Syncope as the presenting symptom of COVID-19 infection

Application of in-silico drug discovery techniques to discover a novel hit for target-specific inhibition of SARS-CoV-2 Mpro's revealed allosteric binding with MAO-B receptor: A theoretical study to find a cure for post-covid neurological disorder

Several studies have revealed that SARS-CoV-2 damages brain function and produces significant neurological disability. The SARS-CoV-2 coronavirus, which causes COVID-19, may infect the heart, kidneys, and brain. Recent research suggests that monoamine oxidase B (MAO-B) may be involved in metabolomics variations in delirium-prone individuals and severe SARS-CoV-2 infection. In light of this situation, we have employed a variety of computational to develop suitable QSAR model using PyDescriptor and genetic algorithm-multilinear regression (GA-MLR) models (R2 = 0.800-793, Q2LOO = 0.734-0.727, and so on) on the data set of 106 molecules whose anti-SARS-CoV-2 activity was empirically determined. QSAR models generated follow OECD standards and are predictive. QSAR model descriptors were also observed in x-ray-resolved structures. After developing a QSAR model, we did a QSAR-based virtual screening on an in-house database of 200 compounds and found a potential hit molecule. The new hit's docking score (-8.208 kcal/mol) and PIC50 (7.85 M) demonstrated a significant affinity for SARS-CoV-2's main protease. Based on post-covid neurodegenerative episodes in Alzheimer's and Parkinson's-like disorders and MAO-B's role in neurodegeneration, the initially disclosed hit for the SARS-CoV-2 main protease was repurposed against the MAO-B receptor using receptor-based molecular docking, which yielded a docking score of -12.0 kcal/mol. This shows that the compound that inhibits SARS-CoV-2's primary protease may bind allosterically to the MAO-B receptor. We then did molecular dynamic simulations and MMGBSA tests to confirm molecular docking analyses and quantify binding free energy. The drug-receptor complex was stable during the 150-ns MD simulation. The first computational effort to show in-silico inhibition of SARS-CoV-2 Mpro and allosteric interaction of novel inhibitors with MAO-B in post-covid neurodegenerative symptoms and other disorders. The current study seeks a novel compound that inhibits SAR's COV-2 Mpro and perhaps binds MAO-B allosterically. Thus, this study will enable scientists design a new SARS-CoV-2 Mpro that inhibits the MAO-B receptor to treat post-covid neurological illness.

Prevalence of symptoms in 1512 COVID-19 patients: have dizziness and vertigo been underestimated thus far?

The relationship between SARS-CoV-2 infection and dizziness is still unclear. The aim of this study is to assess the prevalence and characteristics of dizziness and vertigo among patients with mild-to-moderate COVID-19. Patients discharged from the emergency rooms with a confirmed SARS-CoV-2 diagnosis were assisted by daily telephone calls until nasopharyngeal swab negativization, and specific symptoms concerning balance disorders were investigated through targeted questions posed by experienced physicians. The study included 1512 subjects (765 females, 747 males), with a median age of 51 ± 18.4 years. New-onset dizziness was reported by 251 (16.6%) patients, among whom 110 (43.8%) complained of lightheadedness, 70 (27.9%) of disequilibrium, 41 (16.3%) of presyncope, and 30 (12%) of vertigo. This study analyzed in detail the prevalence and pathophysiological mechanisms of the different types of balance disorders in a large sample, and the results suggest that dizziness should be included among the main symptoms of COVID-19 because one-sixth of patients reported this symptom, with females being significantly more affected than males (20.3 vs 12.9%, P < 0.001). Most cases of dizziness were attributable to lightheadedness, which was probably exacerbated by psychophysical stress following acute infection and mandatory quarantine. Vertigo should not be underestimated because it might underlie serious vestibular disorders, and disequilibrium in elderly individuals should be monitored due to the possible risk of falls.

Molecular mechanisms highlighting the potential role of COVID-19 in the development of neurodegenerative diseases

Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In addition to the pulmonary manifestations, COVID-19 patients may present a wide range of neurological disorders as extrapulmonary presentations. In this view, several studies have recently documented the worsening of neurological symptoms within COVID-19 morbidity in patients previously diagnosed with neurodegenerative diseases (NDs). Moreover, several cases have also been reported in which the patients presented parkinsonian features after initial COVID-19 symptoms. These data raise a major concern about the possibility of communication between SARS-CoV-2 infection and the initiation and/or worsening of NDs. In this review, we have collected compelling evidence suggesting SARS-CoV-2, as an environmental factor, may be capable of developing NDs. In this respect, the possible links between SARS-CoV-2 infection and molecular pathways related to most NDs and the pathophysiological mechanisms of the NDs such as Alzheimer's disease, vascular dementia, frontotemporal dementia, Parkinson's disease, and amyotrophic lateral sclerosis will be explained.

Asystole in a COVID-19 patient without systemic illness: a case report

There is growing evidence that patients with severe systemic illness from coronavirus disease 2019 (COVID-19) are at risk for developing a variety of cardiac arrhythmias. Less is known about patients with milder symptoms. Here, we report on the case of a 62-year-old male, admitted to the hospital following an episode of syncope, who experienced multiple episodes of cardiac arrest due to asystole lasting up to 30 seconds. History revealed a recent asymptomatic COVID-19 infection, and recurrent episodes of prolonged asystole necessitated permanent pacemaker placement. To our knowledge, this is the first report of an asymptomatic COVID-19 patient experiencing prolonged asystole. Cardiac arrhythmias in asymptomatic or oligosymptomatic COVID-19 patients may be underestimated.

A case report of severe cardioinhibitory reflex syncope associated with coronavirus disease 2019

BACKGROUND

Coronavirus disease 2019 (COVID-19) has been recognized as a disease with a broad spectrum of clinical manifestations. In this report, we illustrate an extraordinary case of severe cardioinhibitory reflex syncope with prolonged asystole associated with COVID-19.

CASE SUMMARY

A 35-year-old male patient presented to the emergency department with a 10-day history of postural syncope and fever. Electrocardiogram monitoring during positional change revealed reflex syncope with cardioinhibitory response, exhibiting sinus bradycardia, subsequent asystole, and syncope. The patient tested positive for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) and was admitted to the intensive care unit where temporary transvenous pacing was necessary because of prolonged episodes of asystole. Work-up included extensive cardiac and neurological diagnostic testing, but did not yield any structural abnormalities. Although temporary pacing was able to abort syncope, a decision was made to hold off on permanent pacing as the most likely aetiology was felt to be temporary cardioinhibitory reflex syncope associated with COVID-19. The patient was discharged with mild symptoms of orthostatic intolerance and responded well to education and lifestyle modification. Outpatient follow-up with repeat tilt testing after 3 and 6 months initially showed residual inducible syncope but was eventually normal and the patient remained asymptomatic.

DISCUSSION

We believe that autonomic imbalance with a strong vagal activation due to acute SARS-CoV-2 infection played a pivotal role in the occurrence of transient syncope in this patient's condition. Although pacemaker implantation would have been a reasonable alternative, a watch-and-wait approach should be considered in similar instances.

Neurally Mediated Syncope Triggered by COVID-19 Nasopharyngeal Swab Specimen Collection: A Case Report

There are few reports describing adverse events associated with nasopharyngeal swab specimen collection in patients tested for SARS-Cov-2 (COVID-19). Despite the lack of data, providers should be aware of complications associated with swab collection. Instances of nasopharyngeal swab as a syncope trigger are mostly anecdotal and not well described in the medical literature. We present a case of neural reflex mediated syncope associated with the nasopharyngeal swab specimen collection process in a healthy patient undergoing COVID-19 testing prior to elective surgery. This response may be mediated by the trigeminocardiac reflex or via glossopharyngeal nerve stimulation. Less invasive collection practices, such as saliva sampling, may be warranted, particularly in those predisposed to syncopal episodes.

Vitamin D and its' role in Parkinson's disease patients with SARS-CoV-2 infection. A review article

A novel coronavirus reportedly called 2019-nCoV started to spread around the world at the end of 2019. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was later renamed after links with SARS were observed. Multiple studies have reported possible connections between the COVID-19 virus and neurodegenerative diseases, including Parkinson's disease. Theories support that vitamin D deficiency plays a part in the pathogenicity of Parkinson's disease or the credibility of the associated dopamine system. Administration of vitamin D3 was shown to significantly enhance the motor and non-motor manifestations of Parkinson's disease and enhance the quality of life. Also, multiple recent reviews have shown specific ways in which vitamin D reduces the risk of pathogenic infections. Recent studies supported the potential role of vitamin D in reducing the risk of COVID-19 infections and mortality. On the immunological level, immune response regulation remains one of the well-recognized actions of vitamin D. Vitamin D deficiency has been linked to complications in patients with SARS-CoV-2 infection and Parkinson's disease. Whereas more studies are required, Vitamin D supplementation with a moderate and well-calculated dosage of vitamin D3 in patients with Parkinson's disease can help minimize the risk and burden of COVID-19 complications.

Effusive pericarditis in the pathogenesis of cardiac arrhythmias in COVID-19: a case series

A wide variety of non-pulmonary manifestations of a coronavirus disease 2019 (COVID-19) has enriched clinical performance of cardiac diseases with atypical symptoms. Two COVID-19 cases are presented, where sinus bradycardia and syncope, which are rare in COVID-19, were the leading ones after the infection. The patients had no prior cardiovascular diseases, while the examination did not detected neurological pathology and myocarditis. Echocardiography showed relatively small pericardial effusion, which is supposed to be a cause of the symptoms as the diagnosis to exclude. A local buildup of inflammatory fluid around the sinus node and extensive ganglion plexuses around the atria can possibly affect the automatism and chronotropic compensation in addition to the myocardial inflammation. As part of the treatment against the hydropericardium syndrome, the symptoms disappeared, without reoccurring within subsequent 6-month follow-up. The third clinical case regards the pandemic outbreak, when we could not even suspect that the systemic inflammation would persist for many months after COVID-19 and radiofrequency ablation can lead to sudden cardiac death.

Syncope and COVID-19 disease - A systematic review

BACKGROUND

Syncope is not a common manifestation of COVID-19, but it may occur in this context and it can be the presenting symptom in some cases. Different mechanisms may explain the pathophysiology behind COVID-19 related syncope. In this report, we aimed to examine the current frequency and etiology of syncope in COVID-19.

METHODS

A systematic review across PubMed, ISI Web of Knowledge and SCOPUS was performed, according to PRISMA guidelines, in order to identify all relevant articles regarding both COVID-19 and syncope.

RESULTS

We identified 136 publications, of which 99 were excluded. The frequency of syncope and pre-syncope across the selected studies was 4.2% (604/14,437). Unexplained syncope was the most common type (87.9% of the episodes), followed by reflex syncope (7.8% of the cases). Orthostatic hypotension was responsible for 2.2% of the cases and syncope of presumable cardiac cause also accounted for 2.2% of cases. Arterial hypertension was present in 52.0% of syncope patients. The use of angiotensin receptor blockers or angiotensin converting enzyme inhibitors were not associated with an increased incidence of syncope (chi-square test 1.07, p 0.30), unlike the use of beta-blockers (chi-square test 12.48, p < 0.01).

CONCLUSION

Syncope, although not considered a typical symptom of COVID-19, can be associated with it, particularly in early stages. Different causes of syncope were seen in this context. A reevaluation of blood pressure in patients with COVID-19 is suggested, including reassessment of antihypertensive therapy, especially in the case of beta-blockers.

Mental Health Issues During and After COVID-19 Vaccine Era

The COVID-19 pandemic has persisted for more than a year, and post-COVID-19 sequelae of neurological complications, including direct and indirect effects on the central nervous system (CNS), have been recognized. There is a plethora of evidence for neurological, cognitive, and emotional deficits in COVID-19 patients. Acute neurological symptoms like neuroinflammation, cognitive impairment, loss of smell, and brain stroke are common direct effects among SARS-CoV-2 infected individuals. Work-associated stress, lockdowns, social distancing, and quarantine in response to contain SARS-CoV-2 have also affected the mental health of large populations, regardless of age. Public health emergencies have affected individuals and communities, resulting in emotional reactions and unhealthy behaviors. Although vaccines have been widely distributed and administered among large populations, vaccine hesitancy still exists and may be due to apprehension about vaccine efficacy, preliminary trials, and associated side effects. This review highlights the impact of COVID-19 on the CNS by outlining direct and indirect effects and factors contributing to the decline in people's mental health throughout the COVID-19 pandemic both during and after vaccine administration. Furthermore, we also discuss reasons for vaccine hesitancy and why some groups of people are deprived of vaccines. Finally, we touched upon the social determinants of mental health and their impact on disadvantaged populations during times of crisis which may help policymakers set up some action plans to mitigate the COVID-19 mental health turmoil during this ongoing pandemic.

Linking COVID-19 and Parkinson's disease: Targeting the role of Vitamin-D

COVID-19 pandemic has a major effect on world health, particularly on individuals suffering from severe diseases or old aged persons. Various case studies revealed that COVID-19 might increase the progression of Parkinson's disease (PD). Coxsackievirus, dengue virus Epstein-Barr virus, hepatitis C virus, Japanese encephalitis, Western equine encephalomyelitis virus, West Nile virus, and human immunodeficiency virus have all been linked to the development of transient or permanent parkinsonism, owing to the induction of neuroinflammation/hypoxic brain injury with structural/functional damage within the basal ganglia. Coronavirus mainly infects the alveolar cells and may lead to acute respiratory distress syndrome. SARS-CoV-2 invades cells via the ACE2 receptor, which is widely expressed in the central nervous system, where the virus may precipitate or accelerate dementia. SARS-CoV-2 could enter the central nervous system directly by the olfactory/vagus nerves or through the bloodstream. Here, we talked about the importance of this viral infection in terms of the CNS as well as its implications for people with Parkinson's disease; anosmia & olfaction-related impairments in COVID-19 & PD patients. And, also discussed the role of vitamin D to sustain the progression of Parkinson's disease and the COVID-19; regular vitamin D3 consumption of 2000-5000 IU/day may reduce the risk and severity of COVID-19 in parkinsonian patients.

COVID-19 Pneumonia in Vaccinated Population: A Six Clinical and Radiological Case Series

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and its related disease (COVID-19) continue to represent a challenge for humans. To date, vaccination programs have represented an opportunity to navigate the pandemic. However, the advent of new genetic COVID-19 variants has increased more attention representing a worrying threat not only for not vaccinated but also for vaccinated people as virus infections have been shown also in the last ones. Herein, we report different clinical cases and radiological findings of COVID-19 pneumonia in six fully vaccinated patients. Two patients had a history of Rituximab therapy for follicular lymphoma and with persistent positivity for SARS-CoV-2 on nasopharyngeal/oropharyngeal (NP/OP) swabs and with moderate pneumonia on the chest computed tomography (CT). One patient who resulted to be positive to delta variant 8 days after the second vaccination dose, died shortly after. Two patients were hospitalized due to the worsening of fever and dyspnea in presence of mild pneumonia on CT. In one patient mild pneumonia was found on the chest-CT performed after a lipothymic episode associated with chest pain and positive NP/OP swab tested for SARS-CoV-2. These data suggested that in fully vaccinated people, caution should be preserved, and the use of masks and social distancing should be continued in all closed environments. However, further clinical trials should be done to better understand how various factors can influence vaccine immunogenicity as the presence of virus mutations, age factors, and the presence of an immunocompromised state.

The Influence of Coronavirus Disease-2019 (COVID-19) On Parkinson's Disease: An Updated Systematic Review

Background

COVID-19 has affected global communities with multiple neurological complications in addition to other critical medical issues. COVID-19 binds to the host’s angiotensin-converting enzyme 2 (ACE2) receptors, which are expressed in the neurons and glial cells, acting as an entry port to the central nervous system (CNS). ACE2 receptors are abundantly expressed on dopamine neurons, which may worsen the prognosis of motor symptoms in Parkinson’s disease (PD). SARS-CoV-2 may lead to an indirect response via immune-mediated cytokine storms and propagate through the CNS leading to damage. In this systematic review, we aim to provide thorough analyses of associations between COVID-19 and neurological outcomes for patients with PD.

Methods

Using PRISMA statement 2020, a systematic review was conducted to isolate confirmed COVID-19 patients and analyze the PD-associated neurological outcomes using the following databases: PubMed, Science Direct, Google Scholar, and Cochrane databases. The following keywords were used “COVID19, SARS-CoV-2, Parkinson’s disease, Pandemic, Mortality.” A modified Delphi process was employed.

Results

Of the 355 studies located during the initial round of screening, 16 were included in the final synthesis. Of PD patients who tested positive for SARS-CoV-2, worsening motor symptoms and other viral-associated symptoms were reported. These symptoms included bradykinesia, tremors, gait disturbances, delirium and dementia, and severe spasms of arms and legs. Encephalopathy was presented in 2 of the included studies. Increased mortality rates were identified for hospitalized patients due to COVID-19 and PD as compared to other patient groups.

Conclusion

Patients with PD may experience substantial worsening of symptoms due to COVID 19. Given the novelty of neurological-viral associations, clinical studies in the future ought to explore the disease severity and neurological outcomes in COVID-19 positive patients with PD as compared to non-PD patients, in addition to understanding the role of ACE2 in increased vulnerability to contracting the infection and as a treatment modality.

Clinical Manifestations of COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the third coronavirus causing an outbreak in the twenty-first century. It is related to a contagious coronavirus disease (COVID-19), which its high pace of spreading allowed it to lie to the whole world and be turned into a pandemic only a few months after the identification of the first case. Currently, the reverse transcription-polymerase chain reaction (RT-PCR) test of throat swap is the gold standard of diagnosis; however, several studies have reported false-negative results with non-ideal sensitivity. Because this pandemic constitutes a significant burden on global healthcare systems and due to the high transmission rate of the virus, an accurate diagnosis algorithm is needed to reduce the missing case number. A comprehensive clinical examination and taking a history of all systems (not just limited to the respiratory system) combined with hematologic laboratory tests and chest imaging can lead to a sensitive diagnosis, severity assessment, and RT-PCT test interpretation. This chapter focuses on clinical characteristics, hematologic laboratory, and chest imaging features in COVID-19.

Normalizing images is good to improve computer-assisted COVID-19 diagnosis

The Coronavirus Disease 2019 (COVID-19) outbreak, caused by the SARS-CoV-2 virus, surprised the whole world in an unprecedented and devastating way, resulting in almost 200,000 deaths and 2.3 million infections worldwide in less than 4 months. Moreover, the elevate capability of transmission threatens to collapse both the healthy and economic systems from most countries, stressing worse predictions for emerging countries. In such a turbulent scenario, fast diagnosis is essential for a successful treatment and isolation of patients, thus avoiding increasing the number of contaminations. However, traditional methods of detection using polymerase chain reaction are impractical in large scale due to elevate costs, material scarcity, and time demanded for processing. As an alternative, some researchers proposed a machine learning–based diagnosis considering chest X-ray analysis with promising results, thus opening room for possible improvements. This work introduces a different normalization approach that, together with an EfficientNet-B6-inspired neural network, can deal with COVID-19 diagnosis considering chest X-ray images. Experiments provided competitive results considering a lighter and faster architecture, thus fostering research toward COVID-19 detection.

Syncope at SARS-CoV-2 onset

We describe clinical and laboratory findings in 35 patients tested positive for SARS-CoV-2 by reverse transcriptase-polymerase chain reaction on nasopharyngeal swab experiencing one or multiple syncope at disease onset. Clinical neurologic and cardiologic examination, and electrocardiographic findings were normal. Chest computed tomography showed findings consistent with interstitial pneumonia. Arterial blood gas analysis showed low pO2, pCO2, and ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) indicating hypocapnic hypoxemia. Patients who presented with syncope showed significantly lower heart rate as compared to 68 SARS-CoV-2 positive that did not. Such poorer than expected compensatory heart rate increase may have led to syncope based on individual susceptibility. We speculate that SARS-CoV-2 could have caused angiotensin-converting enzyme-2 (ACE2) receptor internalization in the nucleus of the solitary tract and other midbrain nuclei, impairing baroreflex and chemoreceptor response, and inhibiting the compensatory tachycardia during acute hypocapnic hypoxemia.

Syncope and presyncope in patients with COVID-19

Introduction

Recent studies have described several cardiovascular manifestations of COVID‐19 including myocardial ischemia, myocarditis, thromboembolism, and malignant arrhythmias. However, to our knowledge, syncope in COVID‐19 patients has not been systematically evaluated. We sought to characterize syncope and/or presyncope in COVID‐19.

Methods

This is a retrospective analysis of consecutive patients hospitalized with laboratory‐confirmed COVID‐19 with either syncope or presyncope. This “study” group (n = 37) was compared with an age and gender‐matched cohort of patients without syncope (“control”) (n = 40). Syncope was attributed to various categories. We compared telemetry data, treatments received, and clinical outcomes between the two groups.

Results

Among 1000 COVID‐19 patients admitted to the Mount Sinai Hospital, the incidence of syncope/presyncope was 3.7%. The median age of the entire cohort was 69 years (range 26‐89+ years) and 55% were men. Major comorbidities included hypertension, diabetes, and coronary artery disease. Syncopal episodes were categorized as (a) unspecified in 59.4% patients, (b) neurocardiogenic in 15.6% patients, (c) hypotensive in 12.5% patients, and (d) cardiopulmonary in 3.1% patients with fall versus syncope and seizure versus syncope in 2 of 32 (6.3%) and 1 of 33 (3.1%) patients, respectively. Compared with the “control” group, there were no significant differences in both admission and peak blood levels of d‐dimer, troponin‐I, and CRP in the “study” group. Additionally, there were no differences in arrhythmias or death between both groups.

Conclusions

Syncope/presyncope in patients hospitalized with COVID‐19 is uncommon and is infrequently associated with a cardiac etiology or associated with adverse outcomes compared to those who do not present with these symptoms.

Neuronophagia and microglial nodules in a SARS-CoV-2 patient with cerebellar hemorrhage

We document the neuropathologic findings of a 73-year old man who died from acute cerebellar hemorrhage in the context of relatively mild SARS-CoV2 infection. The patient developed sudden onset of headache, nausea, and vomiting, immediately followed by loss of consciousness on the day of admission. Emergency medical services found him severely hypoxemic at home, and the patient suffered a cardiac arrest during transport to the emergency department. The emergency team achieved return of spontaneous circulation after over 17 min of resuscitation. A chest radiograph revealed hazy bilateral opacities; and real-time-PCR for SARS-CoV-2 on the nasopharyngeal swab was positive. Computed tomography of the head showed a large right cerebellar hemorrhage, with tonsillar herniation and intraventricular hemorrhage. One day after presentation, he was transitioned to comfort care and died shortly after palliative extubation. Autopsy performed 3 h after death showed cerebellar hemorrhage and acute infarcts in the dorsal pons and medulla. Remarkably, there were microglial nodules and neuronophagia bilaterally in the inferior olives and multifocally in the cerebellar dentate nuclei. This constellation of findings has not been reported thus far in the context of SARS-CoV-2 infection.

COVID-19 and possible links with Parkinson's disease and parkinsonism: from bench to bedside

This Viewpoint discusses insights from basic science and clinical perspectives on coronavirus disease 2019 (COVID-19)/severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection in the brain, with a particular focus on Parkinson's disease. Major points include that neuropathology studies have not answered the central issue of whether the virus enters central nervous system neurons, astrocytes or microglia, and the brain vascular cell types that express virus have not yet been identified. Currently, there is no clear evidence for human neuronal or astrocyte expression of angiotensin-converting enzyme 2 (ACE2), the major receptor for viral entry, but ACE2 expression may be activated by inflammation, and a comparison of healthy and infected brains is important. In contrast to the 1918 influenza pandemic and avian flu, reports of encephalopathy in COVID-19 have been slow to emerge, and there are so far no documented reports of parkinsonism apart from a single case report. We recommend consensus guidelines for the clinical treatment of Parkinson's patients with COVID-19. While a role for the virus in causing or exacerbating Parkinson's disease appears unlikely at this time, aggravation of specific motor and non-motor symptoms has been reported, and it will be important to monitor subjects after recovery, particularly for those with persisting hyposmia.

SARS-CoV-2 infection associated with micturition syncope: Our experience with 4 case reports

RATIONALE

Syncope is described as the loss of consciousness and postural muscle tone with a short duration and fast onset. Micturition syncope can be caused by abnormal vasovagal response or by the dysfunction of the blood pressure regulating mechanism, which occurs before, during, or immediately after urination.

PATIENT CONCERNS

We present 4 cases of COVID-19 hospitalized in the Department of Infectious Diseases of the Academic Emergency Hospital Sibiu, Romania, cases that presented micturition syncope.

DIAGNOSES

During hospitalization, patients confirmed with SARS-Cov-2 infection using real time reverse transcriptase-polymerase chain reaction (RT-PCR) assay, presented micturition syncope in different stages of the infection (at the beginning and in the second week of evolution).

INTERVENTIONS

Other causes of syncope such as adrenal insufficiency secondary to corticosteroids treatment, cardiac rhythm disorders, neurological impairment, dehydration, vasoactive medication, malignancies, pulmonary hypertension and coughing were excluded. The treatment of SARS-CoV-2 infection was performed following the local and national guidelines.

OUTCOMES

The clinical course of all 4 patients diagnosed with COVID-19 and micturition syncope was favorable. To our knowledge, micturition syncope in COVID-19 patients has yet not been reported by other authors.

LESSONS

To our knowledge, micturition syncope associated with the evolution of COVID-19, has yet not been reported by other authors.