Non-respiratory Symptoms Research Articles

Atypical presentations in the hospitalised older adult testing positive for SARS-CoV-2: a retrospective observational study in Glasgow, Scotland.

Introduction: Understanding of how SARS-CoV-2 manifests itself in older adults was unknown at the outset of the pandemic. We undertook a retrospective observational analysis of all patients admitted to older people’s services with confirmed COVID-19 in one of the largest hospitals in Europe. We detail presenting symptoms, prognostic features and vulnerability to nosocomial spread. Methods: We retrospectively collected data for each patient with a positive SARSCoV-2 RT PCR between 18th March and the 20th April 2020 in a department of medicine for the elderly in Glasgow. Results: 222 patients were included in our analysis. Age ranged from 56 to 99 years (mean = 82) and 148 were female (67%). 119 patients had a positive swab for SARS-CoV-2 within the first 14 days of admission, only 32% of these patients presented with primarily a respiratory type illness. 103 patients (46%) tested positive after 14 days of admission – this was felt to represent likely nosocomial infection. 95 patients (43%) died by day 30 after diagnosis. Discussion: This data indicates that older people were more likely to present with non-respiratory symptoms. High clinical frailty scores, severe lymphopenia and cumulative comorbidities were associated with higher mortality rates. Several contributing factors will have led to nosocomial transmission.

S2762 Rapid Deterioration of a COVID-19 Patient With Gastrointestinal Presentation

INTRODUCTION: Severe Acute Respiratory Syndrome Coronavirus 19 (SARS-CoV19) is a known viral pneumonia. However, gastrointestinal involvement is not uncommon, and can be the only presenting feature. Our case presented with only diarrhea; then the patient developed respiratory symptoms. CASE DESCRIPTION/METHODS: A 80 y/o man with history of hypertension and chronic renal failure. He presented with lethargy, generalized weakness, diarrhea, nausea, and oliguria for several days. The patient denied coughing, shortness of breath, fever, or abdominal pain. Social history showed his daughter had a mild febrile illness. Where both reported testing COVID19 positive after the patient was admitted. On physical examination, vitals were stable, except blood pressure 91/54 mm Hg. The patient was alert, and oriented. Mucus membranes were dry. Cardiovascular, lung and abdominal examination were unremarkable. The initial laboratory results showed leukopenia with normal WBC count, serum creatinine 8.84 mg/dL, RT PCR – nasal was positive on admission. CXR was clear on admission. The 4th day, the patient’s reported anxiety, non-productive cough. Crackles and cyanosis on examination. Failure to maintain oxygenation lead to mechanical ventilation. CXR showed bilateral infiltration. The patient finished 5-day course of hydroxychloroquine, azithromycin, ascorbic acid, zinc, and one dose of Intravenous interleukin 6 inhibitor. He also required hemodialysis, and vasopressors. The family decided on providing comfort care with no invasive interventions. DISCUSSION: Fever is the most common symptom (85%), then cough (68%). vomiting (5%) and diarrhea (3.7%). COVID19 cases who present with gastrointestinal symptoms have a worse prognosis compared to those with respiratory presentations. Our patient had severe diarrhea that lead to hypovolemic shock with multiple organ failure. As seen in previous reported cases, respiratory symptoms started within a week of the first gastrointestinal complaint, which correlates with the surge in the inflammatory markers. Screening for COVID19 infection through fecal PCR has shown to have similar accuracy as the PCR from respiratory samples. RT PCR – stool is potentially one of the methods for early detection of SARS-CoV2 disease when it has non-respiratory symptoms or in asymptomatic cases.

Management of Primary Ciliary Dyskinesia

ZusammenfassungDie Primäre Ciliäre Dyskinesie (PCD, MIM 242650) ist eine seltene hereditäre Multisystemerkrankung mit klinisch heterogenem Phänotyp. Leitsymptom ist eine chronische Sekretretention der oberen und unteren Atemwege, welche durch die Dysfunktion motiler respiratorischer Zilien entsteht. In der Folge kommt es zur Ausbildung von Bronchiektasen, häufig zu einer Infektion durch Pseudomonas aeruginosa sowie einer abnehmenden Lungenfunktion bis hin zum Lungenversagen.Bislang gibt es kaum evidenzbasierte Therapieempfehlungen, da randomisierte Langzeitstudien zur Behandlung der PCD fehlten. In diesem Jahr wurden die Daten einer ersten placebokontrollierten Medikamentenstudie bei PCD veröffentlicht. Anlässlich dieses Meilensteins im Management der PCD wurde der vorliegende Übersichtsartikel als Konsens von Patientenvertretern sowie Klinikern, die langjährige Erfahrung in der Behandlung der PCD haben, verfasst. Diese Arbeit bietet eine Zusammenfassung aktuell eingesetzter Behandlungsverfahren, die überwiegend auf persönlichen Erfahrungen und Expertenmeinungen beruhen oder von anderen Atemwegserkrankungen wie der Cystischen Fibrose (CF), COPD oder Bronchiektasen-Erkrankung abgeleitet werden. Da es derzeit keine kurative Therapie für PCD gibt, stehen symptomatische Maßnahmen wie die regelmäßige Reinigung der Atemwege und die Behandlung von rezidivierenden Atemwegsinfektionen im Fokus. Nicht respiratorische Manifestationen werden organspezifisch behandelt. Um neben der ersten Medikamentenstudie mehr evidenzbasiertes Wissen zu generieren, werden weitere Projekte etabliert, u. a. ein internationales PCD-Register. Hierüber wird Patienten der Zugang zu klinischen und wissenschaftlichen Studien erleichtert und die Vernetzung behandelnder Zentren gefördert. Des Weiteren können Erkenntnisse über eine Genotyp-spezifische Erkrankungsschwere erlangt werden, um folglich die therapeutische Versorgung der Patienten zu verbessern und somit zu individualisieren.

COVID-19: What do we know?

• Evidence regarding the provision of orthodontic care during the COVID-19 pandemic is examined.

Trends in clinical presentation of children with COVID-19: a systematic review of individual participant data.

ContextThere are sparse patient-level data available for children with novel coronavirus disease (COVID-19). Therefore, there is an urgent need for an updated systematic literature review that analyzes individual children rather than aggregated data in broad age groups.MethodsSix databases (MEDLINE, Scopus, Web of Science, CINAHL, Google Scholar, medRxiv) were searched for studies indexed from January 1 to May 15, 2020 with MeSH terms: children, pediatrics, COVID-19, SARS-CoV-2. 1241 records were identified, of which only unique papers in English with individual patient information and documented COVID-19 testing were included. This review of 22 eligible studies followed Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data guidelines.Results123 patients from five countries were identified. 46% were females. Median age was five years (IQR=8). At presentation, 62% had fever, 32% had cough, 58% had a single symptom and 21% were asymptomatic. Abnormal chest imaging was seen in 62% (65/105) of imaged and 76.9% (20/26) of asymptomatic children. A minority of children had elevated platelets, CRP, lactate dehydrogenase, and d-dimer.ConclusionData from this independent participant data systematic review revealed that the majority of children with COVID-19 presented with either no symptoms or a single, non-respiratory symptom.

Impact of COVID-19 lockdown on A&E performances in an NHS Foundation Trust

County Durham and Darlington Foundation Trust (CDDFT) is a National Health Service (NHS) Trust and is one of the largest integrated care providers in England. It serves a population of...

Profiling Cases With Nonrespiratory Symptoms and Asymptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Infections in Mexico City.

We profiled cases with non-respiratory symptoms (NRS) and asymptomatic SARS-CoV-2 assessed within Mexico City’s Epidemiological Surveillance System. We show that initially asymptomatic or NRS cases have decreased risk of adverse COVID-19 outcomes compared to cases with respiratory symptoms. Comorbidity and age influence likelihood of developing symptoms in initially asymptomatic cases.

How is the digestive system affected by coronavirus disease?

How is the digestive system affected by coronavirus disease?

Gastrointestinal and Hepatobiliary Manifestations of Coronavirus Disease-19: Potential Implications for Healthcare Resource-Deficient Countries

It is believed that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has evolved and developed with broad tissue tropism as hospitalized coronavirus disease (COVID)-19 patients have been showing non-respiratory manifestations. As evidenced in recent clinical studies, even if the results of oral or nasal swab test were negative, the tests on rectal swab, feces, and blood samples in recovered patients could still be positive. The viral shedding in these specimens provides a cautionary warning that fecal-oral route may represent a hidden trigger of rampant spread of COVID-19 in developing countries with poor sanitization. In addition, the presence of SARS-CoV-2 in rectal, fecal, and blood samples endorses gastrointestinal and hepatic origins for the pathogenesis of COVID-19. These observations highlight the importance for the infected patients to obtain accurate and timely diagnosis as well as the treatment of COVID-19 and its associated non-respiratory symptoms to reduce the risk of spreading the infection through unexpected routes. This review also discusses the potential implications of fecal-oral transmission of COVID-19 for healthcare resource-deficient countries.

Clinical features and high resolution CT imaging evolution of coronavirus disease 2019

Objective: To investigate the clinical manifestations of the clinical characteristics of 141 patients with coronavirus disease 2019 (COVID-19) and the imaging evolution characteristics of High Resolution CT (HRCT) in the chest. Methods: From January 20, 2020 to February 8, 141 COVID-19 patients in Renmin Hospital of Wuhan University, 77 males and 64 females, with a median age of 49 (9,87) , were retrospectively analyzed. The clinical features, laboratory examination indexes and HRCT evolution findings of 141 COVID-19 patients were analyzed. Results: Laboratory examinations of 141 COVID-19 patients showed a decrease in white blood cell count and lymphocyte ratio. Among the 141 patients with COVID-19, fever (>37.5℃) was the most common clinical manifestation in 139 cases (98.58%) , and occasionally non-respiratory symptoms such as diarrhea in 4 cases (2.84%) . 141 patients with COVID-19had abnormal HRCT. 52 (36.88%) chest HRCT images showed ground-glass opacity (GGO) , mainly under pleural; 23 (16.31%) GGO with focal consolidation; 27 (19.15%) small flaky shadows; 20 cases (14.18%) large flaky consolidation shadows; 48 cases (34.04%) bronchovascular bundle thickening and vascular penetrating signs; 5 cases (3.55%) had air bronchial signs; 7 cases (4.96%) of small nodule shadows; 5 cases (3.55%) of fibrosis, grid shadows or strand shadows.135 cases (95.74%) were positive for the first time nucleic acid test, 6 cases (4.26%) were negative, and 71 cases (50.35%) of common type, 47 cases (33.33%) of severe type and 23 cases (16.31%) of critical type were found during the same period. The average time from onset of each type to the first CT examination was: (2.51±1.32) , (5.02±2.01) , and (5.91±1.76) days; 19 (19/47, 40.43%) of which were severe for the first time CT classification worsened at the second examination and lessened at the third examination. 141 cases (100%) were positive for the second nucleic acid test, and the HRCT results for the same period were 44 cases (31.21%) of common type, 53 cases (37.59%) of severe type, and 44 cases (31.21%) of critical type; the average interval time was (3.32±1.61) , (3.93±1.84) , (4.15±1.57) days;the third nucleic acid test were positive among 113 cases and 28 cases were negative, HRCT results of the same period were 79 cases (56.03%) of common type, 46 cases (32.62%) of severe type, and 16 cases (11.35%) of critical type;the average interval from the first CT examination were: (5.59±1.83) , (7.32±1.37) , (7.55±1.78) days. The differences in CT typing at different time were statistically significant (P<0.05) . Conclusion: The clinical features of COVID-19 and HRCT images are diverse, extensive GGO and infiltrates in both lungs are typical. Viral nucleic acid tests usually occur earlier or at the same time as the CT examination positive, and there are false negatives in nucleic acid tests. In some epidemiological backgrounds, CT imaging manifestations and evolutionary characteristics are of great significance for early warning of lung injury, assessment of disease severity, and assistance in clinical typing and post-treatment follow-up.

Epidemiological, Clinical, and Immunological Features of a Cluster of COVID-19–Contracted Hemodialysis Patients

BackgroundThe outbreak of highly contagious coronavirus disease 2019 (COVID-19) has posed a serious threat to human life and health, especially for those with underlying diseases. However, the impact of COVID-19 epidemic on hemodialysis (HD) centers and HD patients has not been reported.MethodsWe reviewed the whole course of the COVID-19 in the HD center of Renmin Hospital, Wuhan University (from January 14, 2020, to March 12, 2020). We compared the clinical manifestation and immune profiles among different patient groups with healthy individuals.ResultsForty-two of 230 HD patients (18.26%) and 4 of 33 medical staff (12.12%) were diagnosed with COVID-19 during the study period. Fifteen HD patients (6.52%), including 10 COVID-19 diagnosed, died. Only 2 deaths of the COVID-19 HD patients were associated with pneumonia/lung failure, others were ascribed to cardiovascular/cerebrovascular diseases or hyperkalemia. Except for 3 patients who were admitted to the intensive care unit for a severe condition (8.11%), including 2 who died, most COVID-19 diagnosed patients presented mild or nonrespiratory symptoms. The flow cytometric analysis of peripheral blood showed that multiple lymphocyte populations in HD patients were significantly decreased. HD patients with COVID-19 even displayed more remarkable reduction of serum inflammatory cytokines than other patients with COVID-19.ConclusionsCompared with the general population, HD patients and health care professionals are the highly susceptible population and HD centers are high-risk areas during the outbreak. Most HD patients with COVID-19 exhibited mild clinical symptoms and did not progress to severe pneumonia, likely due to the impaired cellular immune function and incapability of mounting cytokine storm. More attention should be paid to prevent cardiovascular events, which may be the collateral impacts of the COVID-19 epidemic on HD patients.

Coping with hypoxemia: Could erythropoietin (EPO) be an adjuvant treatment of COVID-19?

A very recent epidemiological study provides preliminary evidence that living in habitats located at 2500 m above sea level (masl) might protect from the development of severe respiratory symptoms following infection with the novel SARS-CoV-2 virus. This epidemiological finding raises the question of whether physiological mechanisms underlying the acclimatization to high altitude identifies therapeutic targets for the effective treatment of severe acute respiratory syndrome pivotal to the reduction of global mortality during the COVID-19 pandemic. This article compares the symptoms of acute mountain sickness (AMS) with those of SARS-CoV-2 infection and explores overlapping patho-physiological mechanisms of the respiratory system including impaired oxygen transport, pulmonary gas exchange and brainstem circuits controlling respiration. In this context, we also discuss the potential impact of SARS-CoV-2 infection on oxygen sensing in the carotid body. Finally, since erythropoietin (EPO) is an effective prophylactic treatment for AMS, this article reviews the potential benefits of implementing FDA-approved erythropoietin-based (EPO) drug therapies to counteract a variety of acute respiratory and non-respiratory (e.g. excessive inflammation of vascular beds) symptoms of SARS-CoV-2 infection.

Guess Who's Coming to Dinner: COVID-19 in a COVID-free Unit

ObjectiveTo assess the impact of the pandemic on surgical activity and the occurrence and features of Covid-19 in a Covid-free urologic unit in a regional hospital in Northern Italy. Materials and MethodsOur Department is the only urologic service in the Trento Province, near Lombardy, the epicenter of Covid-19 in our Country. We reviewed the surgical and ward activities during the 4 weeks following the national lockdown (March 9 to April 5, 2020). The following outcomes were investigated: surgical load, rate of admissions and bed occupation, and the rate and characteristics of unrecognized Covid-positive patients. Data were compared with that of the same period of 2019 (March 11 to April 7). Results and ConclusionAbout 63%, 70%, 64%, and 71%, decline in surgery, endoscopy, bed occupation, and admission, respectively, occurred during the 4 weeks after the lockdown, as compared to 2019. Urgent procedures also declined by 32%. Three (8%) of 39 admissions regarded unrecognized Covid-19 overlapping or misinterpreted with urgent urologic conditions such as fever-associated urinary stones or hematuria. In spite of a significant reduction of activity, a non-negligible portion of admissions to our Covid-free unit regarded unrecognized Covid-19. In order to preserve its integrity, we propose an enhanced triage prior to the admission to a Covid-free unit including not only routine questions on fever and respiratory symptoms but also nonrespiratory symptoms, history of exposure, and a survey about the social and geographic origin of the patient.

CT Scans Obtained for Nonpulmonary Indications: Associated Respiratory Findings of COVID-19.

BackgroundAtypical manifestations of coronavirus disease 2019 (COVID-19) are being encountered as the pandemic unfolds, leading to non–chest CT scans that may uncover unsuspected pulmonary disease.PurposeTo investigate patients with primary nonrespiratory symptoms who underwent CT of the abdomen or pelvis or CT of the cervical spine or neck with unsuspected findings highly suspicious for pulmonary COVID-19.Materials and MethodsThis retrospective study from March 10, 2020, to April 6, 2020, involved three institutions, two in a region considered a hot spot (area of high prevalence) for COVID-19. Patients without known COVID-19 were included who presented to the emergency department (ED) with primary nonrespiratory (gastrointestinal or neurologic) symptoms, had lung parenchymal findings suspicious for COVID-19 at non–chest CT but not concurrent chest CT, and underwent COVID-19 testing in the ED. Group 1 patients had reverse transcription polymerase chain reaction (RT-PCR) results obtained before CT scan reading (COVID-19 suspected on presentation); group 2 had RT-PCR results obtained after CT scans were read (COVID-19 not suspected). Presentation and imaging findings were compared, and outcomes were evaluated. Descriptive statistics and Fisher exact tests were used for analysis.ResultsGroup 1 comprised 62 patients (31 men, 31 women; mean age, 67 years ±17 [standard deviation]), and group 2 comprised 57 patients (28 men, 29 women; mean age, 63 years ± 16). Cough and fever were more common in group 1 (37 of 62 [60%] and 29 of 62 [47%], respectively) than in group 2 (nine of 57 [16%] and 12 of 57 [21%], respectively), with no significant difference in the remaining symptoms. There were 101 CT scans of the abdomen or pelvis and 18 CT scans of the cervical spine or neck. In group 1, non–chest CT findings provided the initial evidence of COVID-19–related pneumonia in 32 of 62 (52%) patients. In group 2, the evidence was found in 44 of 57 (77%) patients. Overall, the most common CT findings were ground-glass opacity (114 of 119, 96%) and consolidation (47 of 119, 40%). Major interventions (vasopressor medication or intubation) were required for 29 of 119 (24%) patients, and 27 of 119 (23%) died. Patients who underwent CT of the cervical spine or neck had worse outcomes than those who underwent abdominal or pelvic CT (P = .01).ConclusionIn a substantial percentage of patients with primary nonrespiratory symptoms who underwent non–chest CT, CT provided evidence of coronavirus disease 2019–related pneumonia.© RSNA, 2020

High Prevalence of Concurrent Gastrointestinal Manifestations in Patients With Severe Acute Respiratory Syndrome Coronavirus 2: Early Experience From California

High Prevalence of Concurrent Gastrointestinal Manifestations in Patients With Severe Acute Respiratory Syndrome Coronavirus 2: Early Experience From California

Health consequences of thick forest fire smoke to healthy residents in Riau, Indonesia: a cross-sectional study

BACKGROUND Indonesia forest fire in 2015 emitted a huge amount of pollutants into the air. This study was aimed to assess the health consequences of forest fire smoke in healthy residents in Riau during forest fire disaster in 2015.&#x0D; METHODS This cross-sectional study was performed in healthy residents who lived in Pekanbaru, Riau Province, Sumatera, for at least 6 months during forest fire disaster in 2015, and data were taken in October 2015. Questionnaires consisting of respiratory and non-respiratory symptoms were collected. Lung function was assessed by spirometry (MIR II Spirolab™ spirometer, Medical International Research, Italy) and exhaled carbon monoxide (CO) was assessed using piCO+ Smokerlyzer®. Heart rate at rest and oxygen saturation in the room air were measured using Onyx 9591 Pulse Oximeter®.&#x0D; RESULTS A total of 89 subjects were mostly female (75.3%), housewife (37.7%), nonsmoker (86.5%) with mean age of 38.9 years old. The non-respiratory and respiratory symptoms were reported in 84.7% and 71.4% subjects, respectively. Lung function was impaired in 72.6% subjects, mostly with mild obstruction and mild restriction. Exhaled CO was highly detected over normal values (mean [standard deviation] = 32.6 [9.97] ppm) with predicted carboxyhemoglobin (COHb) of 5.74 (1.56).&#x0D; CONCLUSIONS Forest fire smoke exposure increased the respiratory and nonrespiratory symptoms among healthy individuals, which showed impairment in lung function, exhaled CO, and predicted COHb. Long term health effects on healthy individuals exposed to forest fire smoke warrant further evaluation.

Patients with respiratory symptoms are at greater risk of COVID-19 transmission.

The situation with the ongoing epidemic of coronavirus disease 2019 (COVID-19) that started in Wuhan, China, continued to rapidly evolve. As of 10 March 2020, China had confirmed 80 754 cases of COVID-19 and there had been 3136 deaths. Except for China, 109 other nations have reported 32 555 cases and 878 deaths. The clinical and laboratory characteristics of hospitalized COVID-19 patients were described [[1]Zhang J.J. Dong X. Cao Y. et al.Clinical characteristics of 140 patients infected by SARS-CoV-2 in Wuhan, China.Allergy. 2020 Feb 19; https://doi.org/10.1111/all.14238Google Scholar,[2]Guan W.J. Ni Z.Y. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N. Engl. J. Med. 2020; (published online Feb 28)https://doi.org/10.1056/NEJMoa2002032Google Scholar]. Cough is one of the most common symptoms at onset of illness [[3]Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; (published online Jan 24)https://doi.org/10.1016/S0140-6736(20)30183-5Google Scholar]. Here, we described the differences in characteristics of nasopharyngeal swab detection between patients with and without respiratory symptoms. The 82 COVID-19 patients were divided into respiratory symptoms group (26 cases) and non-respiratory symptoms group (56 cases). The two groups were comparable in gender (11 [42.3%] men vs 20 [35.7%] men; P = 0.567) and age (median age, 56 years [IQR, 35–65] vs 51 years [IQR, 36–64]; P = 0.398). Compared with patients who did not presented with respiratory symptoms, those patients who presented with cough were more likely to have longer duration of COVID-19 positive testing by nasopharyngeal swab (median duration, 17 days [IQR, 12–23] vs 13 days [IQR, 6–20]; P = 0.041), and have more stable results of COVID-19 testing by nasopharyngeal swab (24 [92.3%] vs 38 [67.9%], P = 0.016). We believe that patients with respiratory symptoms are more harmful to close contacts. First, the virus can be shed explosively from the COVID-19 patients’ upper respiratory tract into the air through coughing. Second, the duration of virus shedding from nasopharynx was longer. It is an effective precaution to stop droplets spreading by hand or with towel when coughing. After coughing, the importance of frequent and proper hand hygiene should be emphasized. Moreover, strict precautions must be observed when handling the towel contaminated with spittle. One encouraging finding is that the results of nasopharyngeal swabs are more stable in patients with cough symptoms. The incidence of nasopharyngeal swabs testing shown as negative and positive fluctuating repeatedly is less, which provides a basis for clinicians to better grasp the appropriate time to cancel quarantine based on the results of asopharyngeal swabs. Supported by Medical Science Advancement Program (Basical Medical Sciences) of Wuhan University, Grant NO. TFJC2018002. We declare no competing interests.

Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection

It has been known that, the novel coronavirus, 2019-nCoV, which is considered similar to SARS-CoV, invades human cells via the receptor angiotensin converting enzyme II (ACE2). Moreover, lung cells that have ACE2 expression may be the main target cells during 2019-nCoV infection. However, some patients also exhibit non-respiratory symptoms, such as kidney failure, implying that 2019-nCoV could also invade other organs. To construct a risk map of different human organs, we analyzed the single-cell RNA sequencing (scRNA-seq) datasets derived from major human physiological systems, including the respiratory, cardiovascular, digestive, and urinary systems. Through scRNA-seq data analyses, we identified the organs at risk, such as lung, heart, esophagus, kidney, bladder, and ileum, and located specific cell types (i.e., type II alveolar cells (AT2), myocardial cells, proximal tubule cells of the kidney, ileum and esophagus epithelial cells, and bladder urothelial cells), which are vulnerable to 2019-nCoV infection. Based on the findings, we constructed a risk map indicating the vulnerability of different organs to 2019-nCoV infection. This study may provide potential clues for further investigation of the pathogenesis and route of 2019-nCoV infection.

Delayed inpatient diagnosis and isolation of active pulmonary tuberculosis patients, a large tertiary care academic hospital experience in Riyadh, Saudi Arabia. What are we missing?

Objectives:To identify pulmonary tuberculosis (PTB) delayed inpatient diagnosis duration and contributing factors in an academic center in Saudi Arabia (SA).Methods:Retrospective review of all culture-confirmed PTB cases between May 2015 and April 2019. The outcomes were the timing between admission and suspicion of PTB or isolation to either early group (within 24 hours of admission) and late group (24 hours after admission).Results:Forty-nine cases were included with a median age of 49 years; a third of them were above 65 years of age. Most patients were of Saudi nationality and male. Approximately 38% of the cases were in the delayed group, half of them were smear-positive, with an average delay of 5.5 days. This was significant with age above 65 years (odds ratio [OR]=8.93, 95% confidence interval [CI]=2.22-35.95) presence of non-respiratory symptoms (OR=5.6, 95% CI=1.56-19.98), malignancy (OR=13.38, 95% CI=1.46-122.71), chronic medical problems (OR=4.90, 95% CI=1.31-18.32), missed chest x-ray findings (OR= 48, 95% CI=8.63-266.88) or procalcitonin level above 0.5 ng/mL (OR=12, 95% CI=1.58-91.08).Conclusion:Physicians in SA need to have a low threshold for PTB consideration in elderly patients or those with a history of malignancy. A careful review of the initial chest x-ray might help to overcome missing cases of PTB.

COVID-19: The significance to recognize initial ocular evidence and protective eyewear

Emergence of novel corona virus (2019-nCOV) and evolving into a pandemic in a short span of time has caught the entire humanity unwarranted Most of the population effected had predominant respiratory presentation which in many cases worsened very soon leading to deaths The whole healthcare community was focused on the respiratory system and little did they know about non-respiratory symptoms until mild to moderate cases of COVID started to rise manifesting in various forms though predominantly most patients had lung involvement Important to mention are gastrointestinal symptoms without overt respiratory symptoms Isolated case reports mentioned diverse presentations including eye involvement We here give a brief account of eye involvement in COVID and precautionary measures for eye protection especially for eye care professionals