Laboratory biomarkers associated with COVID-19 severity and management

The heterogeneous disease course of COVID-19 is unpredictable, ranging from mild self-limiting symptoms to cytokine storms, acute respiratory distress syndrome (ARDS), multi-organ failure and death. Identification of high-risk cases will enable appropriate intervention and escalation. This study investigates the routine laboratory tests and cytokines implicated in COVID-19 for their potential application as biomarkers of disease severity, respiratory failure and need of higher-level care.

From analysis of 203 samples, CRP, IL-6, IL-10 and LDH were most strongly correlated with the WHO ordinal scale of illness severity, the fraction of inspired oxygen delivery, radiological evidence of ARDS and level of respiratory support (p ≤ 0.001). IL-6 levels of ≥3.27 pg/ml provide a sensitivity of 0.87 and specificity of 0.64 for a requirement of ventilation, and a CRP of ≥37 mg/l of 0.91 and 0.66.

Reliable stratification of high-risk cases has significant implications on patient triage, resource management and potentially the initiation of novel therapies in severe patients.

Clinical perspectives into the use of thalidomide for central nervous system tuberculosis

BACKGROUND AND PURPOSE

Central nervous system (CNS) tuberculosis (TB) accounts for over 4% of all TB notifications in the UK and causes death or significant disability in over half of those affected. Tumour necrosis factor alpha is a critical cytokine involved in the neuropathogenesis of CNS TB. Thalidomide has been trialled in CNS TB due to its immunomodulatory and immune reconstitution effects through the inhibition of tumour necrosis factor alpha. Despite animal models demonstrating dramatic improvement in survival, studies in paediatric patients have been associated with higher levels of mortality. The effects of thalidomide have not yet been studied in adults with CNS TB. This narrative case series guides clinicians through a range of CNS TB clinical cases seen in a large London teaching hospital, serving a region with a high incidence of TB (32 per 100 000) with 55% of TB cases manifesting as extrapulmonary disease. We aimed to illustrate our experiences of using thalidomide to treat a range of severe CNS TB complications.

METHODS

Five inpatients at The Royal London Hospital, London, UK treated with thalidomide in addition to standard TB treatment are described in detail. The rationale for treatment initiation with thalidomide is explained.

RESULTS

The case examples are used to guide our reflections and lessons learnt regarding the use of thalidomide. Responses to treatment and functional outcomes suggest that thalidomide may be a useful adjunct to standard TB therapy in selected adult cases.

CONCLUSIONS

The experience gained from using thalidomide in this small case series may provide evidence leading to more research into using thalidomide to treat severe CNS TB.

Discussing sudden unexpected death in epilepsy: Are we empowering our patients? A questionnaire survey

OBJECTIVE

To examine patient knowledge about sudden unexpected death in epilepsy (SUDEP) compared to other risks in epilepsy. To explore patients' experiences surrounding SUDEP disclosure and opinions on how information should be delivered.

DESIGN

A cross-sectional questionnaire.

SETTING

Royal Free Hospital, London outpatient epilepsy clinics.

PARTICIPANTS

New and follow-up patients attending epilepsy clinics at a London teaching hospital over six months. Patients identified as being at risk of suffering negative emotional or psychological consequences of SUDEP discussions were excluded.

MAIN OUTCOME MEASURES

Patient knowledge about epilepsy risks; patient opinion regarding source, timing and delivery of SUDEP information; impact on health seeking behaviour.

RESULTS

Ninety-eight per cent of patients were aware of medication adherence, 84% of factors influencing seizure frequency, 78% of driving regulations, 50% of SUDEP and 38% of status epilepticus; 72% of patients felt that SUDEP information should be given to all patients. Preferences for timing of SUDEP discussions varied between those wanting information at diagnosis (40%) and those preferring to receive it after three clinic appointments (18%) to avoid information overload at the first consultation. Emotional responses (48% positive, 38% negative) predominated over measurable behavioural change following SUDEP discussions.

CONCLUSIONS

Less than half the patients knew about SUDEP and status epilepticus. Although the majority of patients with epilepsy wish to be informed about SUDEP early on in their diagnosis, information must be delivered in a way that promotes patient knowledge and empowerment.

Neurology of the cryopyrin-associated periodic fever syndrome

BACKGROUND AND PURPOSE

The cryopyrin-associated periodic fever syndrome (CAPS) is an autosomal dominant autoinflammatory disorder caused by mutations in the NLRP3 gene and is typified by recurrent episodes of systemic inflammation resulting in fever, urticarial rash and arthralgia. In addition to these systemic aspects, CAPS has multiple neurological manifestations. The largest case series to date is presented focusing on the neurological features of this disorder.

METHODS

The case histories of a cohort of 38 UK patients with genetically proven CAPS who were treated with interleukin 1β (IL-1β) inhibition as part of a national treatment programme and underwent detailed neurological assessment were reviewed.

RESULTS

Across the entire disease course neurological manifestations were present in 95% of patients; 84% had some form of headache; 66% sensorineural hearing loss; 60% myalgia; 34% papilloedema and 26% optic atrophy. Patients with the T348M mutation tended to have a more severe neurological phenotype with an earlier age of onset. Four patients had cerebrospinal fluid examination, three of whom had evidence of aseptic meningitis. There was a marked response to IL-1β inhibition, which has revolutionized management of these patients (29/32 patients with headache responding).

CONCLUSION

Neurological symptoms are extremely common in CAPS and these results highlight the importance of increasing awareness amongst neurologists, particularly as highly effective therapies are available.

Lymphocyte activation: changes in intracellular adenosine triphosphate and deoxyribonucleic acid synthesis

Stimulation of human lymphocytes from 20 individuals with phytohaemagglutinin (PHA) for 60 min resulted in a fall in intracellular adenosine triphosphate (ATP) of 35% compared to unstimulated controls of 19% (p less than 0.001). There was a significant (p less than 0.01) correlation (r = 0.57) between ATP decrease at 60 min and deoxyribonucleic acid (DNA) synthesis at 72 h in PHA-stimulated cells. The technique described here is simple, rapid and has possible application in immunodiagnosis and immunologic monitoring.

Control of large-scale plasma thawing for recovery of cryoprecipitate factor VIII

Cryoprecipitation is commonly used as the primary step in the preparation of clinical factor VIII concentrates; yet recovery is usually very low. Much of this loss is due to poor temperature control and a process of continuous plasma thawing has been designed to overcome this. A substantial improvement has resulted, with an increase in both yield and purity of factor VIII:C of over 50% in comparison to a conventional batch thaw process.