(With regular inputs from Dr Monica Vasudev)

Epilepsy and COVID-19

People with epilepsy face the same health challenges as people who do not have the condition and are otherwise healthy. People with epilepsy should therefore exercise the same habits and preventative measures that healthy people follow, such as social distancing, avoiding contact with sick people, regular washing of hands, regular disinfection of surfaces, and avoiding touching hands, eyes, nose and mouth.

High fever associated with coronavirus can incite seizures. The increased risk is another reason why people who have epilepsy should try to avoid getting sick.

 ACE inhibitors in COVID-19

Initial data from a Chinese center on the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in patients hospitalized with COVID-19 appears to provide some reassurance about continued use of these drugs.

The report from a Wuhan hospital noted that among patients with hypertension hospitalized with COVID-19, there was no difference in disease severity or death rate in patients taking ACE inhibitors or ARBs and those not taking these medications. The data appear online April 23 in JAMA Cardiology.

The study adds to another recent report in a larger number of COVID-19 patients from nine Chinese hospitals that pointed to a beneficial effect of ACE inhibitors or ARBs on mortality.

 High incidence of VTE in anticoagulated patients with severe COVID‐19, acute segmental pulmonary emboli associated with COVID-19

A study published in Journal of Thrombosis and Haemostasis has reported a high incidence of venous thromboembolic events (VTE) in anticoagulated patients with severe COVID-19.

Jean‐François Llitjos, MD, Institut Cochin, INSERM, Paris, France, and colleagues analyzed data from 2 French intensive care units (ICUs) where complete duplex ultrasound (CDU) is performed as a standard of care.

From March 19, 2020, to April 11, 2020, 26 consecutive patients with severe COVID‐19 admitted to the ICU were evaluated for VTE early in admission using a CDU from thigh to ankle at selected sites with Doppler waveforms and images.

Anticoagulation dose was decided by the treating physician based on the individual risk of thrombosis. Pulmonary embolism was systematically looked for among patients with persistent hypoxemia or secondary deterioration.

Of the patients, 8 (31%) were treated with prophylactic anticoagulation and 18 (69%) were treated with therapeutic anticoagulation.

The overall rate of VTE was 69%. However, the proportion of VTE was found to be significantly higher in patients treated with prophylactic anticoagulation compared with therapeutic anticoagulation (100% vs 56%; P = 0.03).

A high rate of thromboembolic events was seen in patients with COVID‐19 treated with therapeutic anticoagulation, with 56% of VTE and 6 pulmonary embolisms, noted the authors.

 In a related topic, emergency department physicians from California describe a case of acute segmental pulmonary emboli associated with COVID-19.

Published in the American Journal of Emergency Medicine, Kyla Casey, MD, Naval Medical Center San Diego, San Diego, California, and colleagues presented a case of a man aged 42 years who presented to the emergency department with worsening chest pain, shortness of breath, and hemoptysis. He had been previously diagnosed with mild COVID-19 infection 12 days before and had managed to stay at home until then.

On presentation, he was afebrile and had a normal heart rate, blood pressure, and oxygen saturation, but a respiratory rate of 30 breaths per minute. His physical examination revealed mild respiratory distress with bibasilar rhonchi but otherwise no other acute findings.

Laboratory evaluation revealed a D-dimer of 4.8 μg/dl. Electrocardiography (EKG) showed flattening of the T-waves in the inferior leads as compared to his prior EKGs with right axis deviation and a S1Q3T3 pattern. Chest radiograph showed right lower lobe infiltrate. Considering the evidence of hemoptysis, evidence of right heart strain on his EKG and elevated D-dimer, a chest CT angiography was obtained which revealed bilateral segmental pulmonary emboli and an additional area of consolidation in the right lower lobe concerning for infarct. Additional findings revealed peripheral ground glass opacities consistent with COVID-19 pneumonia.

The patient was admitted to a negative pressure room, started on anticoagulation with heparin and was later discharged on a novel oral anticoagulant.

 Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA