Neuromuscular presentations in patients with COVID-19

Musculoskeletal manifestations of COVID-19

During the COVID-19 pandemic, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected millions of people worldwide, with acute respiratory distress syndrome (ARDS) being the most common severe condition of pulmonary involvement. Despite its involvement in the lungs, SARS-CoV-2 causes multiple extrapulmonary manifestations, including manifestations in the musculoskeletal system. Several cases involving bone, joint, muscle, neurovascular and soft tissues were reported shortly after pandemic onset. Even after the acute infection has resolved, many patients experience persistent symptoms and a decrease in quality of life, a condition known as post-COVID syndrome or long COVID. COVID-19 vaccines have been widely available since December 2020, preventing millions of deaths during the pandemic. However, adverse reactions, including those involving the musculoskeletal system, have been reported in the literature. Therefore, the primary goal of this article is to review the main imaging findings of SARS-CoV-2 involvement in the musculoskeletal system, including acute, subacute, chronic and postvaccination manifestations.

Neuropathic component of chronic musculoskeletal pain in patients with post-COVID-19: A cross-sectional study

Objectives

This study aimed to evaluate the neuropathic component of chronic musculoskeletal pain in post-coronavirus disease 2019 (COVID-19) and examine the relationship between neuropathic pain and clinical and demographic characteristics.

Patients and methods

This cross-sectional study included 163 adult patients (85 females, 78 males; mean age: 41.7±4.3 years; range, 22 to 50 years) with post-COVID-19 musculoskeletal pain between February 1, 2021, and April 30, 2021. Demographic and clinical characteristics, including age, sex, affected site, duration, and severity of post-COVID-19 musculoskeletal pain using the Visual Analog Scale (VAS), as well as a neuropathic component of pain using the Leeds assessment of neuropathic symptoms and signs (LANSS), were collected. The most common post-COVID-19 symptoms, presence of hospitalization, and length of hospital stay during active COVID-19 infection were recorded from the patient records.

Results

The mean duration and severity of pain were 7.85±1.53 months and 5.09±1.95, respectively. Half of the patients were hospitalized, and the mean length of hospital stay was 12.15±18.06 days. The most common pain sites were upper and lower back pain, followed by leg and arm pain. A total of 92 (56.4%) patients had previously received pharmacological or nonpharmacological treatment for post-COVID-19 musculoskeletal pain. Based on the LANSS (scores >12), 31 (19%) patients had neuropathic pain. There was a significant correlation between the presence of neuropathic pain and pulmonary involvement/symptoms. The presence and length of hospital stay were correlated with LANNS scores (p<0.05). The frequency, LANSS scores, and VAS-pain scores of the patients with and without neuropathic pain were similar between male and female patients (p>0.05).

Conclusion

The neuropathic component of chronic musculoskeletal pain may be common, as one-fifth of our patients had neuropathic pain as assessed by the LANNS. Therefore, the awareness of post-COVID-19 chronic neuropathic musculoskeletal pain should be increased. We believe that focusing on the identification of pain phenotypes would provide adequate and tailored chronic neuropathic musculoskeletal pain management in the post-COVID-19 period.

Advance in the mechanism and clinical research of myalgia in long COVID

As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to evolve, mortality rates of coronavirus disease 2019 (COVID-19) have significantly decreased. However, a variable proportion of patients exhibit persistent prolonged symptoms of COVID-19 infection (long COVID). This virus primarily attacks respiratory system, but numerous individuals complain persistent skeletal muscle pain or worsening pre-existing muscle pain post COVID-19, which severely affects the quality of life and recovery. Currently, there is limited research on the skeletal muscle pain in long COVID. In this brief review, we review potential pathological mechanisms of skeletal muscle pain in long COVID, and summarize the various auxiliary examinations and treatments for skeletal muscle pain in long COVID. We consider abnormal activation of inflammatory response, myopathy, and neurological damages as pivotal pathological mechanisms of skeletal muscle pain in long COVID. A comprehensive examination is significantly important in order to work out effective treatment plans and relieve skeletal muscle pain. So far, rehabilitation interventions for myalgia in long COVID contain but are not limited to drug, nutraceutical therapy, gut microbiome-targeted therapy, interventional therapy and strength training. Our study provides a potential mechanism reference for clinical researches, highlighting the importance of comprehensive approach and management of skeletal muscle pain in long COVID. The relief of skeletal muscle pain will accelerate rehabilitation process, improve activities of daily living and enhance the quality of life, promoting individuals return to society with profound significance.

Effectiveness of Mesotherapy in Post-COVID Pain Syndrome: Retrospective Cohort Study of 96 Patients

PURPOSE

Musculoskeletal pain may occur after becoming infected with SARS-Cov2. This study was designed to evaluate the efficacy of mesotherapy in treating chronic pain following COVID-19 infection.

METHODS

A retrospective review was conducted of the records of 96 patients with post-COVID pain syndrome. Those who were eligible for oral therapy or mesotherapy, included in the study. Patients receiving oral treatment with diclofenac potassium, thiocolchicoside and cyanocobalamin were included in one group (n = 46), and patients receiving intradermal mesotherapy with 2% lidocaine + cyanocobalamin were included in another group (n = 50). The results of the Visual Analogue Scale (VAS) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) were individually assessed before and one week after the treatment.

FINDINGS

The participants were 40.2 ± 11.1 years old on average. Of the participants, 35.4% (n = 34) were male and 64.6% (n = 62) were female. Before treatment, there was no statistically significant difference between the patients in terms of VAS and LANSS scores. Following the treatment, a notable positive response was observed in both groups. Nevertheless, when compared to the oral treatment group, the mesotherapy group exhibited a more pronounced enhancement in VAS and LANSS scores (P < 0.001, P < 0.001, respectively).

IMPLICATIONS

While both mesotherapy and oral therapy offer benefits in reducing pain and alleviating neuropathic symptoms in post-COVID pain syndrome, mesotherapy stands out as an especially effective and well-tolerated treatment method, surpassing the efficacy of the oral alternative.

Potential Mechanisms Underlying COVID-19-Mediated Central and Peripheral Demyelination: Roles of the RAAS and ADAM-17

Demyelination is among the most conspicuous neurological sequelae of SARS-CoV-2 infection (COVID-19) in both the central (CNS) and peripheral (PNS) nervous systems. Several hypotheses have been proposed to explain the mechanisms underlying demyelination in COVID-19. However, none have considered the SARS-CoV-2's effects on the renin-angiotensin-aldosterone system (RAAS). Therefore, our objective in this review is to evaluate how RAAS imbalance, caused by direct and indirect effects of SARS-CoV-2 infection, could contribute to myelin loss in the PNS and CNS. In the PNS, we propose that demyelination transpires from two significant changes induced by SARS-CoV-2 infection, which include upregulation of ADAM-17 and induction of lymphopenia. Whereas, in the CNS, demyelination could result from RAAS imbalance triggering two alterations: (1) a decrease in angiotensin type II receptor (AT2R) activity, responsible for restraining defense cells' action on myelin; (2) upregulation of ADAM-17 activity, leading to impaired maturation of oligodendrocytes and myelin formation. Thus, we hypothesize that increased ADAM-17 activity and decreased AT2R activity play roles in SARS-CoV-2 infection-mediated demyelination in the CNS.

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.

COVID-19 in patients with myasthenia gravis: a single-center retrospective study in China

BACKGROUND

Coronavirus disease 2019 (COVID-19) has been a great concern since 2019. Patients with myasthenia gravis (MG) may be at higher risk of COVID-19 and a more severe disease course. We examined the associations between COVID-19 and MG.

METHODS

This single-center retrospective cohort study involved 134 patients who were diagnosed with MG from June 2020 to November 2022 and followed up until April 2023. They were divided into a COVID-19 group and non-COVID-19 group. Logistic regression analysis was used to detect factors potentially associating COVID-19 with MG.

RESULTS

Of the 134 patients with MG, 108 (80.6%) had COVID-19. A higher number of comorbidities was significantly associated with an increased risk of COVID-19 (p = 0.040). A total of 103 patients (95.4%) had mild/moderate COVID-19 symptoms, and 4 patients (3.7%) were severe/critical symptoms (including 2 deaths). Higher age (p = 0.036), use of rituximab (p = 0.037), tumors other than thymoma (p = 0.031), Hashimoto's thyroiditis (p = 0.011), more comorbidities (p = 0.002), and a higher baseline MG activities of daily living (MG-ADL) score (p = 0.006) were risk factors for severe COVID-19 symptoms. The MG-ADL score increased by ≥ 2 points in 16 (15.7%) patients. Dry cough and/or expectoration (p = 0.011), use of oral corticosteroids (p = 0.033), and use of more than one kind of immunosuppressant (p = 0.017) were associated with the increase of the post-COVID-19 MG-ADL score.

CONCLUSION

Most patients with MG have a mild course of COVID-19. However, patients with older age, many comorbidities, a high MG-ADL score, and use of a variety of immunosuppressants during COVID-19 may be more prone to severe symptoms.

Risks of incident major osteoporotic fractures following SARS-CoV-2 infection among older individuals: a population-based cohort study in Hong Kong

Population-based epidemiological studies on post-acute phase coronavirus 2019 (COVID-19)-related fractures in older adults are lacking. This study aims to examine the risk of incident major osteoporotic fractures following SARS-CoV-2 infection among individuals aged ≥50, compared to individuals without COVID-19. It was a retrospective, propensity-score matched, population-based cohort study of COVID-19 patients and non-COVID individuals identified from the electronic database of the Hong Kong Hospital Authority from January 2020 to March 2022. The primary outcome was a composite of major osteoporotic fractures (hip, clinical vertebral, and upper limb). COVID-19 patients were 1:1 matched to controls using propensity-score according to age, sex, vaccination status, medical comorbidities and baseline medications. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression models. A total of 429 459 COVID-19 patients were included, 1:1 matched to non-COVID individuals. Upon median follow-up of 11 months, COVID-19 patients had higher risks of major osteoporotic fractures (5.08 vs 3.95 per 1000 persons; HR 1.22 95%CI [1.15-1.31]), hip fractures (2.71 vs 1.94; 1.33 [1.22-1.46]), clinical vertebral fractures (0.42 vs 0.31; 1.29 [1.03-1.62]), and falls (13.83 vs 10.36; 1.28 [1.23-1.33]). Subgroup analyses revealed no significant interaction. In acute (within 30 days) and post-acute phases (beyond 30 days) following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we consistently observed a significant increase in fractures and falls risks. Our study demonstrated increased risk of major osteoporotic fractures after SARS-CoV-2 infection in both acute and post-acute phases in older adults, partly due to increased fall risk. Clinicians should be aware of musculoskeletal health of COVID-19 survivors.

Neuropathic Corneal Pain after Coronavirus Disease 2019 (COVID-19) Infection

INTRODUCTION

This is a case report of a patient with neuropathic corneal pain after coronavirus disease 2019 (COVID-19) infection.

METHODS

A previously healthy 27-year-old female presented with bilateral eye pain accompanied by increased light sensitivity 5 months after COVID-19 infection. She was diagnosed with neuropathic corneal pain based on clear corneas without fluorescein staining, alongside the presence of microneuromas, dendritic cells, and activated stromal keratocytes identified bilaterally on in vivo confocal microscopy.

RESULTS

The patient's tear nerve growth factor, substance P, and calcitonin gene-related peptide levels were 5.9 pg/mL, 2978.7 pg/mL, and 1.1 ng/mL, respectively, for the right eye and 23.1 pg/mL, 4798.7 pg/mL, and 1.2 ng/mL, respectively, for the left eye, suggesting corneal neuroinflammatory status. After 6 weeks of topical 0.1% flurometholone treatment, decreased microneuroma size, less extensive dendritic cells, and reduced tear nerve growth factor and substance P levels were observed. The scores on the Ocular Pain Assessment Survey showed an improvement in burning sensation and light sensitivity, decreasing from 80% and 70% to 50% for both.

CONCLUSIONS

Neuropathic corneal pain is a potential post-COVID-19 complication that warrants ophthalmologists' and neurologists' attention.

Identification of key genes as potential diagnostic and therapeutic targets for comorbidity of myasthenia gravis and COVID-19

Introduction

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disorder. Coronavirus disease 2019 (COVID-19) has a significant impact on the health and quality of life of MG patients and may even trigger the onset of MG in some cases. With the worldwide development of the COVID-19 vaccination, several new-onset MG cases and exacerbations following the COVID-19 vaccines have been acknowledged. The potential link between myasthenia gravis (MG) and COVID-19 has prompted the need for further investigation into the underlying molecular mechanism.

Methods and results

The differential expression analysis identified six differentially expressed genes (DEGs) shared by myasthenia gravis (MG) and COVID-19, namely SAMD9, PLEK, GZMB, JUNB, NR4A1, and NR1D1. The relationship between the six common genes and immune cells was investigated in the COVID-19 dataset. The predictive value of the shared genes was assessed and a nomogram was constructed using machine learning algorithms. The regulatory miRNAs, transcription factors and small molecular drugs were predicted, and the molecular docking was carried out by AutoDock.

Discussion

We have identified six common DEGs of MG and COVID-19 and explored their immunological effects and regulatory mechanisms. The result may provide new insights for further mechanism research.

Benign fasciculation syndrome and migraine aura without headache as possible adverse events after BNT162b2 mRNA vaccination: a web-based survey

AIM

To determine the characteristics of patients who experienced muscle fasciculations and migraine auras without headache after BNT162b2 immunization.

METHODS

In January 2022, we published a case report that described a 48-year-old female patient who experienced muscle twitching and migraine auras without headache following BNT162b2 immunization. A self-administered online survey was sent to people who had written to us and complained of similar symptoms described in the case report (N=20).

RESULTS

The survey was completed by 11 participants, of whom 10 reported muscle twitching following BNT162b2 immunization lasting a median of 14 (4-36.5) days. Five of these participants (50%) reported migraine auras without headache. Participants further reported on self-identified triggers that altered the intensity of their symptoms, such as anxiety or caffeine. Fifty percent of participants who got an acute SARS-CoV-2 infection (3/6) experienced increased muscle symptom intensity during the acute phase of the disease.

CONCLUSION

To the best of our knowledge, our survey is the first to summarize patients' experiences of these phenomena occurring after BNT162b2 immunization. It is important to note that no causal relationship between vaccination and these phenomena can be inferred.

The first case of SARS-CoV-2-induced eosinophilic fasciitis

Eosinophilic fasciitis (EF), also known as Shulman syndrome, is a rare auto-immune fibrosing disorder of the fascia. Etiopathogeny of EF is still unclear. Nowadays, it is widely known that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may induce hyper-stimulation of the immune system. Several cases with fasciitis and rhabdomyolysis induced by coronavirus disease 2019 vaccines have been reported in the literature. Herein, we report the first case of EF possibly triggered by SARS-CoV-2 infection. A 45-year-old Tunisian woman, with no medical history, presented to our department with severe widespread muscle pain noticed one month after a SARS-CoV-2 infection. Physical examination showed an induration of the skin and subcutaneous tissue of the arms, forearms and legs with a restricted joint mobility. The level of eosinophils was 430 E/mm3 (6.1%) [1-4%]. Electromyography and creatine kinase levels were normal. Myositis-related antibodies were negative. Magnetic resonance imaging of the left arm showed high-intensity signal and thickness of the fascia without evidence of muscle or bone involvement. A muscular biopsy from the right deltoid showed thickening and inflammation of the fascia. The patient received intraveinous injections of 1000 mg of methylprednisolone for 3 days with an oral relay of 1 mg/kg per day of prednisone equivalent during 4 weeks. At one-month follow-up, a significant improvement of the skin induration and myalgia was observed, with a disappearance of the biological inflammatory syndrome. This brief report suggests a potential link between SARS-CoV-2 infection and new-onset of auto-immune fasciitis.

Smartphone-based evaluation of static balance and mobility in long-lasting COVID-19 patients

Background

SARS-CoV-2 infection can lead to a variety of persistent sequelae, collectively known as long COVID-19. Deficits in postural balance have been reported in patients several months after COVID-19 infection. The purpose of this study was to evaluate the static balance and balance of individuals with long COVID-19 using inertial sensors in smartphones.

Methods

A total of 73 participants were included in this study, of which 41 had long COVID-19 and 32 served as controls. All participants in the long COVID-19 group reported physical complaints for at least 7 months after SARS-CoV-2 infection. Participants were evaluated using a built-in inertial sensor of a smartphone attached to the low back, which recorded inertial signals during a static balance and mobility task (timed up and go test). The parameters of static balance and mobility obtained from both groups were compared.

Results

The groups were matched for age and BMI. Of the 41 participants in the long COVID-19 group, 22 reported balance impairment and 33 had impaired balance in the Sharpened Romberg test. Static balance assessment revealed that the long COVID-19 group had greater postural instability with both eyes open and closed than the control group. In the TUG test, the long COVID-19 group showed greater acceleration during the sit-to-stand transition compared to the control group.

Conclusion

The smartphone was feasible to identify losses in the balance motor control and mobility of patients with long-lasting symptomatic COVID-19 even after several months or years. Attention to the balance impairment experienced by these patients could help prevent falls and improve their quality of life, and the use of the smartphone can expand this monitoring for a broader population.

A clinical approach to the investigation and management of long COVID associated neuropathic pain

COVID-19 has been associated with a wide range of ongoing symptoms following recovery from the acute SARS-CoV-2 infection. Around one in three people with COVID-19 develop neurological symptoms with many reporting neuropathic pain and associated symptoms, including paraesthesia, numbness, and dysesthesia. Whilst the pathophysiology of long COVID-19-associated neuropathic pain remains unclear, it is likely to be multifactorial. Early identification, exclusion of common alternative causes, and a biopsychosocial approach to the management of the symptoms can help in relieving the burden of disease and improving the quality of life for patients.

Rhabdomyolysis in a patient with end-stage renal disease and SARS-CoV-2 infection: A case report

RATIONALE

Rhabdomyolysis can be an uncommon complication of coronavirus disease 2019 (COVID-19) infection. However, the diagnosis of rhabdomyolysis could be easily missed due to its atypical clinical presentations. We present a patient with a history of end-stage renal disease (ESRD) who contracted COVID-19 and subsequently developed rhabdomyolysis. We discuss and share our experience in the management of this patient.

PATIENT CONCERNS

An 85-year-old male with ESRD undergoing routine hemodialysis was tested positive for COVID-19. The patient had clinical symptoms of fatigue, muscle pain, and difficulty walking.

DIAGNOSIS

The serum creatine kinase (CK) level was markedly elevated to 32,492.9U/L, supporting the diagnosis of rhabdomyolysis. A computed tomography scan revealed muscle injuries throughout the body, confirming the diagnosis.

INTERVENTIONS

The patient was managed through electrolyte corrections and continuous renal replacement therapy.

OUTCOMES

Repeat tests showed decreased levels of serum CK and negative severe acute respiratory syndrome coronavirus 2. His clinical symptoms, including fatigue and muscle pain, had significantly improved.

LESSONS

COVID-19 infection can cause muscle pain and fatigue, which can mask the symptoms of rhabdomyolysis. A missed diagnosis of rhabdomyolysis can be severe, especially in patients with ESRD. The serum CK level should be tested with clinical suspicion. Appropriate management, including adequate hydration and electrolyte balance, should be provided. Continuous renal replacement therapy should be considered in affected patients with renal insufficiency.

Functional characterisation of the ACE2 orthologues in Drosophila provides insights into the neuromuscular complications of COVID-19

SARS-CoV-2, the virus responsible for the coronavirus disease of 2019 (COVID-19), gains cellular entry via interaction with the angiotensin-converting enzyme 2 (ACE2) receptor of host cells. Although SARS-CoV-2 mainly targets the respiratory system, the neuromuscular system also appears to be affected in a large percentage of patients with acute or chronic COVID-19. The cause of the well-described neuromuscular manifestations resulting from SARS-CoV-2 infection remains unresolved. These may result from the neuromuscular-invasive capacity of the virus leading to direct injury. Alternatively, they may be the consequence of ACE2 inactivation either due to viral infection, ACE2 autoantibodies or both. Here, we made use of the Drosophila model to investigate whether ACE2 downregulation is sufficient to induce neuromuscular phenotypes. We show that moderate gene silencing of ACE2 orthologues Ance or Ance3 diminished survival on exposure to thermal stress only upon induction of neuromuscular fatigue driven by increased physical activity. A strong knockdown of Ance or Ance3 directed to muscle reduced or abolished adult viability and caused obvious motoric deficits including reduced locomotion and impaired flight capacity. Selective knockdown of Ance and Ance3 in neurons caused wing defects and an age-dependent decline in motor behaviour, respectively, in adult flies. Interestingly, RNA sequencing allowed us to discover several differentially spliced genes that are required for synaptic function downstream of Ance or Ance3 depletion. Our findings are therefore supportive of the notion that loss of a RAS-independent function for ACE2 contributes to the neuromuscular manifestations associated with SARS-CoV-2 infection.

Persistent Dysphonia in Hospitalized COVID-19 Patients

INTRODUCTION

The main objective of this study is to estimate the prevalence of persistent dysphonia in hospitalised COVID-19 patients.

METHODS

Data were collected from those COVID-19 patients who, during the months of March to April 2020, were hospitalised in ward or intensive care unit at the University Hospital of Fuenlabrada. Patients with dysphonia prior to SARS-CoV-2 were excluded. Informed consent was obtained orally by a telephone call, as well as clinical and epidemiological data. Patients who reported persistent dysphonia were assessed using the Voice Handicap Index 10, the maximum phonation time, the s/z ratio and a fibrolaryngoscope examination. Patients who reported persistent dysphagia were assessed with the Eating Assessment Tool 10.

RESULTS

A total of 79 patients were included in the study (48 men and 31 women). 10 ICU patients (25%) and 4 ward patients (10,3%) had dysphonia at least 3 months after hospital discharge, but no association was found between ICU admission and the presence of persistent dysphonia (P = 0.139). Persistent dysphonia in patients admitted to the ICU is associated with persistent dysphagia (P = 0.002), also the age of patients with persistent dysphonia is significantly higher than the age of non-dysphonic patients (P = 0.046). The most frequent exploratory finding was vocal cord paresis/paralysis (60.4%).

CONCLUSION

This is one of the first studies to show that persistence of dysphonia may be a consequence of COVID-19, so further studies are needed to assess the evolution and prognosis of these patients and the possible association of dysphonia with the severity of the disease.

Persistent post-COVID-19 neuromuscular symptoms

Neuromuscular symptoms may develop or persist after resolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Besides residual sensorimotor symptoms associated with acute neuromuscular complications of coronavirus disease-2019 (COVID-19), such as Guillain-Barré syndrome, critical illness neuromyopathy, and rhabdomyolysis, patients may report persistent autonomic symptoms, sensory symptoms, and muscle symptoms in the absence of these acute complications, including palpitations, orthostatic dizziness and intolerance, paresthesia, myalgia, and fatigue. These symptoms may be associated with long COVID, also known as post-COVID-19 conditions or postacute sequelae of SARS-CoV-2 infection, which may significantly impact quality of life. Managing these symptoms represents a challenge for health-care providers. Recent advances have identified small-fiber neuropathy as a potential etiology that may underlie autonomic dysfunction and paresthesia in some long COVID patients. The pathogenic mechanisms underlying myalgia and fatigue remain elusive and need to be investigated. Herein we review the current state of knowledge regarding the evaluation and management of patients with persistent post-COVID-19 neuromuscular symptoms.

What Is the Impact of the Novel Coronavirus and the Vaccination on Guillain-Barre Syndrome?

The COVID-19 pandemic, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has resulted in devastating medical and economic consequences worldwide over the past 3 years. As the pandemic enters a new stage, it is essential to consider the potential impact on rare diseases such as Guillain-Barre syndrome (GBS), which has been intimately associated with COVID-19 since the first COVID-19-related GBS case was reported in January 2020. There are notable differences between COVID-19-related GBS and GBS without COVID-19 in terms of diagnostic types and clinical manifestations. Furthermore, with the widespread administration of COVID-19 vaccines, there have been reports of GBS occurring shortly after vaccination, which requires close attention despite its rarity. This review also explores the vaccines associated with heightened GBS risks, offering insights that may guide vaccination policies and clinical practice. To provide a visual summary of these findings, we have included a graphical abstract. This article will discuss the characteristic manifestations of GBS patients after being positive for the novel coronavirus and the safety of several COVID-19 vaccines. Firstly, this article comprehensively expounds and discusses the epidemiological aspects of novel coronavirus-related GBS. For example, from the perspective of the same population, the expected incidence of GBS in the COVID-19-positive population (persons/100,000 persons/ year) is about 43 times that of the COVID-19-negative population, and the incidence of GBS is significantly increased. Secondly, the clinical characteristics of COVID-19-negative GBS patients and SARS-CoV-2-GBS (SC2-GBS) patients were summarized and compared. Thirdly, this article reviews GBS cases in the current adverse events after COVID-19 vaccination and analyzes and discusses from multiple perspectives, such as the incidence of GBS events, the age proportion of patients, and the interval of onset.

Distinguishing COVID-19 from seasonal influenza in patients under age 65 years-a retrospective observational cohort study comparing the 2009 influenza A (H1N1) and 2022 SARS-CoV-2 pandemics

Introduction

This study explored the differences in clinical characteristics between the 2009 pandemic influenza A (H1N1) and SARS-CoV-2 BA.2 variant (Omicron) infections in patients younger than age 65 years, to improve identification of these diseases and better respond to the current epidemic.

Methods

Data from 127 patients with the 2009 pandemic influenza A (H1N1) diagnosed between May and July of 2009 and 3,265 patients with Omicron diagnosed between March and May of 2022 were collected. Using a 1:2 match based on age (difference <2 years), sex, and underlying diseases, data from 115 patients with the 2009 pandemic influenza A (H1N1) infection (H1N1 group) and 230 patients with SARS-CoV-2 Omicron BA.2 infection (Omicron group) were analyzed. The clinical manifestations were compared between the groups, logistic regression was performed to identify possible independent risk factors for each group, and multiple linear regression was used to analyze the factors predicting time for nucleic acid negativization (NAN).

Results

The median [interquartile range] age of the two groups was 21 [11, 26] years. Compared with the H1N1 group, the Omicron group had: lower white blood cell counts and C-reactive protein levels; less fever, nasal congestion, sore throat, cough, sputum, and headache; and more olfactory loss, muscle soreness, and lactate dehydrogenase (LDH) abnormalities. Patients in the Omicron group used fewer antibiotics and antiviral drugs, and the time for NAN was longer (17 [14,20] VS 4 [3,5] days, P<0.001). Logistic regression showed that fever, cough, headache, and increased white blood cell count were more strongly correlated with the H1N1 group, while muscle soreness and LDH abnormalities were more strongly correlated with the Omicron group. Fever (B 1.529, 95% confidence interval [0.149,2.909], P=0.030) significantly predicted a longer time for NAN in patients with Omicron.

Discussion

There are significant differences in clinical characteristics between SARS-CoV-2 Omicron infection and the 2009 pandemic influenza A (H1N1) infection. Recognition of these differences has important implications for clinical practice.

The Potential of Probiotics as Ingestible Adjuvants and Immune Modulators for Antiviral Immunity and Management of SARS-CoV-2 Infection and COVID-19

Probiotic bacteria are able to modulate general antiviral responsiveness, including barrier functionality and innate and adaptive immune responses. The COVID-19 pandemic, resulting from SARS-CoV-2 infection, has created a need to control and treat this viral infection and its ensuing immunopathology with a variety of approaches; one such approach may involve the administration of probiotic bacteria. As with most viral infections, its pathological responses are not fully driven by the virus, but are significantly contributed to by the host's immune response to viral infection. The potential adoption of probiotics in the treatment of COVID-19 will have to appreciate the fine line between inducing antiviral immunity without over-provoking immune inflammatory responses resulting in host-derived immunopathological tissue damage. Additionally, the effect exerted on the immune system by SARS-CoV-2 evasion strategies will also have to be considered when developing a robust response to this virus. This review will introduce the immunopathology of COVID-19 and the immunomodulatory effects of probiotic strains, and through their effects on a range of respiratory pathogens (IAV, SARS-CoV, RSV), as well as SARS-CoV-2, will culminate in a focus on how these bacteria can potentially manipulate both infectivity and immune responsiveness via barrier functionality and both innate and adaptive immunity. In conclusion, the harnessing of induction and augmentation of antiviral immunity via probiotics may not only act as an ingestible adjuvant, boosting immune responsiveness to SARS-CoV-2 infection at the level of barrier integrity and innate and adaptive immunity, but also act prophylactically to prevent infection and enhance protection afforded by current vaccine regimens.

CT findings in "Post-Covid": residua from acute pneumonia or "Post-Covid-ILD"?

The aim of this study was to evaluate if CT findings in patients with pulmonary Post Covid syndrome represent residua after acute pneumonia or if SARS-CoV 2 induces a true ILD. Consecutive patients with status post acute Covid-19 pneumonia and persisting pulmonary symptoms were enrolled. Inclusion criteria were availability of at least one chest CT performed in the acute phase and at least one chest CT performed at least 80 days after symptom onset. In both acute and chronic phase CTs 14 CT features as well as distribution and extent of opacifications were independently determined by two chest radiologists. Evolution of every single CT lesion over time was registered intraindividually for every patient. Moreover, lung abnormalities were automatically segmented using a pre-trained nnU-Net model and volume as well as density of parenchymal lesions were plotted over the entire course of disease including all available CTs. 29 patients (median age 59 years, IQR 8, 22 men) were enrolled. Follow-up period was 80-242 days (mean 134). 152/157 (97 %) lesions in the chronic phase CTs represented residua of lung pathology in the acute phase. Subjective and objective evaluation of serial CTs showed that CT abnormalities were stable in location and continuously decreasing in extent and density. The results of our study support the hypothesis that CT abnormalities in the chronic phase after Covid-19 pneumonia represent residua in terms of prolonged healing of acute infection. We did not find any evidence for a Post Covid ILD.

COVID-19-Triggered Acute Liver Failure and Rhabdomyolysis: A Case Report and Review of the Literature

COVID-19 is primarily known for its respiratory tract involvement, often leading to severe pneumonia and exacerbation of underlying diseases. However, emerging evidence suggests that COVID-19 can result in multiorgan failure, affecting organs beyond the respiratory system. We present the case of a 62-year-old male with COVID-19 who developed acute liver failure (ALF) and rhabdomyolysis in the absence of respiratory failure. Initially, the patient presented with significantly elevated aspartate transaminase (5398 U/L) and alanine transaminase (2197 U/L) levels. Furthermore, a prolonged prothrombin time international normalized ratio (INR) of 2.33 indicated the diagnosis of ALF without hepatic coma, according to Japanese diagnostic criteria. The patient also exhibited elevated creatine kinase (9498 U/L) and a mild increase in creatinine (1.25 mg/dL) levels, but both values improved with intravenous fluid support and molnupiravir administration. To our knowledge, this is the first reported case presenting with both ALF and rhabdomyolysis associated with COVID-19. In addition, we review the existing literature to summarize previously reported cases of ALF triggered by SARS-CoV-2. This case report underscores the significance of recognizing COVID-19 as a significant contributing factor in the development of multiorgan failure. Furthermore, it suggests that COVID-19 can lead to severe illness, irrespective of the absence of respiratory failure.

Pharmacological Proposal Approach to Managing Chronic Pain Associated with COVID-19

BACKGROUND

Post-COVID syndrome is widespread and chronic pain associated with this syndrome is increasingly being seen in pain clinics. Understanding and managing Chronic Post-COVID Pain (CPCoP) is essential in improving the quality of life of patients. Relevant sections: Identify the types of pain associated with post-COVID syndrome and look for ways to treat them.

RESULTS AND DISCUSSION

Based on our experience, we have identified five groups within CPCoP: (1) chronic pain post-hospitalization in intensive care or long hospitalizations, (2) pain associated with rehabilitation, (3) exacerbation of existing chronic pain pre-COVID-19 infection, (4) central and peripheral neuropathic pain post-COVID-19 infection, (5) chronic pain post vaccination. To fight against misinformation, we created an information capsule for doctors, nurses, and other health workers at a conference via the ECHO* program, delivered 2-3 times a year.

CONCLUSIONS

In pandemic and post-pandemic periods, it is important to determine the sequelae that a disease can leave in the general population, and to understand and treat them. The model proposed may serve as an inspiration to other pain centers to treat the increasing number of patients with CPCoP.

SARS-Cov-2 infection and neuropathological findings: a report of 18 cases and review of the literature

INTRODUCTION

COVID-19-infected patients harbour neurological symptoms such as stroke and anosmia, leading to the hypothesis that there is direct invasion of the central nervous system (CNS) by SARS-CoV-2. Several studies have reported the neuropathological examination of brain samples from patients who died from COVID-19. However, there is still sparse evidence of virus replication in the human brain, suggesting that neurologic symptoms could be related to mechanisms other than CNS infection by the virus. Our objective was to provide an extensive review of the literature on the neuropathological findings of postmortem brain samples from patients who died from COVID-19 and to report our own experience with 18 postmortem brain samples.

MATERIAL AND METHODS

We used microscopic examination, immunohistochemistry (using two different antibodies) and PCR-based techniques to describe the neuropathological findings and the presence of SARS-CoV-2 virus in postmortem brain samples. For comparison, similar techniques (IHC and PCR) were applied to the lung tissue samples for each patient from our cohort. The systematic literature review was conducted from the beginning of the pandemic in 2019 until June 1st, 2022.

RESULTS

In our cohort, the most common neuropathological findings were perivascular haemosiderin-laden macrophages and hypoxic-ischaemic changes in neurons, which were found in all cases (n = 18). Only one brain tissue sample harboured SARS-CoV-2 viral spike and nucleocapsid protein expression, while all brain cases harboured SARS-CoV-2 RNA positivity by PCR. A colocalization immunohistochemistry study revealed that SARS-CoV-2 antigens could be located in brain perivascular macrophages. The literature review highlighted that the most frequent neuropathological findings were ischaemic and haemorrhagic lesions, including hypoxic/ischaemic alterations. However, few studies have confirmed the presence of SARS-CoV-2 antigens in brain tissue samples.

CONCLUSION

This study highlighted the lack of specific neuropathological alterations in COVID-19-infected patients. There is still no evidence of neurotropism for SARS-CoV-2 in our cohort or in the literature.

Myasthenia Gravis Associated With COVID-19 Infection

COVID-19 first emerged in Wuhan, China in late December 2019. The disease majorly involves the lungs leading to various respiratory complications; however, neurological manifestations of the disease are also described in the literature. Here, we report a case of COVID-19-induced seronegative myasthenia gravis (MG). We discuss the cases of COVID-19 and MG already described in the literature in regard to their presentation and serological findings to better understand the association between the two disease processes. MG may be missed in patients after COVID-19 infections because of the comorbidities and anti-acetylcholine receptor and anti-muscle-specific tyrosine kinase antibodies being negative. Evidence from more studies will help analyze the pathological timeline of the disease process and the immunological characteristics of COVID-19-induced MG which can prove to have morbidity and mortality benefit in patients with COVID-19-induced MG.

COVID-19 infection with complicated fulminant myocarditis: a case report

Herein, we report the case of a young female patient who suffered from myositis and heart failure due to fulminant myocarditis induced by the 2019 coronavirus disease (COVID-19). After receiving intra-aortic balloon pump (IABP) and immunomodulatory treatment, her vital signs gradually stabilized and the IABP was removed. Cardiac and muscle magnetic resonance imaging confirmed extensive myocardial and skeletal muscle edema. Though it is not uncommon for COVID-19 infection to be complicated by myocarditis and myositis, such serious muscle injury warrants clinical vigilance.

Mapping peripheral and abdominal sarcopenia acquired in the acute phase of COVID-19 during 7 days of mechanical ventilation

Our aim was to map acquired peripheral and abdominal sarcopenia in mechanically ventilated adults with COVID-19 through ultrasound measurements. On Days 1, 3, 5 and 7 after admission to critical care, the muscle thickness and cross-sectional area of the quadriceps, rectus femoris, vastus intermedius, tibialis anterior, medial and lateral gastrocnemius, deltoid, biceps brachii, rectus abdominis, internal and external oblique, and transversus abdominis were measured using bedside ultrasound. A total of 5460 ultrasound images were analyzed from 30 patients (age: 59.8 ± 15.6 years; 70% men). Muscle thickness loss was found in the bilateral anterior tibial and medial gastrocnemius muscles (range 11.5-14.6%) between Days 1 and 3; in the bilateral quadriceps, rectus femoris, lateral gastrocnemius, deltoid, and biceps brachii (range 16.3-39.1%) between Days 1 and 5; in the internal oblique abdominal (25.9%) between Days 1 and 5; and in the rectus and transversus abdominis (29%) between Days 1 and 7. The cross-sectional area was reduced in the bilateral tibialis anterior and left biceps brachii (range 24.6-25.6%) between Days 1 and 5 and in the bilateral rectus femoris and right biceps brachii (range 22.9-27.7%) between Days 1 and 7. These findings indicate that the peripheral and abdominal muscle loss is progressive during the first week of mechanical ventilation and is significantly higher in the lower limbs, left quadriceps and right rectus femoris muscles in critically ill patients with COVID-19.

Quantitative assessment of the effect of SARS-CoV-2 on the corneal sub-basal nerve plexus of post-COVID-19 patients using in vivo confocal microscopy

OBJECTIVES

To investigate whether SARS-CoV-2 causes morphological changes in the corneal sub-basal nerve plexus (CSNP) of post-COVID-19 patients using in vivo confocal microscopy (IVCM).

METHODS

A total of 70 participants were included in the study and were divided into three groups. Post-COVID-19 patients with neurological manifestations were considered Group 1 (n = 24), and post-COVID-19 patients without neurological manifestations were considered Group 2 (n = 24). Healthy control participants were considered Group 3 (n = 22). The parameters of the CSNP, including nerve fibre density (NFD), nerve branch density (NBD), and nerve fibre length (NFL), were investigated in all participants using IVCM. Additionally, corneal sensitivity was tested by corneal esthesiometry.

RESULTS

The mean NFD, NBD, and NFL values of Group 1 (16.12 ± 4.84 fibre/mm², 27.97 ± 9.62 branch/mm², and 11.60 ± 2.89 mm/mm²) were significantly lower than those of Group 2 (19.55 ± 3.01 fibre/mm², 40.44 ± 7.16 branch/mm², and 15.92 ± 2.08 mm/mm²) and Group 3 (25.24 ± 3.75 fibre/mm², 44.61 ± 11.80 branch/mm², and 17.76 ± 3.32 mm/mm²) (p < 0.05 for all). Except the mean NFD value (p < 0.001), there were no significant differences in terms of the mean NBD and NFL values between Group 2 and Group 3 (p = 0.445, p = 0.085). The value of the mean corneal sensitivity was significantly higher in Group 3 (59.09 ± 1.97 mm) compared to Group 1 (55.21 ± 1.02 mm) and Group 2 (55.28 ± 1.18 mm) (p < 0.001, p < 0.001) but there was no significant difference between Group 1 and Group 2 (p = 1.000).

CONCLUSION

In post-COVID-19 patients, the mean parameters of CSNP were lower than in the control group. These differences were more pronounced in patients who had neurological manifestations of COVID-19.

Ultrasound-based neuropathy diagnosis in COVID-19 patients in post-intensive care rehabilitation settings. A retrospective observational study

OBJECTIVES

using ultrasound scanning to examine the correlation between increase of Common Fibular Nerve's (CFN) Cross Sectional Area (CSA) and functional impairment of foot dorsiflexor muscles as an early sign of peripheral neuropathy.

DESIGN

retrospective observational study.

SETTING

in-patient rehabilitation unit between November 2020 and July 2021.

PARTICIPANTS

26 inpatients who underwent prolonged hospitilization in ICU'S and were diagnosed with CRYMINE after SARS-COV-2 infection. Physical examination and ultrasound scanning of the CFN and EMG/ENG were carried out on each patient.

INTERVENTIONS

not applicable MAIN OUTCOME MEASURE(S): CFN's CSA at the peroneal head.

RESULTS

we verified a significant increase in the CSA of the CFN measured at the peroneal head in more than 90% of the nerves tested. A cut off value of CFN's CSA of 0,20 cm was used to identify pathological nerves. No correlations with other variables (BMI, ICU days) were found.

CONCLUSION

US scanning of the CFN appears to be an early and specific test in the evaluation of CPN's abnormalities in post COVID-19 patients. US scanning is a reproducible, cost effective, safe and easily administered bedside tool to diagnose a loss of motor function when abnormalities in peripheral nerves are present.

Comparing the Clinical Manifestations of Bell's Palsy between Pre-COVID-19 Pandemic and COVID-19 Pandemic Periods

BACKGROUND

COVID-19 has been shown to affect the onset and severity of various diseases. We examined whether the clinical characteristics of Bell's palsy differed between before and during the COVID-19 pandemic.

METHODS

From January 2005 to December 2021, 1839 patients were diagnosed and treated for Bell's palsy at Kyung Hee University Hospital. These patients were divided into a pre-COVID period group and COVID-19 period group, and the clinical characteristics of the two groups were compared.

RESULTS

There were 1719 patients in the pre-COVID period group and 120 patients in the COVID-19 period group. There were no between-group differences in sex (p = 0.103) or in the presence of underlying hypertension (p = 0.632) or diabetes (p = 0.807). Regarding symptoms, there were no significant between-group differences in otalgia, dizziness, tinnitus, hyperacusis, or hearing loss (p = 0.304, p = 0.59, p = 0.351, p = 0.605, and p = 0.949). There were also no significant between-group differences in electroneurography results (p = 0.398), electromyography results (p = 0.331), House-Brackmann Grade at visit (p = 0.634), or recovery rate after treatment (p = 0.525).

CONCLUSIONS

Contrary to our expectation that Bell's palsy cases during the COVID-19 pandemic would show different clinical features than those occurring before COVID-19, the present study found no differences in clinical features or prognosis.

Rare case of anti-CV2 paraneoplastic polyneuropathy associated with lung adenocarcinoma

We describe the first case of anti-CV2 paraneoplastic polyneuropathy associated with lung adenocarcinoma. Our patient presented with progressive unsteadiness and numbness involving bilateral upper and lower limbs. He had symmetrical length-dependent lower motor neuron pattern of weakness and numbness involving both small and large fibres with prominent sensory ataxia. An extended workup for the polyneuropathy involving a serum paraneoplastic antineuronal antibody panel showed a positive reaction for anti-CV2 antibody. CT scan of the thorax, abdomen and pelvis revealed a right upper lung nodule and histopathological examination of the nodule revealed lung adenocarcinoma. He was scheduled for chemotherapy following his discharge and there was improvement of his sensorimotor polyneuropathy following his chemotherapy.

SARCOPENIA IS A FREQUENT DISEASE IN SARS-COV-2 INFECTION

Objective

We aimed to investigate the clinical symptoms and specific care requirements of SARS-CoV-2 patients who were admitted to a COVID-19 Rehabilitation Unit while still infectious for SARS-CoV-2 and in the subacute phase of the disease.

Methods

Patients admitted to our COVID-19 Rehabilitation Unit from March 2020 to December 2020 were evaluated for sarcopenia, and they also completed the following assessments: functional independence measure, short physical performance battery and Hamilton Rating Scale for Depression. Age and body mass index and symptoms of dysosmia or dysgeusia were also recorded.

Results

A total of 126 patients were enrolled (50 women, median age 72 years, 18.7 years), of whom 82% of patients presented with low grip strength. Sarcopenia was diagnosed in 52 patients. Sarcopenic patients were older than non-sarcopenic ones (median age 73.4 years, IQR 13.2 vs 63.9 years, IQR 14.5, respectively, p = 0.014). Sarcopenia was associated with the presence of depression (p = 0.008), was more common in women (p = 0.023) and was associated with greater functional deficits (functional independence measure and short physical performance battery analyses, p < 0.05). Sarcopenic patients also had a lower body mass index than other patients (p < 0.01).

Conclusion

More than 40% of our patients suffered from sarcopenia, which was associated with ageing, depression, low body mass index, reduction in functional autonomy and being a woman. Such data provide evidence for the need to assist hospitalized COVID-19 patients by means of a multidisciplinary specialist team.

Graphene Oxide Decreases Pro-Inflammatory Proteins Production in Skeletal Muscle Cells Exposed to SARS-CoV-2 Spike Protein

Aim

The experiments aimed to document the presence of the ACE2 receptor on human muscle cells and the effects of the interaction of these cells with the spike protein of the SARS-CoV-2 virus in terms of induction of pro-inflammatory proteins, as well as to assess the possibility of reducing the pool of these proteins with the use of graphene oxide (GO) flakes.

Methods

Human Skeletal Myoblast (HSkM), purchased from Gibco were maintained in standard condition according to the manufacturer's instruction. The cells were divided into 4 groups; 1. C-control, 2. S-with addition of spike protein, 3. GO-with the addition of graphene oxide, 4. GO-S-with addition of GO followed by the addition of S protein. Protein S (PX-COV-P049) was purchased from ProteoGenix (France). GO was obtained from Advanced Graphene Products (Zielona Gora, Poland). The influence of all the factors on the morphology of cells was investigated using light and confocal microscopy. ACE2 protein expression on muscle cells was visualized and 40 pro-inflammatory cytokines were investigated using the membrane antibody array method. The protein profile of the lysate of cells from individual groups was also analyzed by mass spectrometry.

Conclusion

The experiments confirmed the presence of the ACE2 receptor in human skeletal muscle cells. It has also been documented that the SARS-CoV-2 virus spike protein influences the activation of selected pro-inflammatory proteins that promote cytokine storm and oxidative stress in muscle cells. The use of low levels of graphene oxide does not adversely affect muscle cells, reducing the levels of most proteins, including pro-inflammatory proteins. It can be assumed that GO may support anti-inflammatory therapy in muscles by scavenging proteins that activate cytokine storm.

Acute Phrenic Neuropathy and Diaphragmatic Dysfunction as a Complication of COVID-19: A Report of Four Cases

Among the neurological manifestations associated with coronavirus disease 2019 (COVID-19), neuropathies are rare. They have been associated with prolonged prostration and metabolic failure in a seriously ill patient. We present a case series of four Mexican patients diagnosed with diaphragmatic dysfunction due to phrenic neuropathy during acute COVID-19, documented by conduction velocities of the phrenic nerves. Blood tests, chest computed tomography (CT), and nerve conduction velocities of the phrenic nerves were performed. COVID-19 patients with phrenic nerve neuropathy represent a therapeutic challenge since they have high oxygen requirements due to the malfunction of ventilatory mechanics secondary to neuromuscular damage, as well as the damage that pneumonia generates in lung tissue. We confirm and extend the neurological manifestations of COVID-19, the impact on the neuromuscular dysfunction of the diaphragm, and its consequences such as the difficulty of weaning from mechanical ventilation.

Natural Course of Muscular Strength, Physical Performance, and Musculoskeletal Symptoms in Hospitalized Patients With COVID-19

OBJECTIVE

To investigate the course of muscle strength, musculoskeletal symptoms and physical performance over time in hospitalized COVID-19 patients, and their relation with disease severity at admission.

DESIGN

Prospective cohort study.

SETTING

Pandemic clinic of Gazi University Hospital, Ankara, Turkey.

PARTICIPANTS

76 adult COVID-19 patients (aged >18 years) were enrolled in the study between March 2021 and May 2021 (N=76). The participants were grouped as "mild," "moderate," and "severe" according to clinical and radiological findings.

MAIN OUTCOME MEASURES

The fraction of inspired oxygen (FiO₂), oxygen saturation (SpO₂), hand grip strength (HGS), 5-times sit and stand test (5XSTS), modified Borg scale at rest (mBorg-rest), modified Borg scale during activities of daily living (mBorg-ADL), Barthel index, and visual analog scale for myalgia (myalgia-VAS) values were recorded on the first day of hospitalization and in the first, third, and 12th weeks. Outcome measures were compared between disease severity groups. In addition, the changes in these outcome measures over time were also examined.

RESULTS

There were 15 (19.7%) participants in the mild, 20 (26.3%) in the moderate, and 41 (53.9%) in the severe groups. At the baseline evaluation, SpO₂ (P<.001), FiO₂ (P<.001), 5XSTS (P=.002), mBorg-rest (P=.016), and mBorg-ADL (P<.001) were different in 3 groups, but there were no differences for HGS, Barthel index, and myalgia-VAS score. HGS, 5XSTS, myalgia-VAS, and mBorg-ADL scores improved significantly over time in all the groups (P<.001, P≤.001, and P<.001, respectively). At the end of 12 weeks, only 5XSTS was different between the groups. 5XSTS was significantly longer in the severe group (P=.010).

CONCLUSION

Although significant improvement was observed in the muscle strength, physical performance, and musculoskeletal symptoms of patients with COVID-19 over time, the physical performance of these patients did not reach normal standards. We conclude that post-COVID-19 rehabilitation programs are needed to optimize the physical performance of the patients.

Elevated plasma CAF22 are incompletely restored six months after COVID-19 infection in older men

INTRODUCTION

The long-term complications of COVID-19 appear as significant health problems. However, the long-term muscle decline in these patients is poorly characterized.

METHODS

We investigated the age-related muscle decline, termed sarcopenia, before and following the COVID-19 infection in older male patients (n = 87). We evaluated handgrip strength (HGS) and functional capacity (short physical performance battery; SPPB) in COVID-19 patients 7-42 days before and one week and 6-month after COVID-19 infection. We used ELISA tests to measure plasma c-terminal agrin fragment-22 (CAF22), c-reactive protein (CRP), and 8-isoprostanes as markers of degraded neuromuscular junctions, inflammation, and oxidative stress, respectively.

RESULTS

Before the COVID-19 infection, 54 patients were non-sarcopenic, and 25 patients were sarcopenic, while eight patients subsequently developed sarcopenia. All patients exhibited reduced HGS and SPPB, while elevated CAF22, CRP, and 8-isoprostane levels one week post-COVID-19 infection (all p < 0.05). At six months post-COVID-19 infection, the HGS, SPPB, CAF22, CRP, and 8-isoprostanes were partly restored to baseline levels (all p < 0.05). Correlation analysis revealed that the plasma CAF22 had a significant correlation with HGS, SPPB, and COVID-19 disease severity. CAF22 also demonstrated significant areas under the curves in diagnosing sarcopenia at all three time-points.

CONCLUSION

Altogether, the muscle detriment due to COVID-19 persists six months post-infection, and plasma CAF22 may be helpful to detect muscle and functional decline in these patients. Timely evaluation and intervention of sarcopenia may be critical in COVID-19 treatment.

Acute Myositis in a Pregnant Woman Complicated With COVID-19 and Hyperemesis Gravidarum: A Case Report

Myalgia is the most frequently reported neuromuscular symptom in COVID-19 patients, with a frequency of around 20% in pregnant women. Acute myositis due to COVID-19 is severe and requires medical intervention. There have been some reports of acute myositis due to COVID-19, mostly in elderly men, but rarely in pregnant women. Here we report a case of a pregnant woman who was diagnosed with acute myositis following COVID-19 illness early in her pregnancy. She had been affected by morning sickness since the 6th week of gestation and was diagnosed with COVID-19 at the 12th week. Muscle pain appeared in her limbs 5 days after the diagnosis of COVID-19, with a predominance of pain in the lower limbs, and her gait gradually became unstable. We concluded that it was acute myositis complicated by COVID-19 and hypokalemia, but we could not determine whether hypokalemia or COVID-19 or both were the cause of the muscle damage in this case. Pregnant women diagnosed with COVID-19 often complain of myalgia and fatigue, and when a pregnant woman's symptoms are severe we should keep in mind that they may be suffering from muscle damage that needs medical intervention.

Necrotizing autoimmune myositis following coronavirus disease 2019 infection: a case report

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 may be associated with late-onset necrotizing myositis, mimicking autoimmune inflammatory myositis; however, the exact underlying pathogenesis of severe acute respiratory syndrome coronavirus 2-induced myositis is still unclear.

CASE PRESENTATION

Herein, we report a rare case of necrotizing autoimmune myositis in a 67-year-old middle eastern male following coronavirus disease 2019 infection, who presented with muscle weakness. The patient had positive anti-NXP2. The diagnosis of necrotizing autoimmune myositis was made according to muscle weakness, increased liver enzymes, electromyography and nerve conduction velocity results, and muscle biopsy. The patient underwent a full malignancy evaluation, which was unremarkable, and was discharged in relatively well condition with a daily dose of 1 mg/kg prednisolone and azathioprine 150 mg (2 mg/kg).

CONCLUSION

Our report highlights the already known possible protracted sequence of coronavirus disease 2019 infection and the potential for delayed-onset necrotizing myositis.

COVID-19 Still Surprising Us-A Rare Movement Disorder Induced by Infection

BACKGROUND

Many neurological manifestations are part of COVID-19 infections, including movement disorders, but a clinical picture closely resembling stiff-person syndrome has not yet been described.

CASE PRESENTATION

We report a case of a stiff-person-like syndrome in the context of COVID-19 infection. A 79-year-old woman, with no prior history of diseases, presented global reversible stiffness associated with SARS-CoV-2 infection. We aim to shed light on several particularities regarding this clinical picture and its evolution in close relationship with the infectious disease progression, with full regression of symptoms and signs once the infectious process ceased. The impairment of speech and motility caused the wrong diagnosis of stroke in the Emergency Room. In addition, we would also like to emphasize the concomitant rhabdomyolysis, closely linked to the grade of muscle rigidity.

CONCLUSIONS

We would like to raise awareness regarding this clinical setting and its association with SARS-COV-2 infection, to aid in its future recognition and management. To our knowledge, this is the first case of a stiff-person-like syndrome to be described in association with COVID-19 infection.

Dysphonia Severity Index and Consensus Auditory-Perceptual Evaluation of Voice Outcomes, and Their Relation in Hospitalized Patients with COVID-19

OBJECTIVES

This study aimed to compare the results of the Dysphonia Severity Index (DSI) and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) between patients hospitalized with COVID-19 and healthy subjects, as well as to investigate the correlation between DSI and CAPE-V.

STUDY DESIGN

Cross-sectional survey.

MATERIAL AND METHODS

Eighty subjects, 40 COVID-19 patients (with a mean age of 41.2± 5.41) and 40 healthy subjects (with a mean age of 44.50± 3.50) participated in this study. Assessments included the DSI for aerodynamic-acoustic measurement and the Persian version of Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) for evaluating auditory-perceptual voice quality. Data were analyzed by means of the independent t-test and Pearson correlation at the 5% significance level.

RESULTS

The results showed COVID-19 patients got significantly lower score in DSI compared to healthy subjects (P < 0.05). Moreover, the patients with COVID-19 had higher scores in all categories of voice production (severity, roughness, loudness, pitch, strain and breathiness) than the healthy group (P < 0.05). Comparing the result of the two voice assessments in each group revealed that there was a greater negative significant correlation in the diseased group (r p: -0.68, P: 0.001) than in the healthy group (r p: -0.37,P: 0.049).

CONCLUSIONS

Hospitalized COVID-19 patients experience deviations in the voice quality and acoustic-aerodynamic features of their voice. Also, the results of this study showed the patient group had higher perceptual dysphonia and lower voice quality compared to the healthy group. Further studies are recommended to determine the relationship between objective and subjective voice evaluation in patients with COVID-19 after recovery.

New-Onset Myasthenia Gravis Confirmed by Electrodiagnostic Studies After a Third Dose of SARS-CoV-2 mRNA-1273 Vaccine

ABSTRACT

Coronavirus disease 2019 vaccine-related pathology is a rare occurrence with few reported cases. We report on a case of a 60-yr-old man experiencing symptoms of dysphagia, dysarthria, diplopia, and weakness with onset 6 days after receiving a third full dose of SARS-CoV-2 vaccine (mRNA-1273 vaccine) in August 2021, which he received outside of the Center for Disease Control recommended guidelines, at 4 mos after his second dose of the Moderna vaccination course in March 2021. The Food and Drug Administration Emergency Use Authorization for mRNA-1273 booster was established in October 2021.Over the next month, the patient's symptoms progressed including his inability to swallow, requiring hospitalization due to dehydration and malnutrition. Evaluation including laboratory prompted referral for electrodiagnostic studies consisting of repetitive nerve stimulation studies and needle electromyography, confirming a case of new onset bulbar myasthenia gravis.

Intra- and Inter-Rater Reliability and Agreement of Ultrasound Imaging of Muscle Architecture and Patellar Tendon in Post-COVID-19 Patients Who Had Experienced Moderate or Severe COVID-19 Infection

COVID-19 is associated with musculoskeletal disorders. Ultrasound is a tool to assess muscle architecture and tendon measurements, offering an idea of the proportion of the consequences of the disease, since significant changes directly reflect the reduction in the ability to produce force and, consequently, in the functionality of the patient; however, its application in post-COVID-19 infection needs to be determined. We aimed to assess the intra- and inter-rater reliability of ultrasound measures of the architecture of the vastus lateralis (VL), rectus femoris (RF), vastus medialis (VM), gastrocnemius lateralis (GL), gastrocnemius medialis (GM), soleus (SO), and tibialis anterior (TA) muscles, as well as the patellar tendon (PT) cross-sectional area (CSA) in post-COVID-19 patients. An observational, prospective study with repeated measures was designed to evaluate 20 post-COVID-19 patients, who were measured for the pennation angle (θp), fascicular length (Lf), thickness, echogenicity of muscles, CSA and echogenicity of the PT. The intra-class correlation coefficient (ICC) and 95% limits of agreement were used. The intra-rater reliability presented high or very high correlations (ICC = 0.71-1.0) for most measures, except the θp of the TA, which was classified as moderate (ICC = 0.69). Observing the inter-rater reliability, all the evaluations of the PT, thickness and echogenicity of the muscles presented high or very high correlations. For the Lf, only the RF showed as low (ICC = 0.43), for the θp, RF (ICC = 0.68), GL (ICC = 0.70) and TA (ICC = 0.71) moderate and the SO (ICC = 0.40) low. The ultrasound reliability was acceptable for the muscle architecture, muscle and tendon echogenicity, and PT CSA, despite the low reliability for the Lf and θp of the RF and SO, respectively.

Diaphragmatic paralysis post COVID-19 treated with robot-assisted plication reinforced with acellular dermal matrix: a report of two cases

Coronavirus disease 2019 (COVID-19) continues to be a disease of global importance, with an increasing array of sequelae attributed to infection by the severe acute respiratory syndrome coronavirus-2. One such complication that has been rarely documented thus far is diaphragmatic dysfunction. Here, we report the cases of 2 individuals who developed diaphragmatic paralysis post COVID-19, which failed to respond to conservative management. Both patients proceeded to undergo robot-assisted thoracoscopic plication of the diaphragm reinforced with a bovine acellular dermal matrix. In both cases, there was significant improvement in symptomatology, namely dyspnoea and fatigue. We conclude that robot-assisted diaphragmatic plication should be considered for the treatment of refractory diaphragmatic paralysis post COVID-19.

Cranial Nerve Impairment Associated With COVID-19 Infections: A Systematic Review

The COVID-19 pandemic has created huge economic and healthcare burdens. In most cases, the virus affects the lungs and causes respiratory symptoms. Additionally, its impact on the cranial nerves remains unclear. We thus aimed to investigate cranial nerve dysfunction in patients with COVID-19 infection.  We conducted a systematic literature search of relevant and eligible literature in five databases: PubMed, Web of Science, Medline, EBSCO, and Google Scholar.  Our sample included 21 case reports, one case series with 29 patients, and one analytical study with 135 cases. Participant ages ranged from 23 months to 72 years (mean age of 47.5 ± 19.02). The mean time from respiratory symptoms to the onset of neurological signs was (9.6 ± 7.4) days, and the mean recovery time was (16.3 ± 15.3) days.  Cranial nerve impairment associated with COVID-19 infection has affected a large population, from infants to the elderly. Facial and abducent nerves were the most commonly affected cranial nerves with reported good prognosis or complete recovery within a few days to weeks. Olfactory dysfunctions were widely detected among COVID-19 patients.

Facial palsy as a manifestation of COVID-19: A systematic review of cases

Background and Aims

Facial palsy is a rare complication of the COVID-19 infection. Herein, we conducted a systematic review of all published cases of facial palsy post-COVID-19 infection in an attempt to educate the general population and medical practitioners regarding the likely occurrence of facial palsy in COVID-19 patients, its detection, effective treatment plan, and prognosis of the condition.

Methods

We searched PubMed, Google Scholar, and Directory of Open Access Journals (DOAJ) from December 1, 2019 to September 21, 2021.

Results

We included 49 studies bearing accounts of 75 cases who had facial palsy. The mean age of patients was 42.9 ± 19.59 years, with a male-to-female ratio of 8:7. The majority of the cases were reported from Brazil (n = 14), USA (n = 9), Turkey (n = 9), and Spain (n = 9). Noticeably, 30.14% of COVID-19 patients were diagnosed with Guillain-Barré syndrome. In total, 22.97% of patients complained of bilateral facial paralysis (n = 17), whereas ipsilateral paralysis was observed in 77.03% (n = 57). These were common complaints of Lagophthalmos, otalgia, facial drooping, dysarthria, and compromised forehead wrinkling. The treatment regimen mainly included the use of corticosteroids (n = 51) (69.86%), antivirals (n = 23) (31.51%), IVIG (n = 18) (24.66%), antibiotics (n = 13) (17.81%), antiretroviral (n = 9) (12.33%), and antimalarial (n = 8) (10.96%) medications. In all, 35.62% of patients (n = 26) adhered to a combination of antiviral and corticosteroid-based therapy. Positive treatment outcomes were observed in 83.58% (n = 56) of cases. In contrast, 10 patients (14.93%) showed nonsignificant recovery, out of which 3 (4.48%) died from the disease.

Conclusion

The association of facial palsy with COVID-19 is controversial and therefore requires further investigation and published work to confirm a causal relationship. However, physicians should not overlook the likelihood of facial palsy post-COVID-19 infection and treat it accordingly.

High-resolution ultrasound of peripheral neuropathies in rheumatological patients: An overview of clinical applications and imaging findings

Peripheral neuropathies are surprisingly common and can be associated with a number of conditions, including rheumatological diseases. Whether the co-existence of peripheral neuropathies with rheumatological disorders is coincidental or related to a common pathogenic mechanism, these disabling conditions can affect the outcome of rheumatological patients and should be targeted with specific treatment. The clinical presentation of peripheral neuropathy can be multifaceted and difficult to recognize in polysymptomatic patients. However, physicians adopting state-of-art diagnostic strategies, including nerve imaging, may improve the detection rate and management of neuropathies. In particular, a diagnostic approach relying exclusively on clinical history and nerve conduction studies may not be sufficient to disclose the etiology of the nerve damage and its anatomical location and thus requires integration with morphological studies. High-Resolution Ultrasound (HRUS) is increasingly adopted to support the diagnosis and follow-up of both joint disorders in rheumatology and peripheral neuropathies of different etiologies. In this review, the different types of nerve disorders associated with the most common syndromes of rheumatological interest are discussed, focusing on the distinctive sonographic features.

Osteosarcopenia and Long-COVID: a dangerous combination

SARS-CoV-2 has caused a global pandemic and an unprecedented public health crisis, infecting more than 580 million people worldwide. Moreover, recent evidence has suggested the emergence of a new syndrome known as Long-COVID, a term used to describe a diverse set of physical and mental symptoms that persist after a diagnosed SARS-CoV-2 infection. Epidemiological data have identified myalgias, muscle and joint dysfunction, and bone fragility as common sequelae in patients with moderate and severe forms of this disease. Significant musculoskeletal dysfunction has also been detected in some healed patients, although knowledge about pathophysiological mechanisms of Long-COVID is still rather scarce. In this context, SARS-CoV-2 infection has been suggested to amplify the effects of aging on the musculoskeletal system by aggravating the osteosarcopenic state. Based on this evidence, our review focused on the muscle and bone tissue alterations induced by SARS-CoV-2 infection and Long-COVID, summarizing the current knowledge on the underlying biological mechanisms and highlighting the need for a multidisciplinary approach to predict the musculoskeletal targets and long-term consequences of COVID-19 disease.

Post-COVID-19 Myositis Based on Magnetic Resonance Imaging: A Case Report

The severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) causes COVID-19, which is known to cause fever, dry cough, exhaustion, headache, and loss of taste and smell. Although fever, sore throat, and cough have historically been the utmost characteristic symptoms of the illness, published case reports have recently started to emphasize additional uncommon and unusual presentations of infection with the coronavirus. In COVID, the musculoskeletal system is seldomly involved. In addition to reviewing the causes and imaging characteristics of COVID-19-related illnesses of the musculoskeletal system, we elaborate on a case of a middle-aged man who developed myositis as sequelae to the COVID-19 infection.

Eccentric Training in Pulmonary Rehabilitation of Post-COVID-19 Patients: An Alternative for Improving the Functional Capacity, Inflammation, and Oxidative Stress

The purpose of this narrative review is to highlight the oxidative stress induced in COVID-19 patients (SARS-CoV-2 infection), describe longstanding functional impairments, and provide the pathophysiologic rationale that supports aerobic eccentric (ECC) exercise as a novel alternative to conventional concentric (CONC) exercise for post-COVID-19 patients. Patients who recovered from moderate-to-severe COVID-19 respiratory distress demonstrate long-term functional impairment. During the acute phase, SARS-CoV-2 induces the generation of reactive oxygen species that can be amplified to a "cytokine storm". The resultant inflammatory and oxidative stress process causes organ damage, particularly in the respiratory system, with the lungs as the tissues most susceptible to injury. The acute illness often requires a long-term hospital stay and consequent sarcopenia. Upon discharge, muscle weakness compounded by limited lung and cardiac function is often accompanied by dyspnea, myalgia, anxiety, depression, and sleep disturbance. Consequently, these patients could benefit from pulmonary rehabilitation (PR), with exercise as a critical intervention (including sessions of strength and endurance or aerobic exercises). Unfortunately, conventional CONC exercises induce significant cardiopulmonary stress and increase inflammatory and oxidative stress (OS) when performed at moderate/high intensity, which can exacerbate debilitating dyspnoea and muscle fatigue post-COVID-19. Eccentric training (ECC) is a well-tolerated alternative that improves muscle mass while mitigating cardiopulmonary stress in patients with COPD and other chronic diseases. Similar benefits could be realized in post-COVID-19 patients. Consequently, these patients could benefit from PR with exercise as a critical intervention.