Rejected

Increasing numbers of COVID-19 patients, continue to experience symptoms months after recovering from mild cases of COVID-19. Amongst these symptoms, several are related to neurological manifestations, including fatigue, anosmia, hypogeusia, headaches and hypoxia. However, the involvement of the autonomic nervous system, expressed by a dysautonomia, which can aggregate all these neurological symptoms has not been prominently reported. Here, we hypothesize that dysautonomia, could occur in secondary COVID-19 infection, also referred to as "long COVID" infection. 39 participants were included from December 2020 to January 2021 for assessment by the Department of physical medicine to enhance their physical capabilities: 12 participants with COVID-19 diagnosis and fatigue, 15 participants with COVID-19 diagnosis without fatigue and 12 control participants without COVID-19 diagnosis and without fatigue. Heart rate variability (HRV) during a change in position is commonly measured to diagnose autonomic dysregulation. In this cohort, to reflect HRV, parasympathetic/sympathetic balance was estimated using the NOL index, a multiparameter artificial intelligence-driven index calculated from extracted physiological signals by the PMD-200 pain monitoring system. Repeated-measures mixed-models testing group effect were performed to analyze NOL index changes over time between groups. A significant NOL index dissociation over time between long COVID-19 participants with fatigue and control participants was observed (p = 0.046). A trend towards significant NOL index dissociation over time was observed between long COVID-19 participants without fatigue and control participants (p = 0.109). No difference over time was observed between the two groups of long COVID-19 participants (p = 0.904). Long COVID-19 participants with fatigue may exhibit a dysautonomia characterized by dysregulation of the HRV, that is reflected by the NOL index measurements, compared to control participants. Dysautonomia may explain the persistent symptoms observed in long COVID-19 patients, such as fatigue and hypoxia. Trial registration: The study was approved by the Foch IRB: IRB00012437 (Approval Number: 20-12-02) on December 16, 2020.

Stereotactic radiosurgery (SRS) is a proven treatment modality for inoperable arteriovenous malformations (AVMs). However, the rate of radiation-induced necrosis (RIN) is as high as 10%. A 6-year-old female patient presented with severe headache, emesis, and syncope, and workup revealed a Spetzler-Martin grade 4 AVM with intraventricular hemorrhage and hydrocephalus. The patient underwent a right frontal ventriculostomy followed by a linear accelerator-based SRS of 16.9 Gy. At 19 years, she developed progressive neurological symptoms. Diagnostic magnetic resonance imaging (MRI) revealed a recurrent parietal AVM nidus. We delivered the linear accelerator-based SRS of 18.5 Gy to the AVM nidus. Within 9 months, she experienced episodic headaches and left-sided weakness and spasticity; symptoms were initially managed with dexamethasone. Follow-up MRI was notable for edema and nondetectable blood flow, consistent with RIN and AVM obliteration. The second course of steroids did not provide the symptom control. Persistent RIN was noted on MRI, and she had stigmata of steroid toxicity (centripetal obesity, depression, and sleep disorder). Two infusions of bevacizumab (5 mg/kg) were administered concurrently with a tapering dose of dexamethasone. The patient noted a near immediate improvement in her headaches, and 2 months following the second bevacizumab infusion, she reported a near-complete resolution of her symptoms and displayed improved ambulation. The development of RIN remains a noteworthy concern post-SRS of AVMs. While steroids aid with initial management of RIN, for persistent and recurrent symptoms, bevacizumab infusions serve as a viable treatment course, with the added benefit of reducing the likelihood of adverse effects resulting from prolonged steroid therapy.

Migraine is a prevalent disabling primary headache disorder that is classified into two major types: migraine without aura and migraine with aura. New therapeutic methods to reduce migraine headaches in the emergency department (ED) include intradermal mesotherapy.

Sphincter of Oddi dysfunction (SOD) is a syndrome caused by either dyskinesia or stenosis of the sphincter of Oddi. It has been categorized into biliary and pancreatic SOD based on clinical features and laboratory findings. We present a case of a 51-year-old female (post-cholecystectomy) who presented with intermittent chronic right upper quadrant pain. Laboratory investigations showed persistently elevated liver function tests and a dilated common bile duct without the presence of any stones. Endoscopic retrograde cholangiopancreatography with manometry showed an elevated sphincter of Oddi pressure, thus confirming the diagnosis of SOD. She underwent endoscopic sphincterotomy and papillotomy with normalization of liver function tests and resolution of her chronic symptoms.

Leprosy is a chronic granulomatous infection, classically presents with cutaneous and neurological manifestations. Joint involvement in leprosy can present as acute symmetrical or chronic polyarthritis with or without tenosynovitis resembling rheumatoidarthritis.

Összefoglaló. Újabb megfigyelések szerint a SARS-CoV-2-fertőzést követően gyermekekben a paediatric inflammatory multisystem syndrome (PIMS) elnevezésű, sokkállapottal szövődött Kawasaki-megbetegedéshez hasonlító, többszervi elégtelenségnek megfelelő tünetegyüttes alakulhat ki. A gyermekek többségében ilyenkor a direkt víruskimutatás már sikertelen, azonban a SARS-CoV-2 ellen képződött antitest igazolhatja a diagnózist. Dolgozatunk célja az egyik első hazai eset ismertetése. Egy 15 éves fiú került gyermek intenzív osztályos felvételre több napon át észlelt magas láz, kesztyű-, zokniszerű exanthema, conjunctivitis, többszervi elégtelenség, szeptikus sokk tüneteivel, akut gyulladásra utaló laboratóriumi eltérésekkel és diffúz hasi panaszokkal. Felvételét megelőzően néhány héttel SARS-CoV-2-fertőzésen esett át. Felvételekor a direkt víruskimutatás sikertelen volt, ám a SARS-CoV-2 elleni antitest vizsgálata pozitív lett. Komplex intenzív terápia mellett állapota stabilizálódott. Az irodalmi ajánlásoknak megfelelően immunglobulin-, acetilszalicilsav- és szteroidkezelésben részesítettük, melynek hatására állapota maradványtünetek nélkül rendeződött. A növekvő esetszámú gyermekkori SARS-CoV-2-fertőzés mellett egyre gyakrabban várható a SARS-CoV-2-fertőzést követő, a Kawasaki-betegség tüneteire emlékeztető PIMS kialakulása. Gyermekekben súlyos szeptikus állapot és többszervi elégtelenség esetén gondolni kell a PIMS lehetőségére, mely esetenként intenzív osztályos ellátást és célzott terápiát igényel. Legjobb tudomásunk szerint a leírásra került beteg a Magyarországon diagnosztizált egyik legkorábbi eset. Orv Hetil. 2021; 162(16): 602-607. Summary. Recently following SARS-CoV-2 infection, a new, multisystem disease (paediatric inflammatory multisystem syndrome, PIMS) with fever was recognized in children with shock and multiorgan failure. On of the first Hungarian cases will be described. A 15-year-old boy was admitted to the Paediatric Intensive Care Unit with persistent high fever, diffuse abdominal pain, septic shock, multiple organ failure, gloves- and socks-shaped cutan exanthema, conjunctivitis and laboratory signs of inflammation. Some weeks preceding his admission, symptoms of mild SARS-CoV-2 infection were revealed. At admission, the SARS-CoV-2 PCR and antigen tests were negative, however, the presence of IgG antibody was shown. Following complex supportive intensive care along with internationally recommended immunoglobulin, aspirin and steroid treatment, the patient was completely cured without any sequalae. In children after SARS-CoV-2 infection, PIMS could occur mimicking Kawasaki syndrome. At this time, in children virus PCR or antigen tests are usually negative already, but the presence of SARS-CoV-2 antibody could prove the preceding disease. Due to the increasing number of SARS-CoV-2 infections, the occurrence of post-SARS-CoV-2 PIMS in childhood is expected to increase. For paediatric patients, in case of severe septic state and multiple organ failure, PIMS should be also considered, which may require intensive care and targeted therapy. As far as we know, the described case is one of the earliest cases of PIMS in Hungary. Orv Hetil. 2021; 162(16): 602-607.

Although the occurrence of cerebral aneurysms in pediatric age group describes as rare, giant ones are more commonly be found than in adults. Insufficient epidemiological information, their association with other medical comorbidities, diagnostic pitfalls, complex surgical anatomy, and issues should be considered during surgery to make them difficult to diagnose and manage. We report a 6-year-old boy with presenting complaint of acute-onset headache without any other symptoms and a small area of intracerebral hemorrhage detected on initial computed tomography (CT) scan. Primary evaluations failed to result in a definite diagnosis, and delayed vascular studies suggested vascular malformation or an aneurysm as the causative factor of hemorrhage. Surgical exploration led to the diagnosis of a giant partially thrombosed aneurysm at the A2 segment of the left anterior cerebral artery and successful clipping. One of our findings on preoperative CT angiography, "fountain sign," may be useful for the diagnosis of partially thrombosed aneurysms when active bleeding from the aneurysm has been ruled out. Fountain sign can be a useful finding in the diagnosis of partially thrombosed aneurysms. Vascular lesions should always be considered as the primary cause of intracranial hemorrhage in pediatrics despite negative initial studies. Therefore, close follow-up and using delayed and multimodality vascular evaluations are crucial for successful management.

We report a pediatric case of Type 1C choledochal cyst presented as acute biliary colic pain. Choledochal cyst is an abnormal expansion of the biliary tract. The Type 1 choledochal cyst is the cystic dilation of the common bile duct. The Type Ic choledochal cyst is the fusiform dilatation of the common bile duct with an anomalous pancreaticobiliary junction. Patients with choledochal cysts may have the formation of cholelithiasis due to chronic biliary stagnation and repeated inflammation. Cholelithiasis may fall into the common bile duct to cause biliary colic. Abdominal sonography can be used as a preliminary examination.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently given to patients with acute pancreatitis (AP) for controlling pain, but their efficacy in treating AP, particularly in reducing systemic complications, remains unclear.

Virtual reality (VR) has been used as nonpharmacologic anxiolysis benefiting patients undergoing office-based procedures. There is little research on VR use in laryngology. This study aims to determine the efficacy of VR as anxiolysis for patients undergoing in-office laryngotracheal procedures.