Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved.This first in a two-part series on COVID-19 updates provides a focused overview of the presentation and evaluation of COVID-19 for emergency clinicians.COVID-19, caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality worldwide. Several variants exist, including a variant of concern known as Delta (B.1.617.2 lineage) and the Omicron variant (B.1.1.529 lineage). The Delta variant is associated with higher infectivity and poor patient outcomes, and the Omicron variant has resulted in a significant increase in infections. While over 80% of patients experience mild symptoms, a significant proportion can be critically ill, including those who are older and those with comorbidities. Upper respiratory symptoms, fever, and changes in taste/smell remain the most common presenting symptoms. Extrapulmonary complications are numerous and may be severe, including the cardiovascular, neurologic, gastrointestinal, and dermatologic systems. Emergency department evaluation includes focused testing for COVID-19 and assessment of end-organ injury. Imaging may include chest radiography, computed tomography, or ultrasound. Several risk scores may assist in prognostication, including the 4C (Coronavirus Clinical Characterisation Consortium) score, quick COVID Severity Index (qCSI), NEWS2, and the PRIEST score, but these should only supplement and not replace clinical judgment.This review provides a focused update of the presentation and evaluation of COVID-19 for emergency clinicians. 

https://doi.org/10.1016/j.ajem.2022.01.028

Clinical update on COVID-19 for the emergency clinician: Presentation and evaluation

Autoimmune and autoinflammatory conditions after COVID-19 vaccination. New case reports and updated literature review

Editor's Choice – Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature

A clear temporal relationship between myocarditis and pericarditis after COVID-19 vaccination has led to the belief that the vaccine may act as a trigger for these cardiologic complications. The aim of this systematic review is to explore the incidence, clinical presentation, management, and association between them.We conducted a systematic literature search on Cochrane, MEDLINE, and EMBASE as per guidelines of PRISMA (Preferred Reporting Items for Systematic Reviews). A total of 41 case reports and case series describing 97 patients, and 5 original articles describing 15,585,309 participants were selected as part of this review.Of the 97 reported cases describing vaccine-associated myocarditis/pericarditis, 67 (69%) patients received Pfizer-BioNTech and 25 (25.7%) received Moderna. The mean onset of symptoms after vaccine administration was 3.8 ± 4.5 days with three-quarters developing symptoms after the second dose. Chest pain (n = 88, 90%) and fever (n = 33, 34%) were the most common presenting complaints. Out of 97, 80 (82.5%) patients recovered while 4 (4.1%) patients expired. The pooled incidence of myocarditis and pericarditis extrapolated from original studies is 0.001% and 0.0004%, respectively. In the original studies, nearly all the cases of myocarditis and pericarditis were mild. Chest pain and fever were the most common presenting symptoms.Myocarditis and pericarditis after the COVID-19 vaccine have been reported more in young adult males and are most likely to occur after the second dose of mRNA vaccines. The presentation is mild and the majority of the patients recover either completely or partially. 

https://doi.org/10.1016/j.amsu.2022.103486

Development of myocarditis and pericarditis after COVID-19 vaccination in adult population: A systematic review

https://run.unl.pt/bitstream/10362/127646/1/1_s2.0_S1078588421006882_main.pdf

Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature.

We report 11 cases of combined diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNK) in coronavirus 2019 patients who presented to our institution in New Jersey, USA. The median age was 47 years (range 12-88 years). Out of the 11 patients, 7 were male and 4 were female. Out of 11 patients, 8 had type 2 diabetes mellitus (DM), 2 had undiagnosed DM, and 1 had type 1 DM. Presenting complaints included altered mental status, weakness, shortness of breath, cough, fever, vomiting, abdominal pain, chest pain, and foot pain. Out of 11 patients, pneumonia was diagnosed at presentation in 8 patients, while in 3 patients, chest X-ray was clear. Median value of initial glucose on presentation was 974 mg/dL (range 549-1556 mg/dL), and hemoglobin A1c on presentation was 13.8%. The median value of anion gap was 34 mEq/L. Out of the 11 patients, ketonemia was moderate in 6 patients, large in 3, and small in 2 patients. Acute kidney injury (AKI) occurred in 9 patients and 2 patients required renal replacement therapy. Out of the 11 patients, 6 required mechanical ventilation and 7 patients died. All the 6 patients requiring mechanical ventilation died. Our case series shows COVID-19 infection can precipitate acute metabolic complications in known DM patients or as first manifestation in undiagnosed DM patients. Patients can present with DKA/HHNK symptoms and/or respiratory symptoms. Mechanical ventilation is a poor prognostic factor. Further studies are needed to characterize prognostic factors associated with mortality in this vulnerable patient population.

https://journals.sagepub.com/doi/pdf/10.1177/23247096211021231

COVID-19 and Combined Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Coma: Report of 11 Cases.

Aim To describe the clinical characteristics and outcome of hospitalized COVID-19 patients with diabetic ketoacidosis (DKA) Methods We report eight cases of diabetic ketoacidosis in COVID-19 who presented to our institution in New Jersey, USA COVID-19 was diagnosed by nasopharyngeal swab reverse transcription polymerase chain reaction (RT-PCR) The patients' electronic medical records were reviewed Data on patients' age, sex, ethnicity, laboratory values, glycosylated hemoglobin level, oral antihyperglycemic agents (OHAs), insulin, and clinical outcomes were collected Results The median age of the patient was 425 years, and seven were males and one was female Out of eight patients, five had type 2 diabetes mellitus (DM), two had undiagnosed DM, and one had type 1 DM Median value of initial glucose on presentation was 454 mg/dL Median value of HbA1c on presentation was 114% and of anion gap was 265 mEq/L Four patients had large ketonemia, one patient had moderate ketonemia, and three patients had small ketonemia All the patients were started on standard treatment protocol for DKA with intravenous fluids and IV insulin infusion Acute kidney injury (AKI) was seen in four patients, and one patient required renal replacement therapy Out of eight patients, three required mechanical ventilation, and the same three patients died Conclusion Our case series shows that COVID-19 infection can precipitate DKA in patients with known diabetes mellitus patients or as a first manifestation in undiagnosed DM patients; COVID-19 with DKA is associated with substantial mortality Further studies are needed to characterize poor risk factors associated with mortality in these patients

/pdf/covid-19-and-diabetic-ketoacidosis-report-of-eight-cases-1fdpfw2sqq.pdf

COVID-19 and Diabetic Ketoacidosis: Report of Eight Cases

ST-Segment Elevation in Patients with COVID-19: A Late Complication.

COVID–19 and arterial thrombosis: Report of 2 cases

BACKGROUND AND OBJECTIVES: To describe the clinical characteristics and outcomes of hospitalized coronavirus disease 2019 (COVID-19) patients with diabetic ketoacidosis (DKA) -- a single center tertiary hospital experience MATERIALS AND METHODS: A retrospective study was conducted among patients admitted to our hospital in the United States between March 1st and June 15th, 2020 with DKA and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection known as COVID-19 We compared the baseline characteristics, laboratory data, and clinical course between survivors and nonsurvivors to identify the risk factors associated with mortality in the patients with DKA RESULTS: A total number of 43 patients were included in this study The median age was 52 years Thirty-three (76 7%) patients were male Median value of initial glucose on presentation was 553 mg/dL (300 0-1927 0 mg/dL) On admission, 33 (76 7%) patients had glycated hemoglobin (HbA1c)>=8% (64 mmol/mol) and HbA1cwas not obtained in 10 (23 3%) patients Acute kidney injury (AKI) was seen in 37 (86 0%) patients, 6 (14%) patients required renal replacement therapy and 22 (51 2%) required mechanical ventilation Among the 43 patients, 25 (58 1%) died Out of 25 patients who died 15 (60 0%) were Hispanics, 6 (24 0%) were White, 3 (12 0%) were African American, 1 (4%) was Arabic, and 1 (4%) was Asian The patients who died were older in age than who survived (mean age 58 +/- 6 13 vs 46 +/- 9 39;p = 0 023) Some 95% of the patients requiring mechanical ventilation died (odds ratio [OR]: 89 25;95% confidence interval [CI]: 9 10-874 96);p=0 001) Compared to survivors, nonsurvivors had significantly higher d-dimer (13 00 +/- 3 20 mcg/mL vs 6 15 +/- 3 66 mcg/mL;p< 0 006) and peak ferritin values (2763 66 +/- 1105 32 ng/mL vs 835 16 +/- 257 07 ng/mL;p= 0 016) Conclusion: Our retrospective study shows COVID-19 infection may present as DKA in patients with diabetes mellitus (DM) Older age, mechanical ventilation, elevated d-dimer, and ferritin are associated with poor prognosis in these patients Our study shows that COVID-19 is associated with substantial mortality in DKA patients and adds to the limited literature available regarding poor risk factors associated with mortality in these patients

COVID-19 and Diabetic Ketoacidosis: A Single Center Experience

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