bit.ly/3sI8e0Y

Vertebral Pain in Acute COVID-19—Cases Report

Pain is one of the most common complaints among patients infected by SARS-CoV-2. While headache and chest pain are reported widely among COVID-19 presentations, there are only scarce reports about vertebral pain. This study aims to describe cases of four healthy and physically active adults, in whom the new onset of back pain was the early or only sign of COVID-19 and the reason for seeking medical outpatient care. The vertebral pain showed great variability and changed dramatically during the course of disease. Pseudoradicular symptoms were present inconstantly and variably; in some patients they varied through the day from left to right side and irradiated from various sensory root segments. Clinical symptoms did not correspond with minor morphological changes presented on MRI scans. Our experience indicates that new onset of vertebral algic syndrome should be considered as an initial indicator of novel coronavirus infection in healthy and physically active adults. There is a pressing need for attention to be paid in the examination of patients with new vertebral pain onset in the coronavirus pandemic.

Musculoskeletal Problems in Patients with COVID-19: A Review Study

Context: SARS-COV-2 is a coronavirus belonging to the beta-coronavirus group that primarily targets the human respiratory system and causes symptoms similar to those of pneumonia. It should be noted that clinical symptoms of patients with COVID-19 vary in different people. These patients do not only experience respiratory problems. In fact, COVID-19 infection may show a variety of symptoms, including fever, shortness of breath, dry cough, nasal congestion, sore throat, nausea, vomiting, myalgia, arthralgia, fatigue (muscular and mental), joint swelling, headache, diarrhea, as well as some musculoskeletal symptoms. Therefore, the aim of this article was to investigate the major musculoskeletal problems in patients with COVID-19 through a narrative review study. Evidence Acquisition: This study collected the related published studies in the PubMed, ScienceDirect, and Google Scholar sources between 2019 - 2020. The main keywords were COVID-19, coronavirus, and musculoskeletal problems such as muscle fatigue, myalgia, arthralgia, and joint swelling. Results: The major musculoskeletal symptoms included muscle fatigue (25.6%), myalgia and arthralgia (15.5%), joint swelling (as reactive arthritis), and such conditions as joint limitations, tendon shortening, and muscle weakness due to prolonged bed rest. Conclusions: Our findings revealed that attention to musculoskeletal rehabilitation of patients with COVID-19 is as essential as their respiratory rehabilitation. Besides, it would be effective in reducing the physical complications of hospitalization, returning to independence and functional activities, as well as improving the quality of the patients’ life.

Comprehensive Review on Neuro-COVID-19 Pathophysiology and Clinical Consequences

Aside from the respiratory distress as the predominant clinical presentation of SARS-CoV-2 infection, various neurological complications have been reported with the infection during the ongoing pandemic, some of which cause serious morbidity and mortality. Herein, we gather the latest anatomical evidence of the virus's presence within the central nervous system. We then delve into the possible SARS-CoV-2 entry routes into the neurological tissues, with the hematogenous and the neuronal routes as the two utmost passage routes into the nervous system. We then give a comprehensive review of the neurological manifestations of the SARS-CoV-2 invasion in both the central and peripheral nervous system and its underlying pathophysiology via investigating large studies in the field and case reports in cases of study scarcity.

Endothelial Senescence and Chronic Fatigue Syndrome, a COVID-19 Based Hypothesis

Myalgic encephalomyelitis/chronic fatigue syndrome is a serious illness of unknown etiology, characterized by debilitating exhaustion, memory impairment, pain and sleep abnormalities. Viral infections are believed to initiate the pathogenesis of this syndrome although the definite proof remains elusive. With the unfolding of COVID-19 pandemic, the interest in this condition has resurfaced as excessive tiredness, a major complaint of patients infected with the SARS-CoV-2 virus, often lingers for a long time, resulting in disability, and poor life quality. In a previous article, we hypothesized that COVID-19-upregulated angiotensin II triggered premature endothelial cell senescence, disrupting the intestinal and blood brain barriers. Here, we hypothesize further that post-viral sequelae, including myalgic encephalomyelitis/chronic fatigue syndrome, are promoted by the gut microbes or toxin translocation from the gastrointestinal tract into other tissues, including the brain. This model is supported by the SARS-CoV-2 interaction with host proteins and bacterial lipopolysaccharide. Conversely, targeting microbial translocation and cellular senescence may ameliorate the symptoms of this disabling illness.

Emerging COVID-19 Neurological Manifestations: Present Outlook and Potential Neurological Challenges in COVID-19 Pandemic

The unremitting coronavirus disease 2019 (COVID-19) pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) marked a year-long phase of public health adversaries and has severely compromised healthcare globally. Early evidence of COVID-19 noted its impact on the pulmonary and cardiovascular functions, while multiple studies in recent time shed light on its substantial neurological complications, though a comprehensive understanding of the cause(s), the mechanism(s), and their neuropathological outcomes is scarce. In the present review, we conferred evidence of neurological complications in COVID-19 patients and shed light on the SARS-CoV-2 infection routes including the hematogenous, direct/neuronal, lymphatic tissue or cerebrospinal fluid, or infiltration through infected immune cells, while the underlying mechanism of SARS-CoV-2 invasion to the central nervous system (CNS) was also discussed. In an up-to-date manner, we further reviewed the impact of COVID-19 in developing diverse neurologic manifestations associated with CNS, peripheral nervous system (PNS), skeletal muscle, and also pre-existing neurological diseases, including Alzheimer's disease, Parkinson's disease, multiple sclerosis, epilepsy, and myasthenia gravis. Furthermore, we discussed the involvement of key factors including age, sex, comorbidity, and disease severity in exacerbating the neurologic manifestations in COVID-19 patients. An outlook of present therapeutic strategies and state of existing challenges in COVID-19 management was also accessed. Conclusively, the present report provides a comprehensive review of COVID-19-related neurological complications and emphasizes the need for their early clinical management in the ongoing COVID-19 pandemic.

Non-Respiratory Symptoms of Patients Infected with SARS-CoV-2 (Coronavirus Disease 2019): Lessons from Their Initial Presentation at the Hospital

Background and objectives: As the COVID-19 pandemic spreads, it is becoming increasingly evident that this coronavirus is not limited to the respiratory system and that the musculoskeletal system can also be affected. The purpose of the present study was to describe non-respiratory symptoms of laboratory-confirmed COVID-19 cases. Materials and Methods: All patients with SARS-CoV-2 admitted to our hospital, between 1 August and 30 September 2020, were included in this retrospective study. Data were extracted from medical records. Epidemiological, clinical, laboratory and radiological characteristics at the initial presentation at the hospital were collected and analyzed. Results: A total of 79 COVID-19 patients were enrolled. The mean age of the patients was 44.08 years (age range, 18–87 years) and 59.5% were male. The most common symptoms were fatigue in 60 (75.9%) patients, followed by fever (73.4%), myalgia (51.9%), cough (41.8%), anosmia (38%) and arthralgia (36.7%). The muscles of the upper back and the knee joint were the most painful anatomic region and joint, respectively. The laboratory findings on admission showed that D-dimer, CRP and procalcitonin levels were increased, without significant gender differences (p > 0.05). Chest imaging demonstrated pneumonia in 20 (25.3%) patients. Conclusions: Our results indicate that from the onset of the symptoms of COVID-19 patients, musculoskeletal symptoms, such as fatigue, myalgia and arthralgia, were present in three-quarters of all patients. These findings could help elaborate updated triage and admission protocols for suspect COVID-19 patients at the hospital and Emergency Department presentation.

Abnormal Liver Function Test in Patients Infected with Coronavirus (SARS-CoV-2): A Retrospective Single-Center Study from Spain

The outbreak of the novel coronavirus SARS-CoV-2 epidemic has rapidly spread and still poses a serious threat to healthcare systems worldwide. In the present study, electronic medical records containing clinical indicators related to liver injury in 799 COVID-19-confirmed patients admitted to a hospital in Madrid (Spain) were extracted and analyzed. Correlation between liver injury and disease outcome was also evaluated. Serum levels of Alanine aminotransferase (ALT), Aspartate aminotransferase (AST), Gamma-glutamyltransferase (GGT), Alkaline phosphatase (ALP), Lactate dehydrogenase (LDH) and AST/ALT ratio were elevated above the Upper Limit of Normal (ULN) in 25.73%, 49.17%, 34.62%, 24.21%, 55.84% and 75% of patients, respectively. Interestingly, significant positive correlation between LDH levels and the AST/ALT ratio with disease outcome was found. Our data showed that SARS-CoV-2 virus infection leads to mild, but significant changes in serum markers of liver injury. The upregulated LDH levels as well as AST/ALT ratios upon admission may be used as additional diagnostic characteristic for COVID-19 patients.

Assessment of musculoskeletal pain, fatigue and grip strength in hospitalized patients with COVID-19

BACKGROUND

Although there are some retrospective studies to present musculoskeletal findings of the COVID-19, still the muscle strength and fatigue has not been studied in detail.

AIM

To reveal the symptoms of musculoskeletal system in COVID-19 patients, to evaluate myalgia, arthralgia and physical/mental fatigue, to assess handgrip muscle strength, and to examine the relations of these parameters with the severity and laboratory values of the disease.

DESIGN

This study was designed as a cross-sectional, single-center case series.

SETTING

This study took place from May 15, 2020, to June 30, 2020 at the Istanbul University-Cerrahpasa, Cerrahpasa Pandemia Services.

POPULATION

Hospitalized 150 adults with laboratory and radiological confirmation of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) according to WHO interim guidance were included in the study.

METHODS

The disease severity 2007 IDSA/ATS guidelines for community acquired pneumonia was used. Myalgia severity was assessed by numerical rating scale (NRS). Visual analog scale and Chalder Fatigue Scale (CFS) were used for fatigue severity determination. Handgrip strength (HGS) was measured by Jamar hand dynamometer.

RESULTS

One hundred three patients (68.7%) were non-severe, and 47 patients (31.3%) were severe. The most common musculoskeletal symptom was fatigue (133 [85.3%]), followed by myalgia (102 [68.0%]), arthralgia (65 [43.3%]) and back pain (33 [22.0%]). Arthralgia, which was mostly notable at wrist (25 [16.7%]), ankle (24 [16.0%]) and knee (23 [15.3%]) joints, was significantly higher among the severe group. Severe myalgia was prevalent among myalgia sufferers regardless of COVID-19 severity. The physical fatigue severity score was significantly higher in severe cases, whereas this difference was not significant in mental fatigue score. Female patients with severe infection had "lower" grip strength, whereas grip strength among males did not differ significantly between non-severe and severe COVID-19 cases. Nevertheless, the mean values in both genders and in age decades were below the specified normative values. CRP, ferritin, and LDH levels were significantly higher in women with "lower" grip strength compared to the "normal" group.

CONCLUSIONS

Aside from other multisystemic symptoms, musculoskeletal symptoms are quite common in patients with COVID-19. Patients have severe ischemic myalgia regardless of disease activity. Although there is a muscle weakness in all patients, the loss of muscle function is more of a problem among women in connection with disease severity. Muscular involvement in Coronavirus disease is a triangle of myalgia, physical fatigue, and muscle weakness.

CLINICAL REHABILITATION IMPACT

Muscle involvement in COVID-19 patients does not mean only myalgia but also a combination of physical fatigue and muscle weakness, and this should be considered in planning the rehabilitation strategies of COVID-19 patients.

Role of Melatonin on Virus-Induced Neuropathogenesis-A Concomitant Therapeutic Strategy to Understand SARS-CoV-2 Infection

Viral infections may cause neurological disorders by directly inducing oxidative stress and interrupting immune system function, both of which contribute to neuronal death. Several reports have described the neurological manifestations in Covid-19 patients where, in severe cases of the infection, brain inflammation and encephalitis are common. Recently, extensive research-based studies have revealed and acknowledged the clinical and preventive roles of melatonin in some viral diseases. Melatonin has been shown to have antiviral properties against several viral infections which are accompanied by neurological symptoms. The beneficial properties of melatonin relate to its properties as a potent antioxidant, anti-inflammatory, and immunoregulatory molecule and its neuroprotective effects. In this review, what is known about the therapeutic role of melatonin in virus-induced neuropathogenesis is summarized and discussed.

Road Map to Understanding SARS-CoV-2 Clinico-Immunopathology and COVID-19 Disease Severity

SARS-CoV-2, a novel coronavirus, was first identified in Wuhan, China in December 2019. The rapid spread of the virus worldwide prompted the World Health Organization (WHO) to declare COVID-19 a pandemic in March 2020. COVID-19 discontinuing's a global health crisis. Approximately 80% of the patients infected with SARS-CoV-2 display undetectable to mild inflammation confined in the upper respiratory tract. In remaining patients, the disease turns into a severe form affecting almost all major organs predominantly due to an imbalance of innate and adaptive arms of host immunity. The purpose of the present review is to narrate the virus's invasion through the system and the host's reaction. A thorough discussion on disease severity is also presented regarding the behavior of the host's immune system, which gives rise to the cytokine storm particularly in elderly patients and those with comorbidities. A multifaceted yet concise description of molecular aspects of disease progression and its repercussion on biochemical and immunological features in infected patients is tabulated. The summary of pathological, clinical, immunological, and molecular accounts discussed in this review is of theranostic importance to clinicians for early diagnosis of COVID-19 and its management.

Severe Acute Respiratory Syndrome Coronavirus 2-Induced Neurological Complications

Our review aims to highlight the neurological complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the available treatments according to the existing literature, discussing the underlying mechanisms. Since the end of 2019, SARS-CoV-2 has induced a worldwide pandemic that has threatened numerous lives. Fever, dry cough, and respiratory symptoms are typical manifestations of COVID-19. Recently, several neurological complications of the central and peripheral nervous systems following SARS-CoV-2 infection have gained clinicians' attention. Encephalopathy, stroke, encephalitis/meningitis, Guillain-Barré syndrome, and multiple sclerosis are considered probable neurological signs of COVID-19. The virus may invade the nervous system directly or induce a massive immune inflammatory response via a "cytokine storm." Specific antiviral drugs are still under study. To date, immunomodulatory therapies and supportive treatment are the predominant strategies. In order to improve the management of COVID-19 patients, it is crucial to monitor the onset of new neurological complications and to explore drugs/vaccines targeted against SARS-CoV-2 infection.

Decision on Chemotherapy Amidst COVID-19 Pandemic: a Review and a Practical Approach from Iran

To provide a step-by-step approach to chemotherapy (CTx) in the novel coronavirus disease 2019 (COVID-19) era. The COVID-19 pandemic is the current global issue resulting in vast health implications. Amid the COVID-19 era, special attention must be paid to at-risk groups, including patients with cancer. To our knowledge, there is a paucity of data on the decision for CTx during the pandemic. We herein provide practical recommendations on the CTx of cancer patients over the pandemic based on our experience in an educational hospital. The decision on CTx should be considered to be individualized based on clinical findings. We hope that our experience provides a practical guide for clinical oncologists to deliver more effective cancer care over the COVID-19 pandemic.

COVID-19 and Liver Damage: Narrative Review and Proposed Clinical Protocol for Critically ill Pediatric Patients

SARS-CoV-2 shares nearly 80% of its' genomic sequence with SARS-CoV and MERS-CoV, both viruses known to cause respiratory symptoms and liver impairment. The emergence of pediatric cases of multisystem inflammatory syndrome related to the SARS-CoV-2 infection (PIM-TS) has raised concerns over the issue of hepatic damage and liver enzyme elevation in the critically ill pediatric population with COVID-19. Some retrospective cohorts and case series have shown various degrees of ALT/AST elevation in SARS-CoV-2 infections. A limited number of liver histopathological studies are available that show focal hepatic periportal necrosis. This liver damage was associated with higher levels of inflammatory markers, C-reactive protein (CRP), and pro-calcitonin. Proposed pathophysiological mechanisms include an uncontrolled exacerbated inflammatory response, drug-induced liver injury, direct viral infection and damage to cholangiocytes, hypoxic-ischemic lesions, and micro-thrombosis in the liver. Based on the physiopathological characteristics described, our group proposes a clinical protocol for the surveillance, evaluation, management, and follow-up of critically ill pediatric COVID-19 patients with liver damage.

Analysis of the Factors Associated with Negative Conversion of Severe Acute Respiratory Syndrome Coronavirus 2 RNA of Coronavirus Disease 2019

AIM: To understand the factors associated with negative conversion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA, targeted surveillance and control measures can be taken to provide scientific basis for the treatment of the disease and to improve the prognosis of the disease. METHODS: Using the method of retrospective cohort study, we collected the data of Coronavirus Disease 2019 (COVID-19) patients in Tongji Hospital of Wuhan, China from 10 January to 25 March, 2020. Among the data of 282 cases, 271 patients, according to whether the negative conversion happened, were divided into negative conversion group and control group. We made the quantitative variables into classification; Chi-square test single-factor and Cox regression were used in univariate analysis and extracted 30 meaningful variables, then through the collinearity diagnosis, excluded the existence of collinear variables. Finally, 22 variables were included in Cox regression analysis. RESULTS: The gender distribution was statistically significant between two groups (p < 0.05). While in the negative conversion group, the patients of non-severe group occupied a large proportion (p < 0.001). The median time for the negative conversion group was 17 days, and at the end of the observation period, the virus duration in control group was 24 days (p < 0.05). A total of 55 variables were included in univariate analysis, among which 30 variables were statistically different between the two groups. After screening variables through collinearity diagnosis, 22 variables were included in the Cox regression analysis. Last, lactate dehydrogenase (LDH), age, fibrinogen (FIB), and disease severity were associated with negative conversion of SARS-CoV-2 RNA. CONCLUSION: Our results suggest that in the treatment of COVID-19, focus on the age of more than 65 years old, severe, high level of LDH, FIB patients, and take some targeted treatment, such as controlling of inflammation, reducing organ damage, so as to provide good conditions for virus clearance in the body.

COVID-19 Outbreak: Pathogenesis, Current Therapies, and Potentials for Future Management

At the end of 2019, a novel coronavirus (CoV) was found at the seafood market of Hubei province in Wuhan, China, and this virus was officially named coronavirus diseases 2019 (COVID-19) by World Health Organization (WHO). COVID-19 is mainly characterized by severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) and creates public health concerns as well as significant threats to the economy around the world. Unfortunately, the pathogenesis of COVID-19 is unclear and there is no effective treatment of this newly life-threatening and devastating virus. Therefore, it is crucial to search for alternative methods that alleviate or inhibit the spread of COVID-19. In this review, we try to find out the etiology, epidemiology, symptoms as well as transmissions of this novel virus. We also summarize therapeutic interventions and suggest antiviral treatments, immune-enhancing candidates, general supplements, and CoV specific treatments that control replication and reproduction of SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV).

Pathophysiological Mechanisms and Neurological Manifestations in COVID-19

With increasing knowledge of the coronavirus disease-2019 (COVID-19), we now understand that COVID-19 presents with various extrapulmonary manifestations with multi-organ involvement. Involvement of the central nervous system (CNS) occurs probably via transsynaptic spread or transfer across the blood-brain barrier. Hypoxia, immune-mediated injury, and vascular damage are the potential mechanisms for the CNS manifestations. Headache, dizziness, chemosensory disturbances, such as loss of smell, taste, encephalopathy, stroke, etc., are among the commonly encountered neurological presentations. Headache is identified as one of the red flag symptoms for COVID-19. Sudden onset of loss of smell and/or taste in the absence of nasal congestion can help in COVID-19 case identification and testing prioritization. Both hemorrhagic and ischemic brain injury is common in patients developing stroke. Besides these, COVID-19-associated CNS involvement demands more careful attention toward patients with existing neurological disorders especially that are managed with immunosuppressant agents. In all, neurological involvement in COVID-19 is not uncommon and may precede, occur concomitantly or after the respiratory involvement. It may also be the sole presentation in some of the patients necessitating high vigilance for COVID-19. In this review, we briefly discussed the pathogenesis of CNS involvement and some important neurological manifestations in COVID-19. How to cite this article: Zirpe KG, Dixit S, Kulkarni AP, Sapra H, Kakkar G, Gupta R, et al. Pathophysiological Mechanisms and Neurological Manifestations in COVID-19. Indian J Crit Care Med 2020;24(10):975-980.

Alpha-lipoic acid may protect patients with diabetes against COVID-19 infection

COVID-19 pandemic is spreading rapidly worldwide, and drug selection can affect the morbidity and mortality of the disease positively or negatively. Alpha-lipoic acid (ALA) is a potent antioxidant and reduces oxidative stress and inhibits activation of nuclear factor-kappa B (NF-kB). ALA reduces ADAM17 activity and ACE2 upregulation. ALA is known to have antiviral effects against some viruses. ALA may show antiviral effect by reducing NF-kB activation and alleviating redox reactions. ALA increases the intracellular glutathione strengthens the human host defense. ALA activates ATP dependent K+ channels (Na+, K+-ATPase). Increased K+ in the cell raises the intracellular pH. As the intracellular pH increases, the entry of the virus into the cell decreases. ALA can increase human host defense against SARS-CoV-2 by increasing intracellular pH. ALA treatment increases antioxidant levels and reduces oxidative stress. Thus, ALA may strengthen the human host defense against SARS-CoV-2 and can play a vital role in the treatment of patients with critically ill COVID-19. It can prevent cell damage by decreasing lactate production in patients with COVID-19. Using ALA with insulin in patients with diabetes can show a synergistic effect against SARS-CoV-2. We think ALA treatment will be beneficial against COVID-19 in patients with diabetes.

The Neurological Complexities and Prognosis of COVID-19

Several neurological manifestations and complications linked to SARS-CoV-2 have been reported along with well-known respiratory pathology. The global active transmission of SARS-CoV-2 and its unexplained characteristics has led to a pandemic. Since its rapid emergence from Wuhan, China, in December 2019, several studies have reported the impacts of COVID-19 on the CNS and PNS and its implications. This comprehensive review article comprises case reports, case series, metaanalysis, cohort studies, retrospective studies, and narrative reviews focusing on COVID-19-associated CNS and PNS complexities. The authors searched for over 200 articles and used 52 publications related to the neurological complexities of COVID-19 affecting the CNS and PNS as part of the literature review process. The predominant CNS symptoms noted in COVID-19 patients were headaches and dizziness, and the most common PNS symptoms were alterations in smell and taste. Case reports on headache/dizziness, intracerebral hemorrhage, acute hemorrhagic necrotizing encephalopathy, meningitis/encephalitis, encephalopathy, cerebrovascular events, chemosensory dysfunction, Guillain-Barre syndrome, and acute transverse myelitis/acute necrotizing myelitis in PCR-confirmed SARS-CoV-2 subjects are also reported. New-onset neurological symptoms were also observed in children with PCR-confirmed SARS-CoV-2 that developed pediatric multisystem inflammatory syndrome (PIMS). This comprehensive review article will assist the clinicians and researchers to gain information about the neurological manifestations and complications associated with COVID-19 and develop planning to treat these symptoms in concerned patients of all ages. However, it is unclear whether SARS-CoV2-associated neurological effects are due to primary infections or secondary response to the possible mechanisms discussed in this review.