Prolonged presence of SARS-CoV-2 in a COVID-19 case with rheumatoid arthritis taking iguratimod treated with ciclesonide

We report a coronavirus disease 2019 (COVID-19) case with rheumatoid arthritis taking iguratimod. The patient who continued iguratimod therapy without dose reduction was treated with ciclesonide had an uneventful clinical course, but prolonged detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was observed after resolution of symptoms. The effects of disease-modifying antirheumatic drugs (DMARDs) and ciclesonide on clinical course and viral shedding remain unknown and warrant further investigation.     

Post-COVID-19 vaccination arm pain diagnosed as complex regional pain syndrome: A case report

As the vaccination efforts against the coronavirus disease-2019 (COVID-19) continue, more patients are likely to present with complications related to COVID-19 vaccination. We describe the first reported case of complex regional pain syndrome (CRPS), involving the upper extremities, that occurred after COVID-19 vaccination. The patient presented with acute-onset severe arm pain and swelling following vaccine administration. Based on the clinical, electrodiagnostic, and radionuclide three-phase bone scan findings, the patient was diagnosed with postvaccination CRPS. The COVID-19 vaccine possibly elicited an immune-mediated inflammatory response to the injected antigen in the patient, who was predisposed to CRPS due to inflammatory immunity. The COVID-19 vaccine elicited an immune-mediated inflammatory response to the injected antigen, resulting in CRPS following COVID-19 vaccination.     

Groin and hip pain due to fractures at or near the pubic symphysis

Three patients with fractures at or near the pubic symphysis presented with groin pain simulating hip fracture or arthritis. A 71-year-old osteoarthritic woman was treated with a nonsteroidal antiinflammatory drug (NSAID) and exercises for right-sided sciatic pain after a minor fall, but developed left groin pain and tenderness over the pubic symphysis after two days of exercise. She had an impacted fracture of the left pubic symphysis which responded to use of a cane. The second patient was a 90-year-old woman with rheumatoid arthritis (on steroids) who complained of right hip pain after a series of falls in her home. Initially treated with Buck traction for a presumed hip fracture, she was later treated with heat and exercises after negative hip x-rays were obtained. Retrospective analysis of pelvic films and bone scan revealed a right pubic symphysis fracture. The third patient was an 83-year-old rheumatoid arthritic woman with inability to walk secondary to left groin pain. Pubic tomograms revealed disruption of the superior aspect, and bone scan showed increased uptake of the left pubic bone. She was treated with moist heat, rest, and NSAID. Twenty-four cases of os pubis fractures without major trauma or symphysis disruption have been reported. All patients had osteoporosis, and six had rheumatoid arthritis. Our three cases are presented to increase awareness of pubic symphysis fractures as a cause for groin pain, especially in patients with osteoporosis and rheumatoid arthritis.     

Lung abscess as a secondary infection of COVID-19: A case report and literature review

A 16-year-old male was admitted with persistent fever, diarrhea, and anorexia 8 days after the diagnosis of coronavirus disease-2019 (COVID-19). Radiological examination of the lungs showed a cavitary lesion with an air-fluid level, but no apparent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. The lesion was diagnosed as a lung abscess after COVID-19. Treatment with antimicrobials was initiated, which attenuated symptoms and the lung lesion. Specific pathogens were not detected despite repeated sputum cultures, which suggested that lung abscess was caused by oral bacteria as a secondary infection of COVID-19. To date, several cases of lung abscess as a complication of COVID-19 have been reported. However, the majority of cases occurred after intubation to treat COVID-19, and there have been no cases involving young adults. This healthy young patient may have developed lung abscess due to COVID-19.     

Adverse reactions to the first and second doses of Pfizer-BioNTech COVID-19 vaccine among healthcare workers

IntroductionIn the current coronavirus infection 2019 (COVID-19) pandemic, the messenger RNA vaccines have been shown to help protect high-risk groups from COVID-19. Among healthcare workers vaccinated with Pfizer-BioNTech COVID-19 vaccine, a survey was conducted to analyze the relationship between the incidence and severity of adverse reactions after vaccination.MethodsWe conducted a prospective self-reported survey of adverse reactions among healthcare workers vaccinated with the Pfizer-BioNTech COVID-19 vaccine (Comirnaty®) in Japan. After the first and second dose of vaccine, local and systemic reactions for 8 days after vaccination were reported by volunteer participants using a website. After receiving vaccination, 374 respondents participated in this matched-pair study.ResultsBoth the incidence and severity of adverse reactions tended to be higher after the second vaccine dose than after the first dose. However, the incidence and numeric rating scale (NRS) score of muscle and skin pain were nearly the same after the first and second doses. In a comparison by sex, women had significantly higher incidence and NRS scores for adverse reactions such as headache, skin pain, erythema, and itching. The results also showed that younger age groups had higher incidence rates and NRS scores for all adverse reactions investigated, except for muscle pain, compared with older age groups.ConclusionSome adverse reactions to the Pfizer-BioNTech Comirnaty® COVID-19 vaccine showed gender and age differences. However, generally speaking, all side reactions disappear within a week. Therefore, these side reactions are not a significant concern in recommending vaccination.     

Interhospital transportation of a COVID-19 patient undergoing veno-venous extracorporeal membrane oxygenation by helicopter

Some coronavirus disease 2019 (COVID-19) patients develop rapidly progressive acute respiratory distress syndrome and require veno-venous extracorporeal membrane oxygenation (V-V ECMO). A previous study recommended the transfer of ECMO patients to ECMO centers. However, because of the pandemic, a limited number of ECMO centers are available for patient transfer. The safe long-distance interhospital transport of these patients is a concern. To minimize transportation time, helicopter use is a suitable choice. We report the first case of a COVID-19 patient on V-V ECMO, transferred to our ECMO center by helicopter.A 45-year-old man with rheumatoid arthritis history, treated with immunosuppressants, presented with fever and sore throat. He was diagnosed with COVID-19 following a positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test result and was subsequently prescribed favipiravir. However, his respiratory failure progressively worsened. On day 10 of hospitalization at the previous hospital, he was intubated, and we received a request for ECMO transport on the next day. The ECMO team, who wore personal protective equipment (N95 respirators, gloves, gowns, and face shields), initiated V-V ECMO in the referring hospital and safely transported the patient by helicopter. The flight time was 7 min. He was admitted to the intensive care unit of our hospital and received tocilizumab. He was discharged on hospital day 31 with no significant sequelae.In this case report, we discuss important factors for the safe and appropriate interhospital transportation of COVID-19 patients on ECMO as well as staff and patient safety during helicopter transportation.     

Pure red cell aplasia accompanied by COVID-19 successfully treated using cyclosporine

A 67-year-old Japanese man was admitted to our hospital with severe coronavirus disease 2019 (COVID-19) in March 2020. Mechanical ventilation was initiated 8 days after admission, due to severe respiratory failure. Multiple severe complications such as liver dysfunction, arrhythmia, brain infarction, and venous thromboembolism were also observed. We initially diagnosed Coombs test-positive warm autoimmune hemolytic anemia. Corticosteroids proved ineffective and anemia worsened with severe erythroid hypoplasia (0.5% erythroblasts in bone marrow), so we diagnosed pure red cell aplasia (PRCA). We also identified massive infiltration of cytotoxic T-lymphocytes expressing CD8, granzyme B, and perforin in bone marrow. Systemic cyclosporine was started, with full resolution of anemia and no need for blood transfusions after 4 weeks. We believe that this represents the first report of COVID-19-associated PRCA successfully treated using cyclosporine.     

Surgical treatment of rheumatoid arthritis]

Synovectomy, total arthroplasty and arthrodesis are the main surgical methods for rheumatoid arthritis. Although recurrent synovitis and radiological deterioration after synovectomy have been reported, the procedure can be an effective treatment if it is performed in the early stage where articular cartilage and bone are minimally damaged. Arthrodesis is indicated for severely destroyed joints. However, since loss of motion in the proximal joints often leads to severe disability, its indication is limited to the distal joints, such as the wrist and ankle. Total rthroplasty seems to be an ideal method because relief of pain and recovery of function can be obtained simultaneously. However, there are some complications, such as loosening and wear of the prosthesis. Solution of these would bring much benefit to the disabled rheumatoid arthritis patient.     

Intraarticular interferon-beta gene therapy ameliorates adjuvant arthritis in rats

Interferon (IFN)-beta has significant immunomodulatory properties and has received much interest as a potentially therapeutic agent for rheumatoid arthritis (RA). Systemic IFN-beta treatment of patients with RA was not effective, probably because of pharmacokinetic issues. Therefore, we studied the effect of local IFN-beta production by adenovirus-mediated gene transfer to the ankle joints of arthritic rats. Adjuvant arthritis (AA) in rats was used as a model to study intraarticular gene therapy with an adenoviral vector encoding the rat IFN-beta gene (Ad.IFN-beta). The effect on paw swelling was measured by water displacement plethysmometry. Synovial tissue of the hind paws was examined by immunohistochemistry. Bone destruction was analyzed on the basis of radiographs. In addition, quantitative real-time polymerase chain reaction was used to assess IFN-beta expression. Levels of IFN-beta mRNA and protein peaked 2 days after intraarticular injection and declined thereafter. Local delivery of Ad.IFN-beta after the onset of disease reduced paw swelling significantly. This was accompanied by a reduction in synovial inflammation. The clinical effects in rat AA lasted up to 9 days. Strikingly, Ad.IFN-beta treatment protected bone from erosion, reduced levels of c-Cbl and Cbl-b (both signaling molecules essential for osteoclast activity), and reduced the matrix metalloproteinase-3:tissue inhibitor of metalloproteinase-1 ratio in the joint. Immunohistochemical analysis of the synovial tissue revealed a clear shift toward a more antiinflammatory cytokine profile. Local overexpression of IFN-beta inhibits arthritis progression and protects against bone destruction in rat AA. These findings validate IFN-beta as a therapeutic molecule for intraarticular gene therapy of arthritis.     

Bilateral spontaneous pneumothorax in SARS-CoV-2 infection: A very rare,life-threatening complication

In the coronavirus disease 2019 (COVID-19) era, the presence of acute respiratory failure is generally associated with acute respiratory distress syndrome; however, it is essential to consider other differential diagnoses that require different, and urgent, therapeutic approaches. Herein we describe a COVID-19 case complicated with bilateral spontaneous pneumothorax. A previously healthy 45-year-old man was admitted to our emergency department with sudden-onset chest pain and progressive shortness of breath 17 days after diagnosis with uncomplicated COVID-19 infection. He was tachypneic and presented severe hypoxemia (75% percutaneous oxygen saturation). Breath sounds were diminished bilaterally on auscultation. A chest X-ray revealed the presence of a large bilateral pneumothorax. A thoracic computed tomography (CT) scan confirmed the large bilateral pneumothorax, with findings consistent with severe COVID-19 infection. Chest tubes were inserted, with immediate clinical improvement. Follow-up chest CT scan revealed resolution of bilateral pneumothorax, reduction of parenchymal consolidation, and formation of large bilateral pneumatoceles. The patient remained under observation and was then discharged home. Bilateral spontaneous pneumothorax is a very rare, potentially life-threatening complication in patients with COVID-19. This case highlights the importance of recognizing this complication early to prevent potentially fatal consequences.     

核磁共振与关节镜对类风湿关节炎患者膝关节病变诊断的比较

目的 探讨核磁共振成像（MRI）在膝关节类风湿关节炎中的诊断价值.方法 随机选取我院2008年10月至2012年10月临床及MRI检查均高度疑为类风湿关节炎的患者106例,进一步行关节镜检查确诊,分析MRI诊断类风湿关节炎的敏感性、特异性、阳性预测值、阴性预测值、一致率和Kappa值.结果 与关节镜金标准结果对比,MRI对诊断类风湿关节炎的病变种类包括关节积液、滑膜增厚/血管翳形成、软骨和骨侵蚀、周围软组织病变等的敏感度、特异性、阳性预测值、阴性预测值、一致率和Kappa值分别为90.91％、88.10％、66.67％、97.37％、91.51％和0.712,MRI诊断类风湿关节炎的敏感度、特异性、阳性预测值、阴性预测值、一致率和Kappa值分别为94.74％、83.91％、56.25％、98.48％、85.85％和0.687,膝关节软骨退行性变损害的MRI分级与关节镜分级的符合率为99.06％,Kappa值为0.654,两者具有高度一致性（P＜0.05）.结论 MRI诊断类风湿关节炎有较好的一致性,并可准确判断病变种类和软骨损伤的程度,对类风湿关节炎的早期诊断和指导临床治疗都有重要意义.     

Bell’s palsy after inactivated COVID-19 vaccination in a patient with history of recurrent Bell’s palsy: A case report

BACKGROUNDWith rapid and extensive administration of inactivated coronavirus disease 2019 (COVID-19) vaccine to the general population in China, it is crucial for clinicians to recognize neurological complications or other side effects associated with COVID-19 vaccination.CASE SUMMARYHere we report the first case of Bell’s palsy after the first dose of inactivated COVID-19 vaccine in China. The patient was a 36-year-old woman with a past history of Bell’s palsy. Two days after receiving the first dose of the Sinovac Life Sciences inactivated COVID-19 vaccine, the patient developed right-side Bell’s palsy and binoculus keratoconjunctivitis. Prednisone, artificial tears and fluorometholone eye drops were applied. The patient’s symptoms began to improve by day 7 and resolved by day 54.CONCLUSIONAs mRNA COVID-19 vaccine trials reported cases of Bell’s palsy as adverse events, we should pay attention to the occurrence of Bell’s palsy after inactivated COVID-19 vaccination. A history of Bell’s palsy, rapid increase of immunoglobulin M and immunoglobin G-specific antibodies to severe acute respiratory syndrome coronavirus 2 may be risk factors for Bell‘s palsy after COVID-19 vaccination.     

Thymosin as a possible therapeutic drug for COVID-19: A case report

BACKGROUNDThere are no effective antiviral therapies for coronavirus disease 2019 (COVID-19) at present. Although most patients with COVID-19 have a mild or moderate course of disease, up to 5%-10% of patients may have a serious and potentially life-threatening condition, indicating an urgent need for effective therapeutic drugs. The therapeutic effect of thymosin on COVID-19 has not been previously studied. In this paper, for the first time we report a case of thymosin treatment of COVID-19.CASE SUMMARYA 51-year-old man with imported COVID-19 was admitted with definite symptoms of chest tightness, chest pain, and fatigue. The polymerase chain reaction results for severe acute respiratory syndrome coronavirus 2 were negative. The antibody test was positive, confirming the diagnosis of COVID-19. As many orally administered drugs were not well tolerated due to gastrointestinal symptoms, an emergency use of thymosin, a polypeptide consisting of 28 amino acids, was administered by injection. Finally, after the implementation of the treatment program, symptoms and lung imaging improved significantly.CONCLUSIONIn this case report, it is confirmed that thymosin may help alleviate the severity of COVID-19 symptoms.     

Comparison of 2 fully automated tests detecting antibodies against nucleocapsid N and spike S1/S2 proteins in COVID-19

Automated assays for detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in coronavirus disease 2019 (COVID-19) diagnostics have recently come available. We compared the performance of the Elecsys® Anti–SARS-CoV-2 and LIAISON® SARS-CoV-2 S1/S2 IgG tests. The seroconversion panel comprised of 120 samples from 13 hospitalized COVID-19 patients. For the sensitivity and specificity testing, samples from COVID-19 outpatients >15 days after positive nucleic acid amplification test (NAAT) result (n = 35) and serum control samples collected before the COVID-19 era (n = 161) were included in the material. Samples for the detection of possible cross-reactions were also tested. Based on our results, the SARS-CoV-2 antibodies can be quite reliably detected 2 weeks after NAAT positivity and 3 weeks after the symptom onset with both tests. However, since some COVID-19 patients were positive only with Elecsys®, the antibodies should be screened against N-antigen (Elecsys®) and reactive samples confirmed with S antigen (LIAISON®), but both results should be reported. In some COVID-19 patients, the serology can remain negative.     

Surgical intervention for acute pancreatitis in the COVID-19 era

Approximately 15%-19% of patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infections develop gastrointestinal symptoms. Acute pancreatitis (AP) has been reported in 0.1% of patients with coronavirus disease 2019 (COVID-19). Biliary AP was most common (78.4%) before the COVID-19 pandemic; idiopathic AP is most common in patients with COVID-19 (up to 57.1%). The number of emergency department presentations decreased by 23.3% during the pandemic and many governments made national recommendations to delay nonurgent endoscopic procedures, leading to decrements of 22% in combined esophagogastroduodenoscopy (EGD) and colonoscopy and 20% in EGD after the COVID-19 pandemic. The symptoms and signs of COVID-19-related AP are fever (63%), abdominal pain (58%), respiratory symptoms (40%), nausea and vomiting (39%), and headache (4%). Approximately 5-10% of patients develop necrotizing or hemorrhagic AP, and patients who required surgical intervention had a higher mortality risk. Compared to 2019, the rates of elective surgery decreased by 41.8% in 2020; including cholecystectomy (40.1% decrease) and pancreas (111.1% decrease). Surgical volumes also decreased by 18.7% in 2020; device-assisted laparoscopic and robot-assisted procedures reduced by 45.4% and 61.9% during the COVID-19 Lockdown in 2020.     

超声对血清学阴性类风湿关节炎与骨性关节炎的鉴别诊断价值

目的探讨超声在血清学阴性的类风湿关节炎(SNRA)与骨性关节炎(OA)鉴别诊断中的应用价值。方法回顾性分析以膝、肘、腕或近端指间关节疼痛为主诉的70例SNRA患者(SNRA组)和75例OA患者(OA组)的超声检查资料,比较两组骨侵蚀、滑膜增厚、滑膜血流信号等超声指标的差异。以临床诊断结果为标准,计算超声特征对RA的诊断效能。结果本研究纳入145例患者,共检查425个关节,其中OA组检查关节194个,SNRA组检查关节231个。两组间0~1级骨侵蚀中滑膜增厚程度、滑膜血流信号比较差异均有统计学意义(均P0.01)。以临床随访6个月的诊断结果为标准,2~3级骨侵蚀判断RA的特异性为93.33%,敏感性为41.82%。结论应用超声识别骨侵蚀、滑膜炎等对鉴别SNRA与OA有重要意义。     

Effect of gentle exercises on injection site reaction after Covid-19 vaccination. A case report

IntroductionA series of atypical acute respiratory diseases were caused in Wuhan, China, in December 2019 by a novel coronavirus (COVID-19). Over six million confirmed COVID-19 cases had been reported worldwide, and total deaths in the USA from March 1 to May 30, 2020, were approximately 7,81,000. Worldwide, scientists are developing many potential COVID-19 vaccines. Few of the companies got success in the development of a vaccine for COVID-19, but most of the recipients reported injection site reactions like pain, redness, or erythema after vaccination. The present study aimed to evaluate the effect of gentle upper limb exercises to reduce injection site reactions, and here we present a case with post vaccination site reaction that reported pre-assessment score 7 for visual analog scale for pain and score 2 for redness and erythema with Investigator-reported and rated injection site reactions. Then he performed gentle upper limb exercises after 8 and 24 hours of vaccination.ResultThe study reported a beneficial effect of these exercises to reduce pain and redness or erythema after Covid-19 vaccination.DiscussionThe potential benefit of gentle exercises may be due to their blood flow boost-up and anti-inflammatory effects. However, high-quality controlled trials are warranted further to evaluate the potential benefit of upper limb gentle exercises for the reduction of injection site reactions after the Covid-19 vaccination injection.ConclusionThe clinical experience with the subect shows that gentle exercises for upper limb may reduce the inection site reaction after COVID-19 vaccination.     

Exacerbation of autoimmune hemolytic anemia associated with pure red cell aplasia after COVID-19: A case report

Autoimmune hemolytic anemia (AIHA) and pure red cell aplasia (PRCA) are rare complications of coronavirus disease 2019 (COVID-19). Herein, we report the case of a 28-year-old Japanese man who showed severe AIHA exacerbation associated with PRCA after COVID-19. AIHA was diagnosed and maintained for 5 years. Approximately 4 weeks after COVID-19, the patient developed severe anemia (hemoglobin level, 3.4 g/dL). Laboratory test results confirmed hemolytic exacerbation of IgG-mediated warm-type AIHA. Despite the hemolysis phase, the bone marrow revealed extreme hypoplasia of erythroblasts with a decreased reticulocyte count, similar to that observed in patients with PRCA. During oral prednisolone treatment, the patient recovered from anemia and showed increased reticulocyte count and reduced hypoplasia of marrow erythroblasts. Exacerbation of AIHA and PRCA was triggered by COVID-19 because other causes were ruled out. Although this case report highlights that COVID-19 could lead to hematological complications such as AIHA and PRCA, the exact mechanisms remain unclear.