Presenting Symptom Of COVID-19 Research Articles

Previous immune checkpoint inhibitor therapy is associated with decreased COVID-19-related hospitalizations and complications in patients with cancer: Results of a propensity-matched analysis of the OnCovid registry

ObjectivesTo date, studies have not provided definitive answers regarding whether previous immune checkpoint inhibitor (ICI) treatment alters outcomes for cancer patients with COVID-19. MethodsThe OnCovid registry (NCT04393974) was searched from February 27, 2020, to January 31, 2022, for patients who received systemic anti-cancer therapy in the 4 weeks before laboratory-confirmed COVID-19 diagnosis. Propensity-score matching using country, vaccination status, primary tumor type, sex, age, comorbidity burden, tumor stage, and remission status investigated differences in predefined clinical outcomes comparing those who had or had not received ICIs. ResultsOf 3523 patients screened, 137 ICI-only and 1378 non-ICI met inclusion criteria. Before matching, ICI patients were older, male, enrolled at centers in Italy, and had histories of smoking, thoracic cancers, advanced cancer stages, and active malignancies (P ≤0.02). After matching, there were 120 ICI and 322 non-ICI patients. ICI patients had no differences (odds ratio: 95% CI) in presenting COVID-19 symptoms (0.69: 0.37-1.28), receipt of COVID-specific therapy (0.88: 0.54-1.41), 14-day (0.95: 0.56-1.61), or 28-day (0.79: 0.48-1.29) mortalities. However, ICI patients required less COVID-19-related hospitalization (0.37: 0.21-0.67) and oxygen therapy (0.51: 0.31-0.83) and developed fewer complications (0.57: 0.36-0.92). ConclusionIn this propensity-score matched analysis, previous ICI therapy did not worsen and potentially improved COVID-19 outcomes in patients with cancer.

Association of presenting symptoms with COVID-19 disease severity and outcomes among hospitalized patients with cancer and COVID-19.

e13581 Background: COVID-19 has led to several waves of outbreaks over the last 2 years. Cancer patients are among the most vulnerable and have high morbidity and mortality rates. We aimed to determine the association between presenting symptoms and symptom burden and COVID hospitalization outcomes among cancer patients. Methods: We conducted a retrospective cohort study on all adult hospitalized cancer patients during their first admission at our cancer center from March 2020 to May 2021. We reviewed medical charts to identify reported symptoms. We used the Foundry data platform to compile and analyze data, including patient and hospitalization characteristics and outcomes. We used the chi-square test to test differences in categorical variables. Results: Our cohort included 595 patients, 272 with hematologic malignancies (45.7%) and 323 with solid tumor malignancies (54.3%). 52.1% were male, with an age range of 18 to 91 years (median age: 62). 64.2% self-identified as Caucasian, 16.1% as other, 14.3% as African American, and 3.5% as Asian. After univariate analysis, we found that female patients had higher rates of abdominal pain (21.4% vs. 14.5%, p=0.03), GI symptoms (36% vs. 27.4%, p=0.03), and sore throat (14.4% vs. 8.4%, p=0.02) than male patients. Smoking status or Charlson comorbidity score were not associated with any presenting symptoms. Solid tumor patients had higher rates of abdominal pain (26.6% vs. 7.4%, p <0.01) than patients with hematologic malignancies. Patients with hematologic malignancies had higher rates of fever (59.2% vs. 42.7%, p<0.01), cough (66.2% vs. 50.8%, p<0.01), and shortness of breath (53% vs. 41.8%, p<0.01) than solid tumor patients. Solid tumor patients more frequently reported more than 3 symptoms (52% vs. 39.2%, p<0.01) than patients with hematologic malignancies. In terms of COVID outcomes, patients with cough (34.4% vs. 12%, p<0.01), shortness of breath (38.5% vs. 12.9%, p <0.01), and fever (29.1% vs. 20.6%, p=0.02) were more likely to have severe COVID-19. Patients with more than 3 symptoms were more likely to have severe COVID-19 (31.7% vs. 21.3% vs. 7.8%, p< 0.01) than those with 1-3 symptoms or no symptoms. Patients with cough (15.1% vs. 6.4%, p<0.01) and shortness of breath (15.5% vs. 7.9%, p< 0.01) had higher inpatient mortality. Patients with chills (5.8% vs. 12.9%, p< value 0.03) and headache (4.4% vs. 12.7%, p=0.02) had lower inpatient mortality. Conclusions: Our study showed that certain presenting COVID-19 symptoms are associated with patient and clinical characteristics, severity of disease, and inpatient mortality among adult hospitalized cancer patients.

Delirium as a Presenting Symptom of COVID-19.

Background:Delirium is a common neurologic manifestation of coronavirus disease 2019 (COVID–19) in older adults who present to the emergency department (ED).Objective:To investigate clinical characteristics associated with delirium as a presenting symptom of COVID–19 in older adults and develop a logistic regression to predict the likelihood of delirium.Method:We compared clinical characteristics in an age- and gender-matched sample of 68 delirious individuals with 68 nondelirious individuals (Mage = 78) who presented to the ED with COVID–19.Results:The delirious group was more likely to have neurologic, psychiatric, and cardiovascular comorbidities; a prior history of delirium; and deliriogenic medications in their medication list. They were less likely to present with respiratory symptoms and more likely to present with sepsis, hypoxia, higher heart rate, and higher sodium. The delirious group had higher mortality (51%) than the nondelirious group (32%). Delirium developed within an average of 2 days of initial COVID–19 symptom onset, with symptom onset to ED within an average of 4 days and symptom onset to death within an average of 11 days. Logistic regression based on five delirium predictors correctly predicted 80% of those with delirium (75% sensitivity at 86% specificity).Conclusion:Our results are largely consistent with prior studies and suggest that delirium is a common, early occurring, and lethal manifestation of COVID–19 in older adults presenting to the ED, in most cases causing acute on chronic neurocognitive dysfunction strongly influenced by inflammatory and hypoxic–ischemic mechanisms.

LOOKING BACK AT A YEAR OF COVID-19 INFECTION IN KINTA DISTRICT, MALAYSIA: THE PUBLIC HEALTH EXPERIENCE TO SUPPRESS THE PANDEMIC


 
 
 COVID-19 has overwhelmed the healthcare system and crippled the economic and social activities globally. This study aims to analyse the epidemiological and presenting symptoms of COVID-19 and understand the public health intervention. A retrospective review of COVID-19 confirmed cases registered in Kinta District, Malaysia between 14th March 2020 to 28th March 2021. Descriptive statistics were used to describe the cases, and the association between the 2nd and 3rd waves of infection was determined using Pearson's chi-squared tests or student t-tests. 3051 COVID- 19 confirmed cases were reported during the 2nd wave and 3rd wave. The characteristics associated with the 2nd and 3rd waves were age, ethnicity, nationality, and transmission location. Asymptomatic cases account for 67.3% and 66.0% during the 2nd and 3rd waves, respectively. Presenting symptoms such as fever with respiratory symptoms, respiratory symptoms only, ageusia or anosmia were associated with the transmissions. Diabetes mellitus, hypertension, chronic kidney disease and multimorbidity were significantly associated with the 2nd and 3rd waves. As most confirmed cases were asymptomatic, a coordinated and systematic approach to tracing, testing, and isolating close contacts is critical to managing the pandemic. It highlights the importance of the public health experience in providing a comprehensive and integrated response to managing the COVID-19 pandemic.
 
 

Evaluation of the Panbio™ COVID-19 ag rapid test at an emergency room in a hospital in São Paulo, Brazil

BackgroundThe performance characteristics of the Panbio™ COVID-19 Ag test was evaluated at an emergency room setting against RT-PCR, considered the gold-standard for the detection of SARS-CoV-2, in São Paulo, Brazil. The study aimed to determine the sensitivity, specificity, Positive Percent Agreement (PPA), and Negative Percent Agreement (NPA) as compared to RT-PCR. MethodsSpecimens from 127 suspected patients were tested by both the Panbio™ COVID-19 Ag test and by RT-PCR. ResultsIn relation to RT-PCR using Ct values ≤ 40 as the upper limit for positivity, the Panbio™ COVID-19 Ag test showed an overall sensitivity of 84.3% (95% CI 75‒93.8%) and 98.2% (95% CI 96‒98.8%) overall specificity. For Ct values ≤ 25 (n = 37), the Panbio™ COVID-19 Ag test showed 97% sensitivity. DiscussionThe concordance between the Panbio™ COVID-19 Ag test and RT-PCR was 97% at Ct values below 25 but decreased at higher Ct values. For disease control, it is very important to identify infected individuals who present COVID-19 symptoms and also those who are suspected of infection due to contact with infected individuals. ConclusionThe Panbio™ COVID-19 Ag test is suitable for use as a diagnostic test for rapid screening of patients presenting COVID-19 symptoms, or those suspected of being infected, prior to being admitted to hospital.

Epilepsy as a Presenting Symptom of Covid-19 in a Tertiary Private Hospital in Northern Mexico

Background. Various manifestations of COVID-19 have been described in patients, including neurological. Few studies describe seizures as a presenting symptom. This study was aimed to identify clinical characteristics, type of epilepsy and electroencephalographic findings in patients with epilepsy as a presenting symptom of COVID-19 in a tertiary private hospital.
 Methods. Descriptive, retrospective, observational and cross-sectional study. Inclusion criteria were patients with epilepsy as a presenting symptom of COVID-19 confirmed with Polimerase Chain Reaction (PCR) for SARS-CoV2 by nasopharyngeal swab from March 2020-July 2021 in a tertiary private hospital. Study variables were age, gender, type of epilepsy, comorbidities and electroencephalographic findings. It was classified into three groups: acute symptomatic seizures, onset of epilepsy, and uncontrolled epilepsy. Information was captured in Excel and analyzed in SPSS.
 Results. Of 203,987 patientes with a confirmed diagnosis of COVID-19 in Nuevo León until July 2021, 10 patients (0.004%) were included with seizures. Two patients had acute symptomatic seizures (20%), four patients had onset seizures (40%) and four patients (40%) had uncontrolled epilepsy with an average epilepsy evolution time of 15.75 years. Focal seizures were predominant in 63%. Electroencephalogram was abnormal in 90% (50% focal frontotemporal sharp waves, 20% encephalopathic, 20% generalized spike wave). Two patients (20%) had status epilepticus.
 Conclusion. This study is important in order to carry out early detection in suspects or with a previous neurological history and to avoid the spread of the coronavirus.

Syncope: a worrisome presenting symptom during the first wave of COVID-19 in Italy

BackgroundCOronaVIrus Disease 19 (COVID-19) pandemic is a global health emergency. Since the first reported cases in Asia, the virus has now spread worldwide. Given its high contagiousness, one of the greatest challenges is early detection of infected patients. People affected by COVID-19 have had a wide range of presenting symptoms, from very mild to severe, including fever, cough, shortness of breath, gastrointestinal upset, anosmia and ageusia among others. Syncope as the presenting symptom of COVID-19 has been reported in case series or small sample size retrospective studies with variable results in terms of incidence, characteristics and outcomes.PurposeThe aim of the present analysis is to investigate all consecutive patients with COVID-19 who presented with syncope during the first wave of the pandemic to a high-volume Emergency Department (ED) in Italy.MethodsA total of 569 patients diagnosed with COVID-19 by positive nose and throat swab and admitted to the hospital between February 20th, 2020 (day of first reported COVID-19 case in Italy) and April 23rd, 2020 were retrospectively evaluated.ResultsSyncope has been reported as the initial symptom which prompted medical attention in 46 out of 569 patients (8%). Mean age of patients presenting with syncope was 72±15 years, 28 were males. Baseline patients' clinical characteristics are reported in Table 1. In 18 out of 46 patients (39%) syncope was an isolated finding, being fever and cough the two most commonly associated symptoms. Arrhythmic etiology was excluded since no arrhythmia was observed at device interrogation or with ECG/prolonged heart monitoring during hospitalization. No significant abnormalities were present at baseline ECG. At the time of admission, all patients were normotensive, median O2 saturation was 94.5%, median D-dimer 362 ng/ml. One-third of the patients presenting with syncope had a complicated clinical course with quite rapid deterioration requiring non-invasive ventilation (30%) and intensive care unit admission with intubation (11%).In our group of consecutive patients with COVID-19 who presented with syncope, the mortality rate was surprisingly high, 15/46 (32%), compared to the mortality rate of the COVID population admitted to our hospital with other symptoms 93/523 (18%), p=0.023. Six out of 15 patients died in the ED, mainly during their first day of hospitalization. The other 9 had a quite rapid deterioration in the following days and died within a week (median syncope-to-death time was 7 days).ConclusionDespite our new finding needs confirmation in studies with larger sample size, our report shows how syncope may be the presenting symptom of COVID-19. Whether the exact mechanism has to be demonstrated, the mortality rate in patients presenting with syncope is higher than the mortality rate of patients presenting with other symptoms; therefore COVID-19 patients presenting with syncope should be on a watch list for rapid deterioration.Funding AcknowledgementType of funding sources: None.

COVID-19 Outcomes in Hospitalized Patients With Neurodegenerative Disease: A Retrospective Cohort Study.

COVID-19 outcomes in patients with neurodegenerative disorders (NDs) are not well understood, and we hypothesize that there may be increased morbidity and mortality in this group. This was a retrospective cohort study performed at 3 hospitals in the Chicagoland area. All patients hospitalized with COVID-19 infection with ND during a 3-month period (March 15, 2020-June 15, 2020) were included and compared with age-matched controls (CL) at 1:1 ratio. Primary outcomes were death, intensive care unit (ICU) admission, and invasive ventilation. Secondary outcomes included presenting COVID-19 symptoms, development of encephalopathy, supplementary oxygen use, discharge disposition, and risk factors for mortality. The study included 132 patients with neurodegenerative disorders and 132 age-matched CL. Ninety-day mortality (ND 19.7% vs CL 23.5%, p = 0.45) and ICU admission (ND 31.5% vs CL 35.9%, p = 0.43) rates were not significantly different between the 2 groups. Patients with ND had a lower rate of invasive ventilation (ND 11.4% vs CL 23.2%, p = 0.0075) and supplementary oxygen use (ND 83.2% vs CL 95.1%, p = 0.0012). Patients with ND were also more likely to have altered mental status or confusion as their presenting COVID-19 symptom and less likely to present with respiratory symptoms. Patients with ND were discharged to nursing home or hospice at higher rates compared with CL. We found that there was no difference in short-term mortality of patients with ND hospitalized for COVID-19 compared with CL, but they may have higher rates of neurologic complications and disability. Future studies should address long-term outcomes.

Skin Rash as Presenting Symptoms of COVID-19 in a Child

A 6-month-old male infant was admitted to our institute with a history of contact with COVID-19 positive relatives. The infant had a history of travel in a region that had registered a local surge 10 days back along with five fellow travelers from his family. The maternal uncle developed fever with myalgia after 3 days for which he tested for SARS-CoV-2 through real-time reverse transcriptase polymerase chain reaction (RT-PCR) and turned out to be positive. Therefore, upon testing of other family members because of close contact, this 6-month old infant, grandfather, and grandmother turned out to be RT-PCR COVID-19 positive. The infant’s father was living in another state because of his job and was therefore, not currently staying with the patient. On admission, the infant was asymptomatic. However, on day 4 of admission, the patient developed a generalized maculopapular rash over the body, predominantly involving face and back ( [Fig. 1] ). On the next day, the infant developed fever and diarrhea which lasted for 3 days which was managed with syrup paracetamol, zinc, and oral rehydration solution (ORS). Since the child was only experiencing mild symptoms, other laboratory investigations were not performed. The mother was tested thrice during the hospital stay and reported negative for SARS-CoV2. The infant was discharged after 7 days of an asymptomatic period.

EVALUATION OF PERFORMANCE OF NINE SEROLOGICALASSAYS FOR THE DETECTION OF SARS-COV-2 ANTIBODIES.

Introduction: Currently, polymerase chain reaction (PCR) based viral RNAdetection is the standard for COVID-19 diagnosis [2]. Though, RNA testing based on throat or nasopharyngeal swabs has shown a number of false-negative results. Antibody detection tests have been developed to detect specic antibodies, IgM and IgG, to SRAS-CoV-2 virus. The clinical relevance of these tests is still under evaluation and is highly related to their clinical performance. Our objective is to assess analytical performances of nine SARS-CoV-2 antibodies immunoassays. Materiel and Method: We collected 80 blood samples from PCR-conrmed COVID-19 patients diagnosed in our Virology department (20 samples collected at day 10 after the onset of symptoms, 60 collected after day 14 following the onset of symptoms) and 20 blood samples from patients SARS-CoV-2 RT-PCR negative. All sera were tested with nine SARS-CoV-2 antibodies immunoassays ARCHITECT SARS-CoV-2 IgG® (Abbott), COVID-19 VIRCLIA® IgG MONOTEST (Vircell), COVID-19 VIRCLIA® IgM+IgA MONOTEST (Vircell), COVID-19 ELISA IgG® (Vircell), COVID-19 ELISA IgM+IgA® (Vircell), Elecsys® Anti-SARS-CoV-2 (Roche), FREND® COVID-19 IgG/IgM Duo (NanoEntek), COVID-PRESTO® (AAZ) and COVID-19 (SARS-CoV-2) IgM/IgG Antibody Test Kit® (Labnovation Technologies). Results: Sensitivity of tests increases once the seroconversion to anti-SARS-CoV-2 IgG positive in most individuals occurs toward the end of week 2 post-infection. COVID-19 PRESTO had the best accuracy in our study showing 100% sensitivity after day 14 following the onset of symptoms. All of the tests had a specicity of 100%. Conclusion: Serological tests are sensitive for the latest stages of COVID-19 infection. Recommendations on using SRAS-COV-2 antibody detection tests are continuously improving based on current knowledge of host antibody responses during infection. They are of great value in cases presenting COVID-19 symptoms with negative RT-PCR.

Mortality of patients with solid and haematological cancers presenting with symptoms of COVID-19 with vs without detectable SARS-COV-2: a French nationwide prospective cohort study.

BackgroundOver 30 million COVID-19 cases have been diagnosed worldwide from late 2019. Among frail persons, cancer patients are at high risk of death from COVID-19.MethodsThe French prospective cohort ONCOVID-19 enrolled patients with solid or haematological tumour, receiving anticancer treatment and presenting with clinical symptoms suggestive of COVID-19. COVID-19 was confirmed through detectable SARS-CoV2 by RT-PCR (repeated twice if negative first) and/or specific CT-scan. The study aims to assess the 28-day mortality rate after the first COVID test.ResultsFrom March 1st to May 21st 2020, 23 French cancer centres and hospitals enrolled 1230 cancer patients with suspicion of COVID-19, including 1162 (94.5%) matching the inclusion criteria. We identified 425 (36.6%) COVID-19 positive patients including 155 (13.3%) diagnosed with CT-scan only, while 737 (63.4%) patients were COVID-19 negative. Death at day-28 occurred in 116/425 (27.8%) COVID-19 positive patients, and in 118/737 (16.3%) COVID-19 negative patients (p < 0·0001). With a median follow-up of 2.1 (1.6–2.4) months, 310 (26.7%) deaths were reported including 143 (33.6%) in the COVID-19 positive population, and 167 (22.7%) in the COVID-19 negative patients. Male gender, age, metastatic disease, immunosuppressive treatments, lymphopenia, COVID-19 diagnosis and diabetes were independent risk factors for death.ConclusionPatients with solid and haematological cancers presenting COVID-19 symptoms with SARS-CoV-2 RT-PCR confirmed or not are both at high-risk of early mortality. COVID-19 is reported as the cause of death in 50% of COVID-19 positive patients with cancer.Clinical trial registrationThis trial is registered with ClinicalTrials.gov, number NCT04363632.

Altered Mental Status: An Important but Overlooked Presenting Symptom of COVID-19 in Older Adults

ObjectivesTo determine whether altered mental status (AMS) as a presenting symptom in older adults with COVID-19 is independently associated with adverse outcomes.MethodsA retrospective single center observational study of admitted patients (n = 421) age greater than 60 and a positive COVID-19 test. Outcomes included mortality, intubation, acute respiratory distress syndrome, acute kidney injury, and acute cardiac injury. Multivariate regression analysis was used to determine if presenting with AMS was associated with adverse outcomes.ResultsThere was an increased risk of mortality (RR 1.29, 95% CI 1.05–1.57), intubation (RR 1.52, 95% CI 1.09–2.12) and AKI (RR 1.42, 95% CI 1.13–1.78) in patients that presented with AMS.ConclusionsDuring a global pandemic, prognostic indicators are vital to help guide the clinical course of patients, reduce healthcare cost, and preserve life. Our study suggests that AMS can play a major role in diagnostic algorithms in older adults with COVID-19.

Presenting symptoms of COVID-19 and clinical outcomes in hospitalised older adults.

BackgroundIn July 2020, a COVID‐19 outbreak was recognised in the geriatric wards at a subacute campus of the Royal Melbourne Hospital affecting patients and staff. Patients were also admitted to this site after diagnosis in residential care.AimsTo describe the early symptoms and the outcomes of COVID‐19 in older adults.MethodsPatients diagnosed with COVID‐19 at the facility in July or August 2020 were identified and their medical records were examined to identify symptoms present before and after their diagnosis and to determine their outcomes.ResultsOverall, 106 patients were identified as having COVID‐19, with median age of 84.3 years (range 41–104 years); 64 were diagnosed as hospital inpatients after a median length of stay of 49 days, 31 were transferred from residential aged care facilities with a known diagnosis and 11 were diagnosed after discharge. There were 95 patients included in an analysis of symptom type and timing onset. Overall, 61 (64.2%) were asymptomatic at the time of diagnosis of COVID‐19, having been diagnosed through screening initiated on site. Of these, 88.6% developed symptoms of COVID‐19 within 14 days. The most common initial symptom type was respiratory, but there was wide variation in presentation, including fever, gastrointestinal and neurological symptoms, many initially not recognised as being due to COVID‐19. Of 104 patients, 32 died within 30 days of diagnosis.ConclusionsCOVID‐19 diagnosis is challenging due to the variance in symptoms. In the context of an outbreak, asymptomatic screening can identify affected patients early in the disease course.

Headache as the Presenting Symptom of COVID-19 in Two Patients with a History of Migraine (4931)

Headache as the Presenting Symptom of COVID-19 in Two Patients with a History of Migraine (4931)

Refractory Focal Status Epilepticus as Presenting Symptom of COVID-19 (1999)

Refractory Focal Status Epilepticus as Presenting Symptom of COVID-19 (1999)

144 Probable Delirium is A Presenting Symptom of COVID-19 in Frail, Older Adults: A Study of Hospitalised and Community-Based Cohorts

IntroductionCOVID-19 exhibits a more severe disease course in older adults with frailty. Awareness of atypical presentations is critical to facilitate early disease identification. This study aimed to assess how frailty affects presenting symptoms of COVID-19 in older adults.MethodsObservational study of two distinct cohorts: (i) Hospitalised patients aged 65 and over; unscheduled admission to a large London teaching hospital between March 1st, 2020-May 5th, 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab (n = 322); (ii) Community-based adults aged 65 and over enrolled in the COVID Symptom Study mobile application between March 24th (application launch)-May 8th, 2020; self-report or report-by-proxy data; reported test-positive for COVID-19 (n = 535). Multivariable logistic regression analysis performed on age-matched samples of both cohorts to determine associations between frailty and symptoms of COVID-19 including delirium, fever and cough.ResultsHospital cohort: there was a significantly higher prevalence of delirium amongst the frail sample, with no difference in fever or cough. Of those presenting with delirium, 10/53 (18.9%) presented with delirium as the only documented symptom. Community-based cohort: there was a significantly higher prevalence of probable delirium in the frail sample, and also of fatigue and shortness of breath. Of those reporting probable delirium, 28/84 (33%) did not report fever or cough.ConclusionsThis study demonstrates a higher prevalence of delirium as a presenting symptom of COVID-19 infection in older adults with frailty compared to their age-matched non-frail counterparts. Clinicians should suspect COVID-19 in frail older adults presenting with delirium. Early detection facilitates infection control measures to mitigate against catastrophic spread and preventable hospitalisations and deaths amongst this population. Our findings emphasise the need for systematic frailty assessment for all acutely ill older patients in both hospital and community settings, as well as systematic evaluation of any change in mental status.

Considerations for delirium screening in response to a case of COVID-19 on an inpatient geriatric psychiatric unit

IntroductionWhile the COVID-19 pandemic caused by the SARS-CoV2 virus has challenged healthcare systems across the country, inpatient psychiatric hospitals struggle with a unique challenge. Psychiatric patients participate in therapy groups and eat meals together on milieus. It is difficult to enforce mask use or self-isolation practices in the setting of psychosis or mania.Additionally, neuropsychiatric disorders such as new onset psychosis, delirium, and affective disorders have all been documented following a SARS-CoV2 infection. A surveillance study from the UK found that primary psychiatric diagnoses were most common in younger patients and encephalopathy was more common in older adults following a SARS-CoV2 infection. A multicenter cohort study looking specifically at older adults found that 226 (28%) of 817 geriatric patients with COVID-19 had delirium at ED presentation. Delirium was the sixth most common of all presenting symptoms of COVID-19. Of patients with delirium, 16% had delirium as a primary presenting complaint and 37% had no fever or shortness of breath.Our psychiatric hospital has a geriatric psychiatry service, which has generated further challenges during the pandemic. The hospital requires COVID-19 testing prior to admission, but false negatives are possible. We continue to adapt our procedures to best serve this vulnerable population as we learn more about COVID-19 and atypical presentations. We provide a case report of a geriatric psychiatry patient who presented with delirium secondary to COVID-19 and the subsequent consideration in our admission process.MethodsA case report of a patient who was admitted to the geriatric psychiatry inpatient service and was found to have delirium as a presenting COVID-19 symptom. A review of neuropsychiatric manifestations of COVID-19 will be presented.ResultsMs. A is an 80-year-old woman with history of major depressive disorder, recent non-ST-elevation myocardial infarction, aortic stenosis, ischemic cardiomyopathy, and hypertension. She was originally admitted to the inpatient psychiatry from the ED for suicidal ideation and worsening depression but was found to be inattentive and disoriented. She had multiple falls in the several days leading up to admission, but no respiratory symptoms or fever. The geriatric psychiatry service determined she was delirious and started medical work up for etiology. Her rapid COVID-19 test at an outside facility was negative. Her medical work up was remarkable for a leukocytosis of 11 ×109 per liter, and an acute kidney injury (AKI) with BUN 20 mg/dL and Creatinine 1.31 mg/dL increased acutely from baseline of 0.9. Urinalysis was negative for infection. She was transferred to the emergency room for encephalopathy and declining oral intake. There, she tested positive for COVID-19 by PCR and was admitted to medicine for delirium of likely multiple etiologies including COVID-19. Her EEG showed generalized slowing and her head CT was negative for hemorrhage or infarction. The consult liaison psychiatry service continued to follow Mrs. A during her three-week hospitalization, during which she required Olanzapine 2.5 mg as needed for agitation related to her hyperactive delirium. Her AKI resolved with intravenous fluids and avoidance of nephrotoxic agents. She was discharged into the care of family on psychiatric medications fluoxetine 40 mg and mirtazapine 45 mg after her delirium gradually resolved with supportive care including physical and occupational therapy.ConclusionsThe diverse clinical presentation, often multifactorial etiology and the waxing and waning course of delirium makes it difficult to diagnose in an emergency room setting even for experienced physicians. Delirium can present with depressive, cognitive, and psychotic symptoms. It is not uncommon for delirious geriatric patients to be admitted to our inpatient unit for agitation, psychosis or depression, as was the case with Ms. A. Delirium can be a presenting symptom of COVID-19. Given this and our unique circumstances on a psychiatric milieu, we need to take greater consideration when assessing for delirium and other possible neuropsychiatric symptoms of SARS-CoV2 infection prior to admission. Grossman et al. developed a modified confusion assessment method for the emergency department (mCAM-ED) that requires 3 to 5 minutes to complete the whole instrument. However, despite having this and other tools, formal assessment tools for delirium are rarely used in the ED.It is important that geriatric patients are triaged to the appropriate level of care so proper medical treatment can be initiated without delay, as prolonged encephalopathy can lead to permanent decline in cognitive function, worse outcomes, and increased mortality. This case reinforces the clinical importance of including delirium on checklists of presenting symptoms of COVID-19, specifically for geriatric patients, that guide standardized screening, evaluation, and treatment.FundingThe authors received no financial support for the research, authorship, and/or publication of this article.

Phenotypes and Subphenotypes of Patients With COVID-19: A Latent Class Modeling Analysis

BackgroundSince COVID-19 was identified, its clinical and biological heterogeneity has been recognized. Identifying COVID-19 phenotypes might help guide basic, clinical, and translational research efforts.Research QuestionDoes the clinical spectrum of patients with COVID-19 contain distinct phenotypes and subphenotypes?Study Design and MethodsWe included adult patients (≥ 18 years) positive for laboratory-confirmed SARS-CoV-2 infection from a prospective COVID-19 registry database in the Cleveland Clinic Health System in Ohio and Florida. The patients were split into training and testing sets. Using latent class analysis (LCA), we first identified phenotypic clusters of patients with COVID-19 based on demographics, comorbidities, and presenting symptoms. We then identified subphenotypes of hospitalized patients with additional blood biomarker data measured on hospital admission. The associations of phenotypes/subphenotypes and clinical outcomes were investigated. Multivariable prediction models were established to predict assignment to the LCA-defined phenotypes and subphenotypes and then evaluated on an independent testing set.ResultsWe analyzed data for 20,572 patients. Seven phenotypes were identified on the basis of different profiles of presenting COVID-19 symptoms and existing comorbidities, including the following groups: young, no symptoms; young, symptoms; middle-aged, no symptoms; middle-aged, symptoms; middle-aged, comorbidities; old, no symptoms; and old, symptoms. The rates of inpatient hospitalization for the phenotypes were significantly different (P < .001). Five subphenotypes were identified for the subgroup of hospitalized patients, including the following subgroups: young, elevated WBC and platelet counts; middle-aged, lymphopenic with elevated C-reactive protein; middle-aged, hyperinflammatory; old, leukopenic with comorbidities; and old, hyperinflammatory with kidney dysfunction. The hospital mortality and the times from hospitalization to ICU transfer or death were significantly different (P < .001). The models for predicting the LCA-defined phenotypes and subphenotypes showed high discrimination (concordance index, 0.92 and 0.91).InterpretationHypothesis-free LCA-defined phenotypes and subphenotypes of patients with COVID-19 can be identified. These may help clinical investigators conduct stratified analyses in clinical trials and assist basic science researchers in characterizing the pathobiology of the spectrum of COVID-19 presentations.

Covid-19 in the elderly: Insight into Symptomatology.

Introduction: Ever since the end of 2019, the SARS-Cov2 virus started to emerge in Wuhan/ China and theories suggested a possible zoonotic transmission to human beings. Older people were considered to be the most afflicted by Covid-19 pandemic worldwide. Serious measures had been taken to mitigate the contagiousness of this virus especially in this age group, most of whom, presented with atypical symptoms. Methods: In this study we retrospectively studied the symptomatology of the disease in 79 subjects within the same care-home within a three-month period, (March-June 2020). Results: Within the total number of participants we were able to confirm the diagnosis of Covid-19 in 40 patients. Symptoms were mainly cough, shortness of breath and fatigue. Surprisingly, the rise in temperature was only a presenting symptom in few patients. However, many patients presented with tiredness, myalgia and worsening confusion as well as cough, which were the main presenting symptoms in the cohort. Conclusion and recommendations: Research is still trying to figure out the variation of symptoms between age groups especially the low temperature rates in the geriatric age groups. This could be explained by the dormancy of interleukins in older patients due to the physiological process of ageing. Mortality rates were predictably high secondary to the plethora of comorbidities in older patients. It is empirical for health care professionals to consider the non- classical presenting symptoms of Covid-19 in elderlies. More public health awareness is needed to help patients, relatives and carers to recognize the disease early, despite the lack of typical symptoms.

Streamlining the dental care during COVID-19 pandemic: updated clinical recommendations and infection control management framework

Several guidelines for dental practice have been published by dental associations and regulatory boards since the beginning of the pandemic. Initially, all non-emergency dental treatment were suspended. Healthcare personnel around the world are gradually expanding back to elective procedures. International updated recommendations alert that professionals must maintain regular observation of local health department reports, ensure personal protective equipment, and screen all patients for COVID-19 signs and symptoms. Telehealth strategies, patient screening, rescheduling when presenting COVID-19 symptoms and/or history of contact with infected people and hand/environment hygiene practices are reinforced. Appropriate cleaning and surface disinfection are mandatory. The dental staff must be trained to use appropriate Personal Protective Equipment (PPE), following a risk assessment and standard precautions: gloves; fluid resistant disposable gown, eye protection (face shield or goggles) and a medical mask. A fit tested N95 or KN95 respirator (or higher) is recommended when aerosol generating procedures are performed. Only essential accompanying persons should attend to dental appointment with the patient and must wear a cloth face covering or facemask. Social distancing and mask wearing by all staff are necessary in all areas of the office. Dental health care providers should keep up to date to the current guidance of clinical practice during the pandemic.