Molecular Diagnostics on Smartphone

During the COVID-19 pandemic, point-of-care genetic testing (POCT) devices were used for on-time and on-site detection of the virus, which helped to prevent and control the spread of the pandemic. Smartphones, which are widely used electronic devices with many functions, have the potential to be used as a molecular diagnostic platform for universal healthcare monitoring. Several integrated diagnostics platforms for the real-time and end-point detection of COVID-19 were developed using the functions of smartphones, such as the operating system, power, sound, camera, data storage, and display. These platforms use the 5V output power of smartphones, which can be amplified to power a micro-capillary electrophoresis system or a thin-film heater, and the CMOS camera of smartphones can capture the color change during a colorimetric loop-mediated isothermal amplification test and detect fluorescence signals. Smartphones can also be used with self-written web-based apps to enable automatic and remote pathogen analysis on POCT platforms. Our lab developed a handheld micro-capillary electrophoresis device for end-point detection of SARS-CoV-2, as well as an integrated smartphone-based genetic analyzer for the qualitative and quantitative colorimetric detection of foodborne pathogens with the help of a custom mobile app. © 2023 SPIE.

Covid-19 vaccine responses in individuals with type 1 diabetes are comparable to control subjects without diabetes

Aims/Hypothesis: Covid-19 has been associated with poorer outcomes in individuals with type 1 diabetes. Most existing data relate to hospitalised patients with few data available on seroprevalence and the effects of Covid-19 on people with diabetes in the general population. We examined antibody responses to SARS Cov-2 infection and vaccination in people with and without diabetes. Method(s): From June 2020, capillary blood samples collected remotely from 1828 individuals (type 1 diabetes n = 267) were analysed for SARS-CoV- 2 antibodies to RBD (infection pre-Jan 2021/vaccination post -Jan 21) and N (infection post Jan 21) antigens using low serum volume luciferase-based assays developed "in house". Questionnaire data recording experiences of Covid-19 and vaccinations dates were collected simultaneously with the samples. Median antibody levels were compared using Kruskal-Wallis tests. Result(s): There was evidence of SARS CoV-2 infection in 317/1828 (17%) of individuals screened with no evidence of more severe self-reported Covid-19 symptoms in those with diabetes (no participants were hospitalised) and almost a quarter of those with type 1 diabetes were asymptomatic. Although samples were collected at variable time points from vaccination, robust antibody responses to vaccination were observed (Pfizer, AstraZeneca, and Moderna) after the second vaccination with no differences in antibody levels between those with and without diabetes (p = 0.3). Conclusion(s): Hospitalised individuals with Covid-19 and type 1 diabetes were at greater risk of complications but this study shows that among the non-hospitalised population, clinical symptoms, antibody responses to infection, and vaccination in those with type 1 diabetes was similar to control subjects.

Advancements in portable instruments based on affinity-capture-migration and affinity-capture-separation for use in clinical testing and life science applications.

The shift from testing at centralized diagnostic laboratories to remote locations is being driven by the development of point-of-care (POC) instruments and represents a transformative moment in medicine. POC instruments address the need for rapid results that can inform faster therapeutic decisions and interventions. These instruments are especially valuable in the field, such as in an ambulance, or in remote and rural locations. The development of telehealth, enabled by advancements in digital technologies like smartphones and cloud computing, is also aiding in this evolution, allowing medical professionals to provide care remotely, potentially reducing healthcare costs and improving patient longevity. One notable POC device is the lateral flow immunoassay (LFIA), which played a major role in addressing the COVID-19 pandemic due to its ease of use, rapid analysis time, and low cost. However, LFIA tests exhibit relatively low analytical sensitivity and provide semi-quantitative information, indicating either a positive, negative, or inconclusive result, which can be attributed to its one-dimensional format. Immunoaffinity capillary electrophoresis (IACE), on the other hand, offers a two-dimensional format that includes an affinity-capture step of one or more matrix constituents followed by release and electrophoretic separation. The method provides greater analytical sensitivity, and quantitative information, thereby reducing the rate of false positives, false negatives, and inconclusive results. Combining LFIA and IACE technologies can thus provide an effective and economical solution for screening, confirming results, and monitoring patient progress, representing a key strategy in advancing diagnostics in healthcare.

Diagnostic and therapeutic considerations in idiopathic systemic capillary leak syndrome: a case report

Background: Systemic capillary leak syndrome (SCLS) is a rare disorder which leads to severe shock. Typically, endothelial dysfunction leads to massive leakage of fluids from the intravascular compartment to the interstitial space, causing hemoconcentration, hypoalbuminemia, hypotension and potential organ failure. The syndrome may be idiopathic or triggered by disease, such as viral infections. The syndrome is often unrecognized and besides resuscitation, no effective treatments are known. Case Description: Here we describe a 46-year-old female with recurrent episodes of shock due to unrecognized SCLS, with the second episode being triggered by an asymptomatic COVID-19 infection. She was, besides resuscitation, treated with high dose vasopressors and intravenous immunoglobulins (IVIG). The case is complicated by compartment syndrome with infected muscle necrosis and eventually amputation of both lower legs. Moreover, the patient still has a chronic kidney insufficiency. In this case report we will discuss pittfalls and potential therapeutic options in SCLS treatment. Conclusions: Vasopressor use may aggravate ischemic complications in a hypovolemic condition and its use should therefore be discouraged in these patients. Cardiac output monitoring should be considered early. The use of IVIG might be beneficial in the acute phase as well as in preventing future episodes of shock. Whether the use of bevacizumab is also of value is yet unclear. © Journal of Emergency and Critical Care Medicine. All rights reserved.

Comparison of HbA1c measurement in remotely prepared capillary versus standard venous blood samples

Background The COVID-19 pandemic has disrupted routine HbA1c testing. This has led to difficulties in monitoring glycaemic control and identifying people with suboptimal glycaemia. Delayed diagnosis of diabetes and suboptimal glycaemic control over extended periods can increase the risk of developing long-term complications of diabetes. The self-collection of capillary blood remotely (at home) for routine HbA1c testing can facilitate monitoring of glycaemic control whilst supporting virtual consultations. The aimof this study was to assess the clinical performance and user acceptance of capillary blood samples prepared remotely using the MiniCollect capillary blood collection device as an alternative to standard venous blood collection for HbA1c analysis. Methods Adult men and women with any type of diabetes were recruited. Following informed written consent, eligible participants provided a venous blood sample at their routine clinic appointment and subsequently prepared a capillary blood sample remotely. Participants also completed a bespoke usability questionnaire. Results Of 84 participants recruited, 62 capillary samples returned to the laboratory, with 41 having a paired venous sample for HbA1c analysis. HbA1c results using both collection methods demonstrated good agreement;Passing-Bablok Regression analysis, y=0 + 1x;R=0.986, Bland-Altman Difference Plot providing a mean difference of 0.3 mmol/mol. Conclusions Over half of participants found the MiniCollect device easy to use. The majority were in favour of the remote capillary blood collection service and would use it if routinely available. The remote self-collection of capillary blood for HbA1c is a convenient alternative for people with diabetes living and working in rural or urban settings ensuring optimal continuance of care.

Vaccination against COVID-19.

Vaccination is essential to manage the COVID-19 pandemic. Vaccination significantly protects against severe COVID-19, hospitalization and death;it also protects against symptomatic infection and reduces the risk of transmission to other people. Protection against the new SARS-CoV-2 variants may be lower, but protection against severe course and death remains high. Two mRNA vaccines (BNT162b2 and mRNA-1273) and two vector vaccines (AZD1222 and Ad26.COV2.S) are currently available in the Czech Republic. Vaccination of persons over 60 years of age and immunocompromised persons, who are demonstrably at the highest risk of a serious course of the disease, is of the utmost importance. In order to achieve adequate vaccination coverage, it is necessary to motivate other groups of people to be vaccinated, including children over 12 years of age and young adults. Vaccination is also recommended in preg-nant women in the 2nd and 3rd trimesters and in breastfeeding women. For selected groups of vaccines, a third dose of vaccination is recommended (additional third dose 4 weeks after the second dose or a booster dose 8 to 12 months after the second dose). The side effects are usually mild, with serious complications (including anaphylaxis, thrombocytopenia with thrombosis syndrome, myocardi-tis, Guillain-Barre syndrome and capillary leak syndrome) being rare.Copyright © 2021, Trios spol. s.r.o.. All rights reserved.

Mechanisms of impaired gas exchange following hospitalisation for severe COVID-19

Introduction/Aim: Reduced carbon monoxide diffusing capacity (DL CO) is common after recovery from severe COVID-19 and cohort studies have found it to be more abnormal than either VC or TLC. There is no specific evidence that this relates to membrane disfunction or vascular injury. Concurrent measurement of nitric oxide diffusing capacity (DL NO) and DL CO can be used to partition gas diffusion into its two components - membrane conductance (D m CO) and capillary blood volume (V C). In this study, we sought to evaluate D m CO and V C in the early and later recovery periods after severe COVID-19. Method(s): Patients attended for post-COVID outpatient clinical review and complex lung function testing including DL NO /DL CO (Hyp'Air;Medisoft, Leeds). Further appointments and repeat testing occurred when indicated. Lung function comparisons were made using t-tests. Result(s): 46 (8 female) subjects (mean+/-SD age 58+/-13, BMI 34+/-8), who had severe COVID pneumonitis, WHO ordinal severity classification of 6+/-1 and prolonged (19+/-22 days) length of hospital stay, were assessed 51+/-29 days post discharge. Mean TLC [z-score -1.64+/-1.31] and D L CO [z-score -1.60+/-1.48] were both reduced. V C and D m CO were reduced to a similar extent (Z-score -1.36+/-1.19 and -1.14+/-1.06, p=0.4). 14 (1 female) patients returned for testing 70+/-35 days later. In this subgroup, D L CO improved but remained below LLN (Z-score -2.98+/-0.73 [Visit 1] Vs -2.17+/-0.69 [Visit 2], p=0.01). D m CO improved (Z-score -1.99+/-0.91 Vs -1.25+/-1.17, p=0.01) but V C was unchanged (Z-score -2.33+/-0.53 Vs -2.03+/-0.76, p=0.17). Conclusion(s): Gas exchange is persistently abnormal after severe COVID. Membrane conductance is abnormal in the earlier recovery phase but improves to a significant extent. In contrast, reduced capillary blood volume persists. Repeat testing at longer intervals after recovery from acute illness is still required but these data raise the possibility that persisting effects of acute vascular injury will contribute to physiological impairment long after severe COVID pneumonitis.

Mechanisms of impaired gas exchange following hospitalisation for COVID-19

Introduction/Aim: Reduced carbon monoxide diffusing capacity (DL CO) is the most prevalent lung function abnormality post COVID-19 infection. Two studies suggested this relates to alveolar unit loss with preserved capillary blood volume. The measurement of nitric oxide diffusing capacity (D L NO) concurrently with D L CO allows for the quantitation of the membrane component of gas diffusion (D m CO) and capillary blood volume (V C). We sought to monitor D m CO and V C in the recovery period of patients hospitalised for severe COVID-19. Method(s): Patients attended outpatient clinical review and lung function testing including DL NO /DL CO (Hyp'Air;Medisoft, Leeds), with further appointment if indicated. Lung function comparisons were made using t-tests and clinical associations using Pearson correlation. Result(s): 46 (8 female) patients (mean+/-SD) (age 58+/-13, BMI 34+/-8), were assessed 51+/-29 days post discharge. WHO ordinal severity classification was 6+/-1, suggesting severe disease, with prolonged (19+/-22 days) length of admission. V C and D m CO were similarly reduced (Z-score -1.36+/-1.19 Vs -1.14+/-1.06, p = 0.4). V C was negatively correlated with length of stay (r=-0.42, p < 0.01). TLC (Z-score -1.64+/-1.31) and D L CO (-1.60+/-1.48) were significantly reduced and negatively correlated with length of stay (r>-0.41, p<=0.02). WHO severity negatively correlated with TLC only (r=-0.45, p < 0.01). Demographic and biochemical data did not correlate with lung function.14 (1 female) patients returned for repeat testing 70+/-35 days later. D m CO improved (Z-score -1.99+/-0.91 Vs -1.25+/-1.17, p = 0.01). V C was unchanged (Z-score -2.33+/-0.53 Vs -2.03+/-0.76, p = 0.17). D L CO improved but remained below LLN (Z-score -2.98+/-0.73 Vs -2.17+/-0.69, p = 0.01). Conclusion(s): Similar reductions in D m CO and V C following hospitalisation for COVID-19 were identified. In those who returned for repeat testing, D m CO values normalised, but V C did not improve. Abnormal lung function related to increasing severity and length of stay. These findings suggests vascular injury may play a more important role rather than alveolar unit loss as the primary contributor to gas exchange impairment following COVID-19.

Capillary leak syndrome following COVID-19 vaccination: Data from the European pharmacovigilance database Eudravigilance.

Capillary leak syndrome (CLS) emerged as new adverse event after immunization (AEFI) associated to COVID-19 vaccination. CLS is a rare condition characterized by increased capillary permeability, resulting in hypoalbuminemia, hypotension, and edema mainly in the upper and lower limbs. Our pharmacovigilance study aims to evaluate the CLS onset following receipt of COVID-19 mRNA vaccines (mRNA-1273 and BNT162b2) compared to viral vector vaccines (Ad26.COV2-S and ChAdOx1-SARS-COV-2). We carried a cross-sectional study using all Individual Case Safety Reports (ICSRs) reporting a COVID-19 vaccine as suspected drug and CLS as AEFI, which were collected in the pharmacovigilance database EudraVigilance from January 1st, 2021, to January 14th, 2022. We applied the Reporting Odds Ratio (ROR) 95% CI for the disproportionality analysis. During our study period, CLS was described as AEFI in 84 out of 1,357,962 ICRs reporting a vaccine COVID-19 as suspected drug and collected in the EV database. Overall, the ICSR reported by CLS were mainly related to the viral vector COVID-19(ChAdOx1-SARS-COV-2 = 36; Ad26.COV2-S = 9). The mRNA COVID-19 vaccines were reported in 39 ICSRs (BNT162b2 =33; mRNA-1273 =6). Majority of ICSRs were reported by healthcare professionals (71.4%). Majority of the patients were adult (58.3%) and the female gender accounted in more than 65% of ICSRs referred both to classes vaccines. In particular, women were more represented in ICSRs referred to mRNA-1273 (83.3%) and to ChAdOx1-SARS-COV-2 (72.2%). The CLS outcome was more frequently favorable in mRNA ICSRs (33,3%) than the viral vector ones (13.3%). Among the ICSRs reporting CLS with unfavorable outcome, we found also 9 fatal cases (BNT162b2 = 1; ChAdOx1-SARS-COV-2 = 4; Ad26.COV2-S = 4). From disproportionality analysis emerged a lower CLS reporting probability after vaccination with mRNA vaccines compared to viral vector-based ones (ROR 0.5, 95% CI 0.3-0.7; p <0.001).Our findings, even if subject to the limitations of spontaneous reporting systems, suggest a small but statistically significant safety concern for CLS following receipt of COVID-19 viral vector vaccines, in particular with Ad26.COV2-S. Cytokine-release following T-cell activation could be involved in CLS occurrence, but a precise mechanism has been not yet identified. COVID-19 vaccines remain attentive as possible triggers of CLS.

Dermatomyositis with Specific Autoantibodies Appearing after Sars-Cov-2 Infection or Mrna Vaccination: Hints at a Shared Pathogenetic Mechanism

Background. Environmental factors such as infections and vaccines are known to trigger dermatomyositis (DM), and during the recent SARS-CoV-2 pandemic this has become even clearer. SARS-CoV-2 infection may share features with anti-MDA5 DM, such as rapidly progressive lung involvement, cutaneous lesions and cytokine release syndrome. A few case reports of DM following SARSCoV-2 vaccination have been published, suggesting the onset of an aberrant immune response leading to DM with specific autoantibody signatures and severe organ impairment. Methods. Clinical and laboratory data of the 2 case reports were obtained from electronic clinical charts in Humanitas Research Hospital (Rozzano, Milan, Italy). Autoantibody analysis was performed by protein-immunoprecipitation for anti-MDA5 and immunoblot for anti-Ro52 and TIF1gamma antibodies as per protocol. Results. Case report 1 is a 71-year-old woman who developed fever, cough, and anosmia, which resolved spontaneously in two weeks, but did not undergo a nasopharyngeal swab, while her relatives were diagnosed with SARS-CoV-2 infection. When symptoms improved, she developed arthralgia and skin lesions on her face, chest, and hands for which she started topical treatment, with negative SARSCoV-2 nasopharyngeal swab and positive serum test for IgG against SARS-CoV-2 spike protein. For the persistence of the skin rash and arthralgia, she was admitted to our Department in March 2021. Blood tests showed mild elevation of C reactive protein (2.1 mg/L -normal value NV<5), aspartate (84 UI/L) and alanine aminotransferase (133 UI/L -NV<35), ferritin (595 ng/ml -NV<306), troponin I (19 ng/L -NV<14), and BNP (251 pg/ml -NV<100) with normal complete blood cell count, creatine kinase, C3 and C4. IgG antibodies for SARS-CoV-2 spike protein were confirmed to be elevated (96 AU/ml -NV<15). Autoantibodies associated with connective tissue diseases were tested and only anti-MDA5 antibodies were positive at immunoprecipitation. A punch biopsy of a Gottron-like lesion on the left hand showed leukocytoclastic vasculitis. We observed reduced capillary density with neoangiogenesis and ectasic capillaries at the nailfold capillaroscopy. EKG and ecocardiography were normal, while cardiac magnetic resonance detected abnormalities in the parametric sequences, consistent with signs of previous myocarditis. A lung CT scan revealed pulmonary emphysema while respiratory function tests demonstrated reduced volumes (FVC 82%, FEV1 64%, inadequate compliance CO diffusion test). Based on the biochemical and clinical findings, a diagnosis of anti-MDA5-associated DM with skin and heart involvement was made and treatment with low-dose methylprednisolone (0.25 mg/kg daily) and azathioprine 100 mg was started, then switched to mycophenolate because not effective on skin lesions. Case report 2 is an 84-year-old woman with history of colon cancer (surgical treatment) and oral lichen treated with low doses steroids in the last 2 years. After the 2nd dose of SARS-CoV-2 mRNA vaccination, in March 2021 she developed skin rash with V-sign, Gottron's papules, periungueal ulcers, muscle weakness and fatigue, thus she performed a rheumatologic evaluation. Blood tests showed mild elevation of creatine kinase (484 UI/L, NV <167), CK-MB (9.6ng/ml, NV <3.4), BNP (215 pg/ml -NV<100) with normal values of complete blood cell count, C3 and C4. Anti-Ro52kDa and TIF1gamma were positive at immunoblot, thus we confirmed a diagnosis of DM. The clinical evaluation also showed active scleroderma pattern at nailfold capillaroscopy, normal echocardiography, bronchiectasia but not interstitial lung disease at lung CT, and normal respiratory function tests (FVC 99%, FEV1 99%, DLCO 63%, DLCO/VA 81%). A PET-CT scan was performed to exclude paraneoplastic DM, and treatment with steroids and mycophenolate was started. Conclusions. SARS-CoV-2 may induce mechanisms for escaping the innate immunity surveillance and causing autoimmune diseases, but more clinical and functional studies are needed to demonstrate this possible association.

Long COVID-19 syndrome: Association of cardiopulmonary impairment with a persistent platelet activation

Background: A considerable proportion of patients do not fully recover from COVID-19 infection and report symptoms that persist beyond the initial phase of infection: This condition is defined long-COVID-19 syndrome (LCS). LCS can involve lungs as well as several extrapulmonary organs, including the cardiovascular system. The risk and 1-year burden of cardiovascular diseases (CVD) is increased in COVID-19 survivors, even in subjects at low risk of CVD. Recently, we documented that acute COVID- 19 infection induces altered platelet activation state characterized by a prothrombotic phenotype and by the formation of platelet-leukocyte aggregates (PLA), that may be involved in the pulmonary microthrombi found in autoptic specimens. No data are yet available on the contribution of platelet activation to residual pulmonary impairment and procoagulant potential in LCS patients. Purpose(s): To study platelet activation status, microvesicle (MV) profile, platelet thrombin generation capacity (pTGC) in LCS patients enrolled at 6 months after resolution of the acute phase (6mo-FU), compared to acute COVID-19 infection patients. Method(s): 6mo-FU COVID-19 patients (n=24) with established LCS were enrolled at Centro Cardiologico Monzino. Residual pulmonary impairment was assessed by Cardiopulmonary Exercise Testing (CPET) and 64-rows- CT scan evaluation. Platelet activation (P-selectin, Tissue Factor [TF] and PLA) and MV profile were assessed by flow cytometry;pTGC by calibrated automated thrombogram. 46 patients enrolled during acute COVID-19 infection and 46 healthy subjects (HS) were used for comparison. Result(s): Dispnea in LCS patients was confirmed by CPET showing compromised alveolus-capillary membrane diffusion and residual pulmonary impairment. TF+-platelet and -MV levels were 3-fold (1.5% [1.2-2.9] vs 2.4% [1.6-5.7]) and 2-fold (217/mul [137-275] vs 435/mul [275-633]) lower at 6mo-FU compared to acute phase, being comparable to HS. pTGC behaved similarly. At 6mo-FU, the MV profile, in terms of total number and cell origin, returned to physiological levels. Conversely, although lower than that measured in acute phase, a 2.5-fold higher platelet P-selectin expression (6.9% [3-13.5] vs 11.7% [5.2-18.9]) and PLA formation (35.5% [27.4- 46.8] vs 67.7% [45.7-85.3]) was observed at 6mo-FU compared to HS. Interestingly, a significant correlation between PLA formation and residual pulmonary impairment was observed (r=-0.423;p=0.02). Conclusion(s): These data strengthen the hypothesis that the presence of PLA in the bloodstream, and thus also in the pulmonary microcirculation, may contribute to support pulmonary dysfunction still observed in LCS patients.

Sars-Cov-2 Associated Myopathy

An association between SARS-CoV-2 infection and myopathy was suspected early in the pandemic: patients with severe COVID-19 showed increased levels of creatine kinase that could not be solely explained by cardiac affection. On the other hand, myalgia and muscle weakness are frequent symptoms in patients with mild or moderate COVID-19 - as with many other viral infections -and subsets of infected patients report persistent muscular weakness and fatigue even months after the initial infection. We performed a case-control autopsy comparing patients with severe COVID-19 to patients with other critical illnesses and assessed inflammation of skeletal muscle tissue by quantification of immune cell infiltrates, expression of major histocompatibility complex (MHC) class I and class II antigens on the sarcolemma. Relevant expression of MHC class I antigens on the sarcolemma was present in 23 of 42 specimens from patients with COVID-19 (55%) and upregulation of MHC class II antigens in 7 of 42 specimens from patients with COVID-19 (17%), but neither were found in any of the controls. In a subset of patients, MHC class I and MHC class II expression showed a clear perifascicular pattern. Signs of degenerating and necrotic fibers could also be found, however there was no statistically significant difference in the frequency of occurrence when compared to non-COVID-19 critically ill patients. We interpreted this as non-specific signs of muscular damage in critically ill patients. Numbers of macrophages, lymphocytes and natural killer cells were found to be increased in muscles from patients with COVID-19. Interestingly, no relevant expression of MxA on myofibers could be found by immunohistochemistry, but in some cases, expression of MxA was found on capillaries. Ultrastructural analysis of selected muscles with perifascicular MHC-expression did not show tubuloreticular inclusions. However, capillaries of the analyzed samples showed basement membrane alterations and signs of ongoing regenerative processes. In addition, we evaluated inflammation of cardiac muscles by quantification of immune cell infiltrates in the same patients, and found that skeletal muscles showed more inflammatory features than cardiac muscles. Moreover, inflammation was most pronounced in patients with COVID-19 with chronic courses. In some muscle specimens, SARS-CoV-2 RNA was detected by reverse transcription-polymerase chain reaction, but no evidence for a direct viral infection of myofibers was found by immunohistochemistry or electron microscopy. This suggests that SARS-CoV-2 may be associated with a postinfectious, immune-mediated myopathy.

Unusual Myositis of the Temporalis Muscle Occurring with Acute Covid-19

Background. SARS-CoV-2 infection can be accompanied by neuromuscular disorders. Rhabdomyolysis and Guillain-Barre syndrome have been described repeatedly. There are case reports of inflammatory myopathies manifesting during COVID-19, presenting as dermatomyositis, polymyositis or immune-mediated necrotizing myopathy, with dermatomyositis-like presentations most commonly reported. Larger cases series are from postmortem examinations of COVID-19 patients, where variable inflammatory pathology of the skeletal muscle has been found frequently but without local detection of the actual virus. Thus, autoimmune mechanisms or the systemic interferon response are discussed as causes. We report a case of focal inflammatory myopathy with perimysial pathology of the temporalis muscle occurring with acute, but mild COVID-19. Methods. Case report of clinical observations, cranial MRI, histopathological, and laboratory findings. 3T cranial MRI was performed with gadolinium contrast. Open temporalis muscle biopsy was performed. The sample underwent standard cryohistological studies as well as immunohistochemistry with antibodies against MHC-I and II, CD3, CD4, CD19, CD68, anti-MAC, p62 and MxA. Testing for auto-antibodies was based on immunoblots or ELISA. RT-PCR for SARS-CoV-2 was run with RNA extracted from cryopreserved muscle. Results. A Caucasian woman in her 60s with no history of autoimmune or muscle complaints developed swelling and pain of the right jaw musculature five days after testing positive for SARS-CoV-2 due to respiratory tract symptoms. In addition, she experienced trismus, but no further neuromuscular complaints. The course of respiratory tract symptoms stayed mild. She had been vaccinated previously with single shot SARS-CoV-2 vector vaccine. Due to persistent swelling and complaints, giant cells arteritis was excluded by unresponsiveness to five days oral steroids and sonography of the temporal artery. Cranial MRI was performed nearly four weeks after the SARS-CoV-2 infection and showed marked swelling and oedema of the temporalis muscle. Its biopsy showed numerous CD68 and acid phosphatase positive cells infiltrating from perimysial perivascular foci towards the endomysium with perimysial damage but little damage of adjacent, perifascicular muscle fibres. Muscle fibres did not react with anti-MHC-II, anti-MAC or -MxA. Capillaries did not react with anti-MAC or -MxA. SARS-CoV-2 RNA was not detected in muscle tissue. Serum creatine kinase was not elevated in the subacute phase. Slightly elevated ANA titre led to detection of autoantibodies against proliferating cell nuclear antigen (PCNA). No pathological results for other autoantibodies, including myositis-specific antibodies and anti-ds-DNA, were found in blood. Neither were antibodies against hepatitis C and B viruses. Retesting 15 weeks after infection, anti-PCNA immunoblot was still positive, but ELISA did not indicate a pathologic titre. The swelling, myalgia and trismus regressed spontaneously a month after onset, yet the latter still persists at the time of reporting. Conclusion. Our case diverges from the majority of COVID-19 associated my-ositis reports in the unusual location of the focal myositis and the histopathological pattern of predominantly perimysial damage and histiocytic infiltration. It concurs with the literature as no SARS-CoV2 RNA could be detected in the muscle. Anti-PCNA is associated very rarely with myositis. Other associated disorder (systemic lupus erythematosus, chronic viral hepatitis B or C) were not found. Increased levels of autoantibodies are reported in COVID-19 and mostly attributed to loss of self-tolerance during the acute disease phase. Interestingly, the structural protein M of SARS-CoV-2 appears to interact notably with PCNA in infected cells. Still, the causal connection between the myositis and COVID-19 in this case is based on the close temporal association in the absence of alternative, competing explanations from the medical history and findings.

Non-contrast cardiac magnetic resonance imaging after SARS-CoV2 infection or vaccination in asymptomatic adolescents: Insights from the EnIGMA study

Background: Myocarditis after SARS-CoV2 infection or vaccination is rare, but seems to be relatively more frequent in young population. Cardiac magnetic resonance (CMR) T2 weighted sequences have the potential to detect subclinical myocarditis. However, there is paucity of data on the potential myocardial involvement after SARS-CoV2 infection or vaccination in asymptomatic adolescents. Purpose(s): To evaluate the presence of subclinical myocardial damage in adolescents who were infected with SARS-CoV2 or vaccinated against SARS-CoV2 using non-contrast CMR imaging. Method(s): Asymptomatic adolescents enrolled in the Early ImaginG Markers of unhealthy lifestyles in Adolescents (EnIGMA) project were scanned using a 3-Tesla CMR scanner between March 2021 and October 2021. CMR scans included CINE imaging and myocardial T2-mapping sequences. SARS-CoV2 IgG antibody testing was performed in capillary blood samples, and date of confirmed SARS-CoV2 infection and/or vaccination if any was collected. Participants were assigned to three different groups according to SARS-CoV2 status: Group 1 (non-infected and nonvaccinated), Group 2 (infected and non-vaccinated), and Group 3 (vaccinated, independently of past infection status). CMR images were analyzed by experienced observers blinded to adolescent's SARS-CoV2 status. ANOVA and multiple regression analysis, together with correlation coefficients, were used to study between-group differences and associations among variables of interest. Result(s): A total of 115 adolescents with a mean age of 16.0 years (standard deviation (SD)=0.4), 54% girls, completed the CMR study and SARSCoV2 data successfully, and were assigned to Group 1 (n=72), Group 2 (n=22), and Group 3 (n=21). Left and right ventricular ejection fraction (LVEF/RVEF) did not significantly differ among groups: Mean LVEF was 62.8% (SD=4.1), 63.0% (SD=3.7) and 60.9% (SD=3.9) [p=0.12] and mean RVEF was 56.5% (SD=4.2), 56.5% (SD=5.5) and 54.5% (SD=5.1) [p=0.23] in Groups 1, 2 and 3, respectively. Similarly, there were no between-group significant differences in myocardial T2 relaxation values: Mean T2 values were 44.1 ms (SD=2.2), 44.1 ms (SD=1.8) and 44.4 ms (SD=1.9) in Groups 1, 2, and 3, respectively (p=0.63) (Figure 1). No differences were found either after adjusting for age and gender. Median time (interquartile range) from date of infection or vaccination to CMR acquisition was 133 (121) days and 28 (38) days in Group 2 and Group 3, respectively. No correlation between time from infection/vaccination to CMR acquisition and T2 values was detected (Figure 2). Conclusion(s): This observational study did not find evidence of subclinical myocardial involvement after SARS-CoV2 infection or vaccination in asymptomatic adolescents, as assessed with T2-mapping magnetic resonance imaging.

The role of cardiometabolic risk factors and endothelial dysfunction in serum albumin levels and capillary leak syndrome of patients with COVID-19

Background: Growing evidence focuses on the role of hypoalbuminemia in the COVID-19 course and the role of vascular inflammation in the progression to Capillary Leak Syndrome (CLS). CLS may be mediated by a derangement of endothelial barrier following vascular endothelial dysfunction. We investigated the role of cardiometabolic risk factors in the association of hypoalbuminemia with endothelial dysfunction of hospitalized COVID-19 patients. Method(s): In this cross-sectional study, patients hospitalized for COVID- 19 at the medical ward or Intensive Care Unit (ICU) were enrolled. Medical history and laboratory examinations were collected while the endothelial function was assessed by brachial artery flow-mediated dilation (FMD) between the first 24-72 hours of their admission to the hospital. According to the body mass index, history of hypertension, dyslipidemia, and diabetes mellitus, COVID-19 patients were categorized in those with Cardiometabolic Risk Factors (CRFact) or without CRFact (no-CRFact). From the study population, we excluded subjects with established cardiovascular disease. Result(s): Sixty-six patients with COVID-19 (37% admitted in ICU) were recruited. From the study population, 41 were in the group of CRFact and 25 in the no-CRFact. Patients with CFRact were older (65+/-9 years vs. 53+/-14 years, p<0.001), had more impaired FMD (1.16+/-2.13% vs. 2.60+/-2.44%, p=0.01), and lower serum albumin levels (3.10+/-0.68 g/dL vs. 3.52+/-0.26 g/dL, p=0.006) compared to the no-CRFact group. Between CRFact and no-CRFact, there was no difference in CRP and IL-6 levels. Interestingly, serum albumin in patients with CRFact was significantly lower than the lower reference limit (LRL) (=3.5 g/dl) of albumin (p=0.001), while no such finding was noted in subjects with no CRFact (p=0.64). Furthermore, regression analysis revealed that, even after adjustment for age, the presence of CRFact was associated with decreased serum albumin levels by 0.31mg/dl (95% CI 0.08 to 0.63, p=0.04). In the CRFact population, there was a correlation of albumin with FMD (R=0.29, p=0.05) and an inverse correlation with CRP (rho=-0.48, p=0.02) and IL-6 (rho=-0.66, p<0.001), while in the no-CRFact group no such correlation were observed (p=NS for all). Conclusion(s): COVID-19 patients with cardiometabolic risk factors present with low serum albumin levels early at the course of the disease, which may be driven by endothelial dysfunction and vascular inflammation. This data gives insights into the potential association of a dysfunctional endothelial layer and the progression to capillary leak syndrome. (Figure Presented).

Concordance of Central Laboratory Hemoglobin A1c Measurements from Capillary Kits Compared to Venous Draws in the Insulin-Only Bionic Pancreas Pivotal Trial.

Capillary hemoglobin A1c (HbA1c) collection has grown in importance due to its convenience during situations such as the coronavirus disease 2019 (COVID-19) pandemic and virtual visits. The viability of capillary blood samples as an accurate alternative to venous samples has previously only been assessed in smaller sample sizes. In this brief report, 773 paired capillary and venous samples taken from 258 study participants in the Insulin-Only Bionic Pancreas Trial were analyzed at the University of Minnesota Advanced Research and Diagnostic Laboratory and assessed for HbA1c value congruency. Results showed that 97.7% of the capillary samples were within 5% of their respective venous measurement, and R2 between the two HbA1c sources was 0.95. These results are consistent with previous studies that also reported high concordance between capillary and venous HbA1c values using the same laboratory method, providing further evidence that capillary HbA1c measurements are an accurate alternative to venous measurements. Clinical Trial Registration number: NCT04200313.

Unusual presentation of alveolar capillary dysplasia with misalignment of the pulmonary veins in a child with respiratory syncytial virus pneumonia: A case report.

Alveolar capillary dysplasia with misalignment of the pulmonary veins (ACDMPV) is a rare congenital diffuse lung disorder, with a fatal course during the neonatal period. We describe an 18-month-old boy who presented with respiratory syncytial virus pneumonia and pulmonary hypertensive crisis requiring extracorporeal membrane oxygenation. Exome sequencing revealed a FOXF1 frameshift variant, NM_001451.2:c.995_998delACTC, inherited from his asymptomatic mother. Genetic findings were compatible with histopathology findings from a lung biopsy. Based on the disease course, histopathology, and outcomes of this case, we believe ACDMPV should be considered a possibility in an infant presenting with hypoxemic respiratory failure, resistant pulmonary hypertension, and vasodilator-induced pulmonary edema. Genetic testing can contribute to the diagnostic process.

Exacerbations of Idiopathic Systemic Capillary Leak Syndrome following BNT162b2 mRNA COVID-19 Vaccine (Pfizer-BioNTech).

A Japanese man experienced three episodes of hypovolemic shock and was diagnosed with systemic capillary leak syndrome (SCLS). He developed SCLS exacerbation 2 days after receiving a second dose of the Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccine, 1 year after the third episode. After fluid therapy and albumin administration, we initiated terbutaline and theophylline prophylaxis for SCLS. A literature review revealed that SCLS attacks often occur 1-2 days after the second COVID-19 vaccination. Patients with a history of SCLS should avoid COVID-19 vaccination and be carefully monitored for 1-2 days if they receive the vaccine.

Time for recovery of function of alveolo-capillary membrane after COVID 19 infections

Background: It is known that a lot of global consequences after COVID 19 infection were seen. In symptomatic cases, after discharge from hospital, global psychological and physical status was changed in approximately 75% of patients, as was reported in recent literature. We follow up recovery of chest x-ray changes and disappearance of lung function sequels six months after discharge. Aim and objectives: To analyze what was the time frame for recovery of function of alveolo-capillary membrane, assessed by measurement of transfer factor for carbon monoxid (DLco) across the alveolo-capillary membrane. Method(s): Patients treated for COVID 19 in General hospital Tesanj were analyzed. Measurement of DLco was performed three months after discharge from hospital. Patients with severe disease, according to classification adopted for assessment of COVID 19 infection, were included in the study. Result(s): We analyzed 60 patients, 30 of them with therapy by metil prednisolone and 30 without. Therapy with metil prednisolone was 8 mg BID (two times a day) 10 days after discharge, then 4 mg BID in next 10 days. Average DLco was 68.45% of predicted value in patients with no steroid treatment, and 76.49 % in treated group. Chest X-ray resolution of sequels of COVID 19 was better in patients with steroid treatment than in those without. Symptoms of cough and fatigation disappeared more effectively in treated group. Conclusion(s): In patients after COVID 19 infection inappropriate DLco was seen, but recovery of function of diffusion of gases across alveolo-capillary membrane, measured by DLco, was better in patients treated with tablets of metal prednisolone than in those without.

Cardiopulmonary exercise testing and ventilatory efficiency in long COVID-19: 15 months follow-up

Long COVID-19 is defined as persistency of symptoms, such as exertional dyspnea, twelve weeks after recovery from SARS-CoV-2 infection;its pathophysiology still needs to be fully understood. We investigated exercise tolerance and ventilatory efficiency using cardiopulmonary exercise testing (CPET) in patients with long COVID-19. Methods. One hundred patients admitted to our hospital from March to August 2020 for a moderate to critical COVID-19 were enrolled in our long COVID-19 program. Medical history, physical examination and chest HRCT were obtained at hospitalization (T0), at 3 (T3) and 15 months (T15). All HRCTs were revised using a semiquantitative CT severity score (Pan, F. et al. Radiology 2020;295(3):715-721). Pulmonary function tests (PFTs) were obtained at T and T . CPET was performed at T15 in twenty patients (10 male/10 female;mean age 62 years) with residual respiratory symptoms (e.g., exertional dyspnea) and/or an impairment in PFTs, DLCO and/or KCO . Results. At CPET, peak oxygen uptake (VO2 -peak) and ventilatory efficiency (VE /VCO2 slope) were 95.9+/-18.4 SD %pred and 31.4+/-3.9 SD, respectively. Of notice, significant correlations between VE/V'CO2 slope and CT score (T0 ) (r=0.403;p=0.039), CT score (T3) (r=0.453;p=0.022) and DLCO (T3 ) (r=-0.465;p=0.019) were observed. Conclusions. At fifteen-months from COVID-19 pneumonia, a significant number of subjects (20%) still complains of exertional dyspnea. At CPET this may be explained by reduced ventilatory efficiency (i.e., increase in VE/VCO2), possibly related to the degree of lung parenchymal involvement in the COVID-19 acute phase, likely reflecting a damage in the interstitial/pulmonary capillary structure.