Introduction: Multiple risk factors of mortality have been identified in patients with COVID-19. Here, we sought to determine the effect of a history of neurological disorder and development of neurological manifestations on mortality in hospitalized patients with COVID-19.Methods: From March 20 to May 20, 2020, hospitalized patients with laboratory confirmed or highly suspected COVID-19 were identified at four hospitals in Ohio. Previous history of neurological disease was classified by severity (major or minor). Neurological manifestations during disease course were also grouped into major and minor manifestations. Encephalopathy, ischemic or hemorrhagic stroke, and seizures were defined as major manifestations, whereas minor neurological manifestations included headache, anosmia, dysgeusia, dizziness or vertigo, and myalgias. Multivariate logistic regression models were used to determine significant predictors of mortality in patients with COVID-19 infection.Results: 574/626 hospitalized patients were eligible for inclusion. Mean age of the 574 patients included in the analysis was 62.8 (SD 17.6), with 298 (51.9%) women. Of the cohort, 240(41.8%) patients had a prior history of neurological disease (HND), of which 204 (35.5%) had a major history of neurological disease (HND). Mortality rates were higher in patients with a major HND (30.9 vs. 15.4%; p = 0.00002), although this was not a significant predictor of death. Major neurological manifestations were recorded in 203/574 (35.4%) patients during disease course. The mortality rate in patients who had major neurological manifestations was 37.4% compared to 11.9% (p = 2 × 10 −12 ) in those who did not. In multivariate analysis, major neurological manifestation (OR 2.1,; p = 0.002) was a predictor of death. Conclusions: In this retrospective study, history of pre-existing neurological disease in hospitalized COVID-19 patients did not impact mortality; however, development of major neurological manifestations during disease course was found to be an independent predictor of death. Larger studies are needed to validate our findings.

Disorders of the pulmonary lymphatic system include macro- and microcystic lymphatic malformations, primary or secondary lymphangiectasias, generalized lymphatic anomalies, diffuse pulmonary lymphangiomatosis, and combinations of lymphatic and other tissue anomalies, including lymphangioleiomyomatosis (LAM). We report a case of a patient with a newly defined entity classified as kaposiform lymphangiomatosis (KLA). This 50-year-old nonsmoking Hispanic woman presented with a 20-year history of cough, hemoptysis, chyloptysis, and pleuritic chest pain. Laboratory evaluation demonstrated a low normal platelet count, elevated d-Dimer, low normal fibrinogen, and elevated fibrin split products. Chest computerized tomography imaging showed enlarged hypodense lymph nodes in the mediastinum and hila, and peribronchovascular thickening, without evidence of cystic parenchymal lesions. Magnetic resonance imaging of the chest showed cystic mediastinal lymph nodes with heterogeneously increased T2 and decreased T1 signal intensity. Fiberoptic bronchoscopy revealed hyperemic mucosa with granular appearance suggestive of a submucosal infiltrative process. Pathological specimens revealed dilated, malformed lymphatic channels within the pleura, pulmonary septa, and bronchovascular bundles, and foci of perilymphatic and intralymphatic spindle cells which reacted with the Prospero homeobox protein 1 (PROX-1) immunostain. The morphology and immunohistochemistry results were consistent with a diagnosis of KLA. This newly recognized clinical-pathological entity among intrathoracic lymphatic anomalies is distinguished from generalized lymphatic anomaly and diffuse pulmonary lymphangiomatosis in part by characteristic hematological abnormalities and hemorrhagic complications, including hemoptysis, as experienced by our patient.

Early warning scores (EWS) were introduced in early 2001 to identify patients at risk of deterioration in a busy clinical environment as a track-and-trigger system where an increasing score produced an escalated response. 1 EWS have demonstrated better capability in identifying deteriorating patients leading to improved clinical outcomes. 2 Furthermore, an EWS at admission can be used to determine in-hospital mortality and intensive care unit (ICU) transfer. 2-4 Our academic medical center developed a modified early warning score (MEWS) system in 2015 and it was rolled out hospital-wide the following year. Since serious adverse events in hospitalized patients are often preceded by signs of clinical deterioration, we believed MEWS scores could be used to predict events, such as cardiopulmonary arrest. As the coronavirus pandemic continues, could MEWS provide any usefulness in predicting ICU level care among hospitalized COVID-19 patients? A retrospective study was conducted at the University of Toledo Medical Center (Toledo, OH) on COVID-19 positive patients hospitalized from late March to the end of May 2020. All patients were confirmed for COVID-19 by real-time reverse transcription polymerase chain reaction. Patient demographics, biometrics, and comorbidities were gathered from the electronic medical record. The highest level of hospital disposition was used to create the medical floor and ICU groups. The MEWS scores, which are calculated hourly using the criteria in Fig. 1 , were retrieved from an electronic database. Initial MEWS scores were considered either at admission or prior to ICU transfer. Sequential organ failure assessment (SOFA)

T A B L E 2 Detailed data regarding positivity of viral culture and subgenomic RNA for each patient in the included studies Patient number Study, year Choi, 2020 Positive (Days 75 and 143) NR Abbreviation: NR, not reported.