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sage-nebula · 11 months ago

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I've decided to make my own post because I am not an idiot, but full disclosure that this post is 50% based on thoughts I was having while I was driving home from the auto repair shop yesterday and 50% a response to a post I saw just now that conflated "redemption arcs" (things fictional characters go through in fictional stories) with "community support" (things real life people offer to other real life people in real life) and how this relates to "fixing people" (making someone who mistreats or abuses themself or others not mistreat or abuse themself or others anymore).

Read my words very carefully.

In fiction, it is more than okay to like whatever type of toxic or fantastical relationship you want. If you like to read stories about toxic, codependent people who are absolutely horrible to one another and will never, ever change, you read those stories. If you like to read stories about a tortured man who just needs The Right Person to teach him to be better, and then he is, sometimes exclusively only to them though, then you read those stories. Sometimes you want to read stories where the main character says "I can fix him" and fails spectacularly, and sometimes you want to read stories where the main character says "I can fix him" and succeeds spectacularly, and either way, you read whatever stories you want, whatever makes you happy, I'm sure it's somewhere in this vast Archive that we call Our Own.

However, in real life?

First of all, "arcs" aren't things real life people have. An arc is something that has a beginning, a middle, and an end. Real life people don't have those, because our stories don't end until we die. Unlike a character, whose life presumably continues even after their story ends (except in circumstances where they die at the end but you know what I mean), we have to keep living day by day, with all the rises and falls that come with it. Now, this does not mean that a person cannot change, or that a person can't get better and learn from their mistakes; but it DOES mean that we can't have a "redemption arc" where we complete a checklist of story beats and then suddenly we're a better person who has experienced the necessary growth to be forgiven. First off, no amount of growth or change ever requires any victims to forgive. And second, that's just not how life works. That's not how change works. Change and growth are baby steps taken each day, and sometimes you go backwards, and you get angry with yourself, but then you pick yourself up and you try again the next day, and the next, and the next. It's an ongoing journey that does not end until you die. That's life.

But second and more importantly, the real idea that I think the original post was trying to get at, but missing the mark on was . . . okay.

So, the original OP of the post (and the person who replied to OP) got angry at the idea that the strawman they had invented (the person who had theoretically said "you can't fix him!") would deny support to someone who needs that help to grow and change as a person. The person who had replied in support of OP added that the strawman clearly believed in punitive justice over rehabilitative justice as well. On the surface, I can see where they are coming from. After all, on the whole humans are a social species and do need support networks in order to not only thrive, but survive. People such as drug addicts need support and assistance in order to get into better places in their lives, and the prison system has been proven to be far less effective at preventing repeated offenses than rehabilitative programs. This is all true.

However.

The reason why "you can't fix them" is still true, and needs to be said and understood particularly by those who are susceptible to falling into abusive relationships (e.g. people who have been abused before, particularly in childhood or adolescence) is because of free will. Specifically, the free will that each of us has, but specifically the other person. Person A can want so, so, so badly to "fix" Person B so that they stop being an abusive alcoholic 75% of the time. But if Person B doesn't actually want to stop being an abusive alcoholic (even if they say they do during the 25% of the time they aren't smacking Person A around), and refuses to put in the work that it takes to become sober and be a better person, then guess what? Nothing Person A does will ever make them be a sober, non-abusive partner. They will be unable to fix Person B. It doesn't matter how much time, energy, money, or commitment they pour into that person. It doesn't matter how much they genuinely, honestly, earnestly love them. Because unless Person B wants to change, and will put the work into doing so, then they will not change, and Person A, for their own health, safety, and sanity, needs to exit that relationship.

Now, does that mean that if, ten years down the line, Person B decides they are ready to put in the work to get their alcoholism under control, no one should help them? Of course not! They should absolutely be put in touch with sober counselors, support groups, medical professionals, friends and family who can help them. Person A could potentially forgive them, if Person A chooses. But that willingness to change and put in the work has to come from within Person B first.

I've been in the position where I've seen people in awful situations just tanking their lives, people I loved and cared about, people I begged to just listen to me and get help, only for them to not . . . and ultimately I had to accept that I couldn't fix them. I could be there to offer support when they were ready to fix themselves, but the core work that needed to be done had to come from within themselves. I couldn't provide that. Not because I was inadequate, not because I didn't love them, but because I couldn't force them to do anything they didn't want, or weren't ready, to do.

So at the end of the day, "you can't fix them" isn't about not giving support. It's about recognizing your limitations as a human being. It's about knowing that:

You cannot force someone to do something they do not want to do.

You cannot force someone to do something they are not ready to do.

Not being able to help or save someone is not a moral failing of yours.

Not being able to help or save someone does not mean you do not love or care about them.

Providing support should never come at risk of your own health and safety, physical or otherwise.

When you love someone, it can be really hard to accept this. You think, "I know I can make them want to try. I know I can inspire them to want to change. I know they love me, so if I just love them a little harder, they will want to change." Nine times out of ten, though, that is just not true. And if someone is abusing you, it is not worth the literal risk to your life to keep trying. You are worth more than that. You are more than just someone else's band-aid.

Keep yourselves safe in 2024.

#not an abuse scenario but: my mom died of covid-19 #it's relevant to this discussion bc she was a trump-supporting republican who refused to get vaccinated #bc the far-right propaganda shows she watched told her the vaccine ''wasn't a real vaccine''#and i know this bc when i literally BEGGED MY PARENTS to get the vaccine my mother LAUGHED IN MY FACE and TOLD ME ''it's not a real vaccine #so anyway both my parents got it. my father almost died from it #my mom seemed like she was doing much better . . . except she CONTINUED to smoke heavily while both having covid #and recovering from covid #and once again i said hey don't you think you should not smoke cigarettes while recovering from a serious respiratory disease #and once again she laughed at me #anyway 2 months later her heart gave out in her sleep and she died #bc her body couldn't handle the stress of the cigarettes + alcohol (she was also an alcoholic) after covid had done its thing to her #she was only 56yo #so this was a case where i wanted to fix my mother. i tried so hard. and i've similarly tried to fix my father (who is still alive)#but i can't! my dad almost died and my mom DID die and my dad STILL won't get the vaccine #I HAVE BEGGED THIS MAN. WHO IS NOW 73. TO GET VACCINATED. AND HE STILL WILL NOT.#you can't fix people!!! you can't!!! you can offer them support if they want to fix themselves #you can help them fix themselves but you can't fix them. you just can't. no matter how much you love them #and in abuse cases it can be really fucking dangerous to keep trying.#anyway. that's my TED talk. thanks for attending or w/e it is they say

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tomorrowusa · 8 months ago

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youtube

Fact checking Donald Trump is a full time, even overtime job. He told over 30,000 lies just during his term.

The problem with live news coverage of Trump is that he gets to spew lies and that the factchecking has to wait until he shuts his porcine mouth or producers cut him off.

Low information voters are therefore likely to hear Trump's semi-coherent rants but miss any attempts to call out his lies.

Having said that, MSNBC on Super Tuesday night did a decent attempt at countering a few of Trump's main lies.

Joy Reid is pointing something out that Democrats need to do much more. Trump TOTALLY botched the US pandemic response right from the start. A reminder of what Trump said at CNBC on 22 January 2020 – the day the first COVID-19 case appeared in the US.

Of course it wasn't just fine under Trump.

The Obama administration, which limited the 2014-2016 Ebola pandemic in the US to under a dozen cases, had put together a pandemic playbook. You can read it here. Trump totally ignored it. He spent 50 days after the first US COVID case doing typically idiotic Trump stuff like criticizing 2020 Oscar Best Picture winner Parasites. And afterwards he became preoccupied with quack cures for COVID as it spread throughout the US.

People who claim they had it better under Trump are hoping that the memories of voters are as impaired as Trump's cognition.

We need to be prepared to offer clear fact checks to anybody hearing Trump's lies. Of course convincing MAGA zombies is a waste of time. But when around low information voters who may not be part of the Trump cult we need to be able to offer convincing short refutations. Pointing out that Trump did nothing for the first 50 days of COVID in the US is a good start. So speak up!

Trump's lack of a competent COVID response led to a cascade of acute economic problems which took several years to sort out.

#donald trump #trump lies #factchecking trump #super tuesday #covid-19 #pandemic #trump did nothing for 50 days after the first us covid case #economic problems caused by trump #the incompetent trump administration #joy reid #election 2024 #vote blue no matter who #Youtube

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jcsmicasereports · 6 days ago

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Trends in incidence of COVID 19 based on performed Rapid Antigen Test by Piratheep kumar.R in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract

The COVID 19 outbreak represents a historically unprecedented pandemic, particularly dangerous and potentially lethal for elderly population. The biological differences in the immune systems between men and women exist which may impact our ability to fight an infection including SARS-2-CoV-2. Men tended to develop more symptomatic and serious disease than women, according to the clinical classification of severity. Age-related changes in the immune system are also different between sexes and there is a marked association between morbidity/mortality and advanced age in COVID-19. This is a single-center, retrospective, data oriented study performed at the private hospital, in Central Province, Sri Lanka. The data of the patients who performed the Rapid Antigen Test (RAT) to know whether they have infected by SARS-CoV-2 or not, were taken for analysis. Test performed date, age, sex, number of positive and negative cases, number of male and female patients were extracted. Finally the data were analyzed in simple statistical method according to the objective of the study. Totally 642 patients performed RAT within the period of one month from 11.08.2021 to 11.09.2021. Among them 426 (66.35%) are male and 216 (33.64%) are female. 20.4% (n=131) of male obtained positive result among the total male population (n=426). Likewise 11.4% (n=73) of female obtained positive result among the total male population (n=216). Large number of positive cases was observed (34.89%) between the age group of 31-40 years in both sexes. The age group of 21-30 and 41-50 years also were shared the almost same percentage (17.13% & 17.75). The large number of positive male patients observed among the age group of 41-50 years. Almost same number of patients was observed in the age group of 21-30 and 31-40. The least number of positive cases (0.7% and 0.9%) observed almost in 0-10 and 81-90 years. When considering the females, large number of positive female patients observed among the age group of 31-40 years.

Key words: Rapid Antigen Test, Covid-19, SARS-CoV-2

Introduction

A rapid antigen test (RAT) or rapid antigen detection test (RADT), is a rapid diagnostic test suitable for point-of-care testing that directly detects the presence of an antigen. It is used to detect SARS-CoV-2 that cause COVID-19. This test is one of the type of lateral flow tests that detect protein, differentiate it from other medical tests such as antibody tests or nucleic acid tests, of either laboratory or point-of-care types. Generally 5 to 30 minutes only will take to get result and, require minimal training or infrastructure, and cost effective (1).

Sri Lanka was extremely vulnerable to the spread of COVID-19 because of its thriving tourism industry and large expatriate population. Sri Lanka almost managed two waves of Covid-19 pandemic well, but has been facing difficulties to control the third wave. The Sri Lankan government has executed stern actions to control the disease including island-wide travel restrictions. The government has been working with its development partners to take necessary action to mobilize resources to respond to the health and economic challenges posed by the pandemic (2) (3).

The COVID 19 outbreak is dangerous and fatal for elderly population. Since the beginning of the actual SARS-CoV-2 outbreak there were an evident that older people were at higher risk to get the infection and develop a more severe with bad prognosis. The mean age of patients that died was 80 years. The majority of those who are infected, that have a self-limiting infection and do recover are younger. On the other hand, those who suffer with more severe disease require intensive care unit admission and finally pass away are older (4).

Sandoval. M., et al mentioned that the number of patients who are affected by SARS-CoV-2 with more than 80 years of age is similar to that with 65–79 years. The mortality rate in very elderly was 37.5% and this percentage was significantly higher compared to that observed in elderly. Further their findings were suggested that the age is a fundamental risk factor for mortality (5).

Since February 2020, more than 27.7 million people in US have been diagnosed with Covid-19 (6). Rates of COVID-19 deaths have increased across the Southern US, among the Hispanic population, and among adults aged 25–44 years (7). Young adults are at increased risk of SARS-CoV-2 because of exposure in work, academic, and social settings. According to the several database of different health organizations young adult, aged 18-29, were confirmed Coid-19 (9).

Go to:Amid of coronavirus disease 2019 (Covid-19) pandemic, much emphasis was initially placed on the elderly or those who have preexisting health conditions such as obesity, hypertension, and diabetes as being at high risk of contracting and/or dying of Covid-19. But it is now becoming clear that being male is also a factor. The epidemiological findings reported across different parts of the world indicated higher morbidity and mortality in males than females. While it is still too early to determine why the gender gap is emerging, this article point to several possible factors such as higher expression of angiotensin-converting enzyme-2 (ACE 2; receptors for coronavirus) in male than female, sex-based immunological differences driven by sex hormone and X chromosome. Furthermore, a large part of this difference in number of deaths is caused by gender behavior (lifestyle), i.e., higher levels of smoking and drinking among men compared to women. Lastly, studies reported that women had more responsible attitude toward the Covid-19 pandemic than men. Irresponsible attitude among men reversibly affect their undertaking of preventive measures such as frequent handwashing, wearing of face mask, and stay at home orders.

The latest immunological study on the receptors for SARS-CoV-2 suggest that ACE2 receptors are responsible for SARS-CoV-2. According to the study by Lu and colleagues there are positive correlation of ACE2 expression and the infection of SARS-CoV (10). Based on the positive correlation between ACE 2 and coronavirus, different studies quantified the expression of ACE 2 proteins in human cells based on gender ethnicity and a study on the expression level and pattern of human ACE 2 using a single-cell RNA-sequencing analysis indicated that Asian males had higher expression of ACE 2 than female (11). Conversely, in establishing the expression of ACE 2 in the primary affected organ, a study conducted in Chinese population found that expression of ACE 2 in human lungs was extremely expressed in Asian male than female (12).

A study by Karnam and colleagues reveled that CD200-CD200R and sex are host factors that together determine the outcome of viral infection. Further a review on association between sex differences in immune responses stated that sex-based immunological differences contribute to variations in the susceptibility to infectious diseases and responses to vaccines in males and females (13). The concept of sex-based immunological differences driven by sex hormone and X chromosome has been well demonstrated via the animal study by Elgendy et al (14) (35). They were concluded the study that estrogen played big role in blocking some viral infection.

The biological differences in the immune systems between men and women may cause impact on fight for infection. Females are more resistant to infections than men and which mediated by certain factors including sex hormones. Further, women have more responsible attitude toward the Covid-19 pandemic than men such as frequent hand washing, wearing of face mask, and stay at home (15).

Most of the studies with Covid-19 patients indicate that males are mostly (more than 50%) affected than females (16) (17) (18). Although the deceased patients were significantly older than the patients who survived COVID-19, ages were comparable between males and females in both the deceased and the patients who survived (18).

A report in The Lancet and Global Health 5050 summary showed that sex-disaggregated data are essential to understanding the distribution of risk, infection and disease in the population, and the extent to which sex and gender affect clinical outcomes (19). The degree of outbreaks which affect men and women in different ways is an important to design the effective equitable policies and interventions (20). A systematic review and meta-analysis conducted to assess the sex difference in acquiring COVID-19 with 57 studies that revealed that the pooled prevalence of COVID-19 confirmed cases among men and women was 55% and 45% respectively (21). A study in Ontario, Canada showed that men were more likely to test positive (22) (23). In Pakistan 72% of COVID-19 cases were male (24). Moreover, the Global Health 5050 data showed that the number of COVID-19 confirmed cases and the death rate due to the disease are high among men in different countries. This might be because behavioral factors and roles which increase the risk of acquiring COVID-19 for men than women. (25) (26) (27).

Men mostly involved in several activities such as alcohol consumption, being involved in key activities during burial rites, and working in basic sectors and occupations that require them to continue being active, to work outside their homes and to interact with other people even during the containment phase. Therefore, men have increased level of exposure and high risk of getting COVID-19 (28) (29) (30).

Men tended to develop more symptomatic and serious disease than women, according to the clinical classification of severity (31). The same incidence also noticed during the previous coronavirus epidemics. Biological sex variation is said to be one of the reasons for the sex discrepancy in COVID-19 cases, severity and mortality (32) (33). Women are in general able to stand a strong immune response to infections and vaccinations (34).

The X chromosome is known to contain the largest number of immune-related genes in the whole genome. With their XX chromosome, women have a double copy of key immune genes compared with a single copy in XY in men. This showed that the reaction against infection would be contain both innate and adaptive immune response. Therefore the immune systems of females are generally more responsive than females and it indirectly reflects that women are able to challenge the coronavirus more effectively but this has not been proven (32).

Sex differences in the prevalence and outcomes of infectious diseases occur at all ages, with an overall higher burden of bacterial, viral, fungal and parasitic infections in human males (36) (37) (38) (39). The Hong Kong SARS-CoV-1 epidemic showed an age-adjusted relative mortality risk ratio of 1.62 (95% CI = 1.21, 2.16) for males (40). During the same outbreak in Singapore, male sex was associated with an odds ratio of 3.10 (95% CI = 1.64, 5.87; p ≤ 0.001) for ITU admission or death (41). The Saudi Arabian MERS outbreak in 2013 - 2014 exhibited a case fatality rate of 52% in men and 23% in women (42). Sex differences in both the innate and adaptive immune system have been previously reported and may account for the female advantage in COVID-19. Within the adaptive immune system, females have higher numbers of CD4+ T (43) (44) (45) (46) (47) (48) cells, more robust CD8+ T cell cytotoxic activity (49), and increased B cell production of immunoglobulin compared to males (43) (50). Female B cells also produce more antigen-specific IgG in response to TIV (51).

Age-related changes in the immune system are also different between sexes and there is a marked association between morbidity/mortality and advanced age in COVID-19 (52). For example, males show an age-related decline in B cells and a trend towards accelerated immune ageing. This may further contribute to the sex bias seen in COVID-19 (53).

Hence, this single center, retrospective, data oriented study performed to identify the gender age influences the RAT results and the rate of positive cases before and after the lockdown.

Methodology

This is a single-center, retrospective, data oriented study performed at the private hospital, Central Province, Sri Lanka. The data of the patients who performed the Rapid Antigen Test (RAT) from 11.08.2021to 11.0.2021 to know whether they have infected by SARS-CoV-2 or not, were taken for analysis. The authors developed a data extraction form on an Excel sheet and the following data from main data sheet. Test performed date, age, sex, number of positive and negative cases, number of female patients and number of male patients were extracted. Mistyping of data was resolved by crosschecking. Finally the data were analyzed in simple statistical method according to the objective of the study.

Results and discussion

Totally 642 patients performed RAT within the period of one month from 11.08.2021 to 11.09.2021. Among them 426 (66.35%) are male and 216 (33.64%) are female. Men mostly involved in several activities such as alcohol consumption, being involved in key activities during burial rites, and working in basic sectors and occupations that require them to continue being active, to work outside their homes and to interact with other people even during the containment phase. Therefore, men have increased level of exposure and high risk of getting COVID-19 (28) (29) (30). The present data descriptive study also were supported certain previous research findings.

The number of male patients got positive result in RAT among the total male patients who performed RAT on every day. According to that, 20.4% (n=131) of male obtained positive result among the total male population (n=426). Philip Goulder, professor of immunology at the University of Oxford stated that women’s immune response to the virus is stronger since they have two X chromosomes which is important when talk about the immune response against SARS-Cov-2. Because the protein by which viruses such as coronavirus are detected is fixed on the X chromosome. This is exactly looks like females have double protection compare to male. The present study also showed that large number of RAT positive cases were observed in males compare to females. Gender based lifestyle would have been another possibility for large number of males got positive in RATs. There are important behavioral differences between the sexes according to certain previous research findings (54).

Shows that the number of female patients got positive result in RAT among the total female patients who performed RAT on every day. According to that, 11.4% (n=73) of female obtained positive result among the total male population (n=216).

The relations between the number of positive cases before and after the lockdown. The lockdown declared by the tenth day from the initial day when the data was taken for analysis. The red vertical line differentiates the period as two such as before and after the lockdown. Though there was no decline observed as soon as immediately considerable decline was observed after the 21 days of onset of lockdown. Staying at home, avoiding physical contacts, and avoiding exposure in crowded areas are the best way to prevent the spread of Covid �� 19 (54). However the significant decline would be able to see after three weeks only from the date of lockdown since the incubation period of SARS-CoV-2 is 14-21 days. The continuous study should be conducted in order to prove it. However the molecular mechanism of COVID-19 transmission pathway from human to human is still not resolved, the common transmission of respiratory diseases is droplet sprinkling. In this type of spreading, a sick person is exposed to this microbe to people around him by coughing or sneezing. Only the way to prevent these kind of respiratory diseases might be prevent the people to make close contact (54) (55). Approximately 214 countries reported the number of confirmed COVID-19 cases (56). Countries including Sri Lanka have taken very serious constraints such as announced vacation for schools, allowed the employers to work from home and etc. to slow down the COVID 19 outbreak. The lockdown days differ by countries. Countries have set the days when the lockdown started and ended according to the COVID-19 effect on their public. Some countries have extended the lockdown by many days due to COVID-19 continues its influence intensely on the public (57) (58).

The incidence of Covid-19 and age group. Accordingly large number was observed (34.89%) between the age group of 31-40 years in both sexes. The age group of 21-30 and 41-50 years also were shared the almost same percentage (17.13% & 17.75). A study provides evidence that the growing COVID-19 epidemics in the US in 2020 have been driven by adults aged 20 to 49 and, in particular, adults aged 35 to 49, before and after school reopening (59). However many researches pointed out that adults over the age of 60 years are more susceptible to infection since their immune system gradually loses its resiliency.

The relations between the positive number of male & female patients and the age group of total patients. According to that the large number of positive male patients observed among the age group of 41-50 years. Almost same number of patients was observed in the age group of 21-30 and 31-40. The least number of positive cases (0.7% and 0.9%) observed almost in 0-10 and 81-90 years. When considering the females, large number of positive female patients observed among the age group of 31-40 years. In USA Ministry of Health has reported 444 921 COVID-19 cases and 15 756 deaths as of August 31. For men, most reported cases were persons aged 30–39 years (22.7%), followed by 20–29 year-olds (20.1%) and 40–49 year-olds (17.1%). Most reported deaths were seniors, especially 70–79 year-olds (29.5%), followed by those aged 80 years and older (29.2%), and 60–69 year-olds (22.8%). Also found a similar pattern for women, except that most deaths were reported among women aged 80 years and older (44.4%) (60).

Conclusion

The present study showed that the male are mostly got positive in RAT test than female. Further comparing the old age young age group in both sexes were noticed as positive in RAT. Moreover there were no relationship observed before and after the lockdown and trend of Covid-19

The limitations of the study

This study has several limitations.

Only 1 hospital was studied.

More than the absence of specific data on mobility patterns or transportation, detail of recovery, detail of mortality etc.

The COVID-19 pandemic is still ongoing so statistical analysis should continue. There are conflicting statements regarding lockdown by countries on COVID-19.

The effect of the lockdown caused by the COVID-19 pandemic on human health may be the subject of future work.

#Rapid Antigen Test #Covid-19 #SARS-CoV-2 #jcrmhs #Journal of Clinical Case Reports Medical Images and Health Sciences #Clinical decision making #Clinical Images submissions

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sarajcsmicasereports · 8 days ago

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Bilateral Aspergillosis endogenous endophthalmitis in post COVID-19 recovered patient; A clinical case report by Zahra Zia, MD in Journal of

Abstract

Coronavirus disease 2019 (COVID-19) Ocular manifestations have a thousand faces and yet each ocular presentation has a unique course, treatment and prognosis. We present a rare case of post-COVID-19 bilateral Aspergillosis endogenous endophthalmitis (EE) with aggressive manifestation at first but an appropriate treatment response. A 54-year-old man presented with bilateral decreased vision four weeks after post-COVID-19 hospitalization. Initially, he was diagnosed with noninfectious uveitis and treated with topical and systemic prednisolone for one week. Subsequently, he was treated with systemic voriconazole after a positive vitreous sample polymerase chain reaction (PCR) result for Aspergillus fumigatus. This case demonstrated the effectiveness of systemic antifungal treatment without surgical intervention in post-COVID-19 bilateral Aspergillosis EE.

Keywords: Aspergillus fumigatus, COVID-19, Fungal endogenous endophthalmitis

Introduction

The coronavirus pandemic has recently challenged the medical system. Various ocular manifestations of coronavirus infection have been reported.[1] One of the disastrous ocular manifestations detected in these patients is endophthalmitis.[2] There have been previous case series of patients with COVID-19 pneumonia having bacterial endogenous endophthalmitis (EE) originating from the throat, kidneys, and teeth as a source of infection, and even the COVID-19 virus had been isolated from the vitreous sample.[3] Regarding fungal EE, Candida species are reported as the most common pathogen, although there are two reports with a specific diagnosis of Aspergillus.[4,5] The present case report on bilateral Aspergillosis EE is novel in disease course and recovery.

Case report presentation

A 54-year-old man presented with both eyes blurred vision two days before visiting an ophthalmologist. He had a history of COVID-19-related pneumonia with approximately 30% lung involvement, confirmed by polymerase chain reaction (PCR), which led to eight days of hospitalization. He received intravenous dexamethasone (8 mg/day) and Ceftriaxone 1gr every 12 hours for seven days during admission. There was no airway intubation or intensive care unit (ICU) admission. The patient had a history of first dose COVID-vaccination with COVIran Barekat (Barkat Pharmaceutical Group) vaccine [6] three weeks before hospitalization. He could not receive the next dose of his vaccine due to subsequent health problems. He did not have any other previous systemic disease.

His ocular symptoms developed four weeks after post-COVID-19 hospitalization. At presentation, the Snellen best-corrected distance visual acuity (BCVA) of the right and left eyes was 20/200 and finger counts (FC) 4 m, respectively. He was diagnosed with noninfectious uveitis by his primary ophthalmologist and received systemic prednisolone (25mgr /day) with topical steroids and cycloplegic drops. Due to a lack of recovery, he was referred to our clinic after one week. On examination, the BCVA of the right and left eyes were CF 6m and CF 1 m, respectively. Anterior segment slit lamp exam was unremarkable; however, vitreous cell (+2 in both eyes) was detected. Fundoscopy in the right eye showed extensive confluent yellowish intraretinal and subretinal collections in the inferior arcade involving the macula. In the left eye, the same lesion with surrounding sub-retinal cream-coloured fluid was seen in the post pole, which involved the fovea [Figure 1A]. Lesions appeared to expand in size [Figure 1B] five days later. Both eyes' macular optical coherence tomography (OCT) revealed intraretinal and subretinal hyper-reflective materials with mild intraretinal and subretinal fluid (SRF), which disrupted macular structure [Figure 2A-B]. Fundus fluorescein angiography of the right eye [Figure 3A] and left eye [Figure 3B] displayed early hyper fluorescence due to vascular leakage around the lesions.

Clinically suspicious of EE, systemic workup was performed, including obtaining blood and urine culture, vasculitis laboratory tests, purified protein derivative (PPD) skin test, trans-esophageal echocardiography, and repeating spiral chest CT, and no systemic source of infection was detected. Because of highly suspicious fungal chorioretinitis, vitreous sampling for smear, culture and PCR for herpes viruses, Mycobacterium, Candida, and Aspergillus species was obtained, then oral voriconazole (200 mg/bid) and systemic antibiotic (ciprofloxacin 500mgr/bid) was started. Although the culture from vitreous aspiration failed to yield any organism, Real-time PCR analysis detected the Aspergillus Fumigatus while negative for Candida, HSV-1, HSV-2, CMV, VZV, and Mycobacterium genome. By diagnosis of confirmed Aspergillus EE, oral voriconazole was continued. After three weeks, vitreous inflammation, the subretinal lesions' size, and SRF reduced significantly. The patient's vision gradually enhanced in both eyes. After eight weeks, in the follow-up, BCVA was 20/32 in the right and 20/40 in the left eye. Fundus photography and OCT showed improved lesions [figure 4A-B]. Informed consent was obtained from the patient to report this case.

Discussion

The presented case is the first bilateral confirmed Aspergillus EE in a COVID-19-recovered patient who responded to the antifungal treatment without surgical intervention. There are various treatment protocols for Aspergillus EE, and systemic voriconazole is a critical drug.[7] It is suggested to begin systemic antifungal drugs in clinically presumed cases until the results of PCR or vitreous aspiration culture reveal the definitive diagnosis.[8] Surgical procedures such as multiple intravitreal injections of antifungal drugs and pars plana vitrectomy with or without silicone injection have been reported as valuable ways to manage fungal EE. [2,3]

it is necessary to consider the positive history of COVID-19 recent infection, corticosteroid use and the existence of posterior pole necrotizing chorioretinal lesion for considering the clinical suspicion of fungal EE. Most of the Aspergillus EE patients are initially misdiagnosed as noninfectious uveitis by their primary ophthalmologists and treated Inadvertent with local or systemic steroids or immunomodulators. This scenario was happening for our patient and recently reported cases.[4,5] Also, all recent reports regarding post-COVID-19 recovery Fungal EE indicate no systemic focus of infection and negative blood and urine culture in these patients; therefore, misdiagnosis of noninfectious uveitis is expected.[3,5] A majority of vitrectomies in all fungal species EE had initial negative tap because the vitreous involvement with filamentous fungi is rare, and initial positive smear is uncommon.[9] Sowmya p et al. showed that the PCR reported for fungal genomes verified a 100% microbial detection rate and can be regarded as a gold standard.[10]

The following chart briefly reviews the recent report of the five patients with confirmed Aspergillus-associated EE in COVID-19-related pneumonia and their characteristic retinal signs. [Table 1] Once comparing clinical details and characteristics of the present case with previous reports, there are some crucial differences. This patient only received systemic voriconazole and did not require a pars plana vitrectomy or intravitreal antifungal injection for treatment; However, baseline BCVA was better than in other cases; therefore, the poor presenting vision may be related to poor visual outcome.[11] The visual outcome and healing process were significantly restored compared to other previous fungal EE cases.[4,5] The lower percentage of lung involvement and milder Covid-19 disease course compared to the previous case reports may play the role in this difference. In this case, since the vaccine course was not completed, the effect of a single dose could not be accurately determined.

Conclusion

The purpose of presenting this case is to draw attention to considering fungal pathogens cause EE in patients following COVID-19. In addition to demonstrating differences in the course of illness, progression, and even treatment compared to previously reported cases. This article highlights the need for an in-depth examination of the fundus of patients who have ocular symptoms after COVID-19 and takes fungal pathogens into account.

Declarations

Ethics approval and consent to participate

The patient consented to publish his data and pictures without mentioning his name.

Availability of data and material Data is available as needed

Conflict of Interest: None of the authors has a conflict of interest.

Author contribution: All authors fulfil the ICJME authorship criteria

#COVID-19 #Aspergillus fumigatus #Fungal endogenous endophthalmitis #jcrmhs #Journal of Clinical Case Reports Medical Images and Health Sciences

2 notes · View notes