Infectious Diseases | Mount Sinai Today

Large-Vessel Stroke and COVID-19 in Young Patients: New Insights

May 11, 2020 | COVID-19, Featured, Patient Stories, Research

The Icahn School Medicine at Mount Sinai team studying the relationship between stroke and COVID-19 included, from left, Thomas J. Oxley, MD, PhD; Johanna T. Fifi, MD; and J Mocco, MD, MS.

Cerebrovascular stroke specialists at the Icahn School of Medicine at Mount Sinai have reported on five patients younger than 50 years of age who presented to the Mount Sinai Health System in New York City with large-vessel stroke and COVID-19, surprising observations that were documented in The New England Journal of Medicine (NEJM) on Tuesday, April 28, 2020. Significantly, they have also determined that stroke patients may be delaying emergency care because of fear of COVID-19.

Large-vessel stroke, the most devastating form of stroke, occurs when there is a large blood clot in a major artery of the brain. It may cause severe symptoms in the patient and, when not diagnosed or treated quickly, may result in death or major disabilities. This form of stroke is typically seen in patients older than age 50.

“As the pandemic surged, we noticed a lot of the patients coming in for stroke were very young, and some of them did not have any traditional risk factors for stroke—but they were testing positive for COVID-19,” says the study’s senior author, Johanna T. Fifi, MD, Associate Director of the Mount Sinai Cerebrovascular Center, Director of Endovascular Stroke, and Associate Professor of Neurosurgery, Neurology, and Radiology. “We realized we had seen five young people with large vessel stroke within two weeks, and that was not usual,” adds Dr. Fifi. “By comparison, every two weeks over the previous 12 months, our service had treated, on average, less than one [0.73] patient younger than 50 years of age with large-vessel stroke.”

The patients described in the report were 33, 37, 39, 44, and 49 years old who presented to Mount Sinai during a two-week period, from March 23 to April 7, 2020. First author Thomas J. Oxley, MD, PhD, Instructor in Neurosurgery, and a specialist in vascular neurosurgery, was in the process of removing a blood clot from one patient. He was threading a tiny device through the artery to retrieve the clot, using an imaging monitor to guide him, and then he saw, he says, “There were new clots forming around the existing clot, in real time.” This was a very unusual finding.

While such observations are limited, and did not receive full peer review, NEJM says that it is sharing case reports like these that offer important teaching points or novel findings to communicate information on the global clinical effort against COVID-19. J Mocco, MD, MS, Director of the Cerebrovascular Center for the Mount Sinai Health System, Vice Chair of Neurosurgery, and Professor of Neurosurgery, says these five cases served as “an alert” to his stroke peers. The discovery of clots forming in the small vessels of many organs—in the lungs, heart, liver, and kidney—had already been reported in COVID-19 patients by several physicians from around the world, including pulmonologists and cardiologists at Mount Sinai.

One case highlighted in the NEJM report was that of a 33-year-old patient—a female who was described as previously healthy, and not having any of the usual risk factors for stroke.

She had reported symptoms of cough, fever, and chills for one week—possible symptoms of COVID-19—which were followed by progressive slowing or slurring of speech, with both numbness and weakness in the left arm and left leg over a period of 28 hours—symptoms of stroke. When she presented to Mount Sinai Brooklyn, her score on the National Institutes of Health Stroke Scale (NIHSS) was 19 (scores range from 0 to 42, with higher numbers indicating greater stroke severity). Dr. Mocco described it as “profound” stroke—the type, he said, that has the potential to result in the most severe physical and cognitive deficiencies.

Adding to the medical challenge was this patient’s delay in seeking medical care. Large-vessel strokes are very treatable, says Dr. Oxley, especially when treated within 6 hours, and up to 24 hours of the onset of symptoms. This patient, however, took more than a day to seek medical care. “She delayed seeking emergency care because of fear of COVID-19,” the report says. “She told us that she lives with elderly relatives, and she was afraid of exposing her family by going to the hospital, so she stayed home,” says Dr. Fifi.

Computed tomography (CT) and CT angiography showed a partial infarction of the right middle cerebral artery with a partially occlusive thrombus (blood clot) in the right carotid artery in the neck. Significantly, patchy ground-glass opacities in the lungs—a finding characteristic of COVID-19—were also seen on CT angiography. Testing to detect SARS-CoV-2, the virus that causes COVID-19, was positive.

The patient received antiplatelet therapy, which was subsequently switched to anticoagulation therapy. After a repeat CT angiography on Day 10 showed a complete resolution of the blood clot, the patient was discharged to a rehabilitation facility.

Among the four other patients, one was discharged home, another to a rehabilitation facility, one to the Mount Sinai stroke unit, and the fourth succumbed to his illness.

Since submitting their NEJM report, Dr. Mocco and his team have begun to analyze every stroke case that occurred while Mount Sinai hospitals were treating COVID-19 patients. “We saw a doubling in the rate of severe strokes, and more than half of the patients were positive for COVID-19,” he says. “And, we saw that they looked very different from the normal stroke population—they looked younger, and they were more likely to be men. It appears—very strongly—that there is an association here between the virus and forming blood-clots.” All of this requires more rigorous research, and the Mount Sinai stroke team will continue to observe and to collaborate on new investigations to increase understanding of the stroke and COVID-19 relationship.

In the meantime, each of them urges any individual who has stroke symptoms to seek immediate help. “Social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes,” they wrote in the NEJM report. “Two patients in our series delayed calling an ambulance because they were concerned about going to a hospital during the pandemic.” Adds Dr. Oxley: “You need to call the ambulance urgently if symptoms such as facial drooping, arm weakness, and speech difficulties appear.”

Some Severely Ill Children May Mount an Overly Aggressive Response to COVID-19

May 8, 2020 | COVID-19, Featured, Research

George Ofori-Amanfo, MD, Chief of the Division of Pediatric Critical Care at The Mount Sinai Hospital and Mount Sinai Kravis Children’s Hospital

Nine pediatric patients admitted to The Mount Sinai Hospital during the past two weeks, who either tested positive for COVID-19 or had antibodies, had severe abdominal pain and low blood pressure, which progressed to shock. Some of the patients also had clinical signs of myocarditis. This inflammation affects the heart muscle and the heart’s electrical system, reducing the heart’s ability to pump and causing abnormal rhythms, or arrhythmias. SARS-CoV-2, which causes COVID-19, is the first coronavirus associated with myocarditis.

Prior to their infections, the patients—six boys and three girls—did not have co-morbidities that would have put them at higher risk for disease, according to George Ofori-Amanfo, MD, Chief of the Division of Pediatric Critical Care at The Mount Sinai Hospital and Mount Sinai Kravis Children’s Hospital.

“These patients presented with very unusual symptoms,” says Dr. Ofori-Amanfo. “Until now, the pediatric patients who came to the Emergency Department with COVID-19 all had respiratory problems like the adults—dry coughs, difficulty breathing, and sometimes decreased oxygen saturation. In this recent series of patients, the children presented with abdominal pain, low-grade fever, vomiting, and in some cases diarrhea.” The pain was so severe that one child was sent to Mount Sinai to determine whether the problem was appendicitis, which was not the case. Another child was sent to the hospital for a CT scan to see whether the cause was inflamed abdominal lymph nodes. This was also ruled out upon closer examination.

Two of the nine pediatric patients also had a rash and conjunctivitis, which put their symptoms in a constellation of conditions that are similar to but not the same as Kawasaki disease, which causes blood vessels to become inflamed and also affects the heart. Both of these patients were among those with the least severe symptoms.

Dr. Ofori-Amanfo says that when the children and young adults progressed into a state of shock with low blood pressure, they did not respond to the traditional methods of resuscitation and large amounts of IV fluids, so the clinicians gave them high doses of blood pressure medication, which helped. Three of the patients required mechanical ventilation for shock and two of these patients also required mechanical cardiac support.

“This is a new phenomenon and it is rare. Perhaps these patients had mild symptoms of COVID-19 or were asymptomatic. We think what we’re seeing is a post-infectious process. It is an aggressive immune response to either the virus or some aspect of the viral infection that we don’t know yet. Because when you look at their lab profiles, the patients have very elevated inflammatory markers and this suggests an acute inflammatory response,” says Dr. Ofori-Amanfo. “The exaggerated immune response affects the heart function, which is mildly to moderately depressed, and their low blood pressure is a result of the hyper state of their immune system.”

At Mount Sinai, a team of specialists in areas that include pediatrics, immunology, hematology, infectious diseases, and basic science is treating this syndrome by targeting and modulating the overwhelming immune response and managing anticoagulation therapies for potential strokes. “This is a real entity, but it is rare, and we are hypervigilant and looking out for our patients,” says Dr. Ofori-Amanfo. “We think we have developed some therapies that are working. We have really smart, dedicated specialists working together. It is a great partnership.”

Other hospitals in the New York metropolitan region, around the country, and in Europe have reported smaller clusters of similar pediatric cases.

“We are studying the children to learn what predisposes them to developing this syndrome,” Dr. Ofori-Amanfo says. “These children had siblings. We don’t know why one child gets this but his brother or sister doesn’t.”

I Think I Have COVID-19. How Can I Take Care of Myself At Home?

May 8, 2020 | COVID-19, Your Health

Most people who have COVID-19 can recuperate at home, while remaining in contact with their doctor. Abigail R. Chen, MD, Senior Medical Director at Mount Sinai Doctors Downtown, tells you what you need to know to address COVID-19 symptoms at home.

Can I stay at home if I have COVID-19?

Generally, yes. Most people who test positive for COVID-19 will have mild symptoms–like a cough or sore throat. If you are experiencing mild symptoms, you can certainly recuperate at home by treating with over-the-counter medications. Below, I outline how to address the most common COVID-19 symptoms at home.

For information on protecting others in your home, read through the CDC guidelines.

How do I treat fever from COVID-19?

The best way to treat fever from COVID-19 is with acetaminophen—the active ingredient in Tylenol and other over-the-counter painkillers. Some early reports suggested that ibuprophen—the active ingredient in Motrin, Advil, and others—may make COVID-19 worse. However, the U.S. Food and Drug Administration has found no link between ibuprofen use and severe COVID-19. Remember to follow the dosage and timing directions on the package.

What should I take for a cough?

Most of the time, coughs that come with COVID-19 are dry and do not bring up phlegm. They can be severe and may even disrupt your sleep—but may still be able to be handled at home. The best approach to a cough can be a cough suppressant like dextromethorphan –the active ingredient in Robitussin, Nyquil, and other over-the-counter medications. If your cough is making it difficult to sleep, try a semi-reclining position (about a 45-degree angle). Since the cough associated with the virus is dry, you do not need an expectorant—such as guaifenesin—which helps to clear mucus from the airways. If your cough is really making you uncomfortable, talk with your doctor, who can give you a prescription-strength medication, or let you know if you need to go to the hospital.

What can I do about fatigue?

The key is to listen to your body. It is not uncommon to feel fatigued even days or weeks after many other symptoms have resolved. If your body is telling you to sleep more than usual, you should respect that and lay down rather than getting back on your computer. If you are having difficulty sleeping, try adjusting your position. Many people have some level of insomnia these days, due to the stress of the stay at home orders.

What if I lose my appetite?

Many people with COVID-19 find their appetite has disappeared. It is important to remain hydrated and take in some calories to give your body strength to fight the virus. Many people find that traditional soups—such as chicken soup or rice porridge (also called congee or jook)—can be helpful. These soups are bland, easy to digest, and offer some nutrition to help your body get energy. But soups do not provide all the hydration you need. You should make sure to drink as much water or other liquid as you can. Once you feel better, try to eat a little more to give your body strength to continue to heal.

What if I have a sore throat?

If you find your throat hurts from coughing, acetaminophen may be able to help. Many people find it also helps to drink something warm or very cold; pick what feels best on your throat.

How do I address shortness of breath?

This is the most dangerous of the COVID-19 symptoms. When you are taking care of COVID-19 at home, your doctor will pay careful attention to how you are breathing. Typically, every video appointment will begin and end with questions about shortness of breath. If you notice a change in your breathing—for instance, if you normally have no trouble with a flight of stairs and now find yourself huffing and puffing—it may be time to go to the hospital. Your doctor can advise you.

What if I lose my sense of taste and smell?

This is one of the more unusual symptoms of COVID-19. It can appear even with the mildest of cases. Make sure to tell your doctor if you have lost either your sense of smell or taste. While we cannot give you back your ability to savor chocolate or sniff flowers, these symptoms can help your doctor determine whether you have seasonal allergies or the COVID-19 virus. To learn more about this unusual symptom, read this post from Mount Sinai rhinologist Patrick Colley, MD.

How often should I check in with my doctor?

You should keep in touch with your doctor regularly. If your doctor does not recommend a follow-up appointment, you should feel comfortable asking for one. It is important to understand that recuperating from COVID-19 is not a linear trajectory. You may start to feel better and then, after a few days, feel worse again. It is important, though, to have a doctor monitor your symptoms; he or she can tell you if what you are experiencing is standard or concerning. These days, many doctors are available by email, as well as phone and video.

Are there certain people who should be extra vigilant?

The elderly and people who have hypertension, obesity, and diabetes should be especially careful about discussing any COVID-19 symptoms with their doctor. These conditions have been closely linked to relatively severe cases of the virus. If you have any of these conditions and are experiencing any symptoms that resemble COVID-19, please keep in contact with your doctor.

What if my doctor tells me to go to the hospital? Do I have to?

If your doctor does advise you to go to the hospital, please do so. These days, many people fear hospitals and doctors’ offices. But health care facilities are taking special care to protect you. If you need hospital-level care, it is important that you get it.

How Mount Sinai is Keeping Patients Safe

Is It Safe to Go to the Hospital for Emergency Care?

May 8, 2020 | COVID-19, Your Health

These days, we are all worried about contracting COVID-19. We know people who have symptoms of the virus often go to a hospital’s emergency department—most known to patients as the emergency room—to seek immediate care. For this reason, many people are nervous about going to the hospital for any other reason. But, that is not always the best approach. Brendan Carr, MD, Chair of Emergency Medicine for the Mount Sinai Health System, explains what you need to know about going to the emergency department during the COVID-19 pandemic.

Should I go to the hospital for emergency care?

In a medical emergency, you should seek help—and that means going to the emergency department. If you delay seeking help for conditions that need immediate attention, we may not be able to do as much for you. If you have a problem with your heart or your breathing, if you have chest pains or symptoms of a stroke, it is important to be evaluated as soon as possible, for the best outcome. We want to help, but we cannot do anything for you if we do not know there is a problem.

I am concerned about safety. What is being done at hospitals to ensure that it is safe for patients?

Throughout the Mount Sinai Health System—and at most other hospitals in the country—we have spent a lot of time changing our set-up and workflow to protect against exposure to COVID-19. We are very diligent about how we clean all the high-traffic areas. We make sure that all staff members wear masks and we give patients masks as they go into the emergency room. We are doing everything we can to protect you from possible exposure.

To help us help you, there are some things that you can bring when you come. Have a list of all your medical problems and the medications you take. It can help to bring the medicines themselves. While this advice is always true, it is especially important during this pandemic. In addition, you might want to bring a cell phone and phone charger so that you can reach out to friends and family about what is happening. You also may end up spending a fair amount of time at the hospital, so it cannot hurt to bring a book or some sort of entertainment to make your wait easier.

Should I go to the hospital, urgent care, or schedule a video visit with a medical provider?

It depends on what is happening. If you are experiencing something that you have been treated for in the past and you have an idea of what is wrong—or it is a minor problem—then it is totally appropriate to go to an urgent care center. You can also call your doctor’s office to arrange for a video appointment. We provide a number of virtual care options through Mount Sinai Now, including virtual urgent care and the ability to text with a physician about your health concerns. If your doctor thinks you need a higher level of care, they will refer you to the emergency department or to a specialist.

Are there special precautions I should take if I have to go to the hospital?

Think about going to the emergency department the way you think about doing all the other important things in your life. There is always a risk of exposure when you leave the house, but we still go to the grocery store and to the pharmacy. Going to the hospital when you are worried that you are ill or injured is another part of taking care of yourself. We are here for you and are doing everything we can to keep you safe. It is important to follow all the safety rules in the emergency department that you would anywhere else. Wear a mask, wash your hands regularly, and practice social distancing.

How Mount Sinai is Keeping Patients Safe

Outcomes Data Published from Large, Diverse COVID-19 Patient Study in NYC

May 7, 2020 | COVID-19, Featured, Research

Li Li, MD, Sema4’s Vice President of Clinical Information and an Assistant Professor at the Icahn School of Medicine at Mount Sinai

Sema4 scientists released results from an analysis of patients tested for SARS-CoV-2 at five hospitals in the Mount Sinai Health System. Spanning more than 28,000 patients, this is one of the largest and most racially diverse COVID-19 studies performed in the United States to date. The study findings were posted as a preprint on medRxiv.

The team at Sema4 analyzed de-identified electronic medical records from 28,336 patients tested for SARS-CoV-2 at Mount Sinai Health System hospitals in Manhattan, Brooklyn, and Queens between February 24 and April 15. Of those patients, 6,158 tested positive for the coronavirus and 3,273 were admitted to the hospital.

Consistent with other reports, this study confirmed that COVID-19 prevalence in African Americans and Hispanics is disproportionately high in New York City. However, for patients admitted to the hospital, the analysis found no differences in mortality rates based on ethnicity, indicating that inpatient care helps to address this health care disparity.

The team also identified several risk factors linked to increased mortality rates for COVID-19 patients, including age, oxygen levels, body mass index, and elevated creatinine, among others. Asthma was associated with longer hospital stays, but did not appear to be linked to increased mortality rates. The study, which found higher mortality rates at hospitals where patients had more severe cases upon entry, can also be used to guide neighborhood-based testing for SARS-CoV-2.

Li Li, MD, Sema4’s Vice President of Clinical Information and an Assistant Professor at the Icahn School of Medicine at Mount Sinai in the Department of Genetics and Genomic Sciences, who was one of the lead scientists on the project, commented: “In a thorough review of published studies investigating COVID-19 mortality rates, we found unintentional biases, such as small sample size, that limited the broader utility of the data. By including all patients tested at these five member hospitals and performing advanced statistical modeling including multivariate analyses, we have removed that bias and generated findings that should be more useful in improving the understanding of which clinical features track with disease progression and associated outcomes.”

COVID-19 and Mount Sinai: The Photographs that Tell a Story

May 6, 2020 | COVID-19

There are many, many significant moments over Mount Sinai’s nearly two centuries of history that have defined who we are as individuals and as an institution. Today, our hospital campuses—and our everyday jobs of caring for the sickest patients and developing the treatments to save them—are being vastly transformed. The work that we do so professionally and respectfully, and with compassion and ingenuity, has taken on new urgency. It is the hurried work that the world now sees—in real time, primarily through dramatic photographs. The photographs that we present here speak—always respectfully—for our patients, for our doctors and nurses and clinical staffs, for our scientists, and for everyone at the Mount Sinai Health System. As we all continue to work under extraordinary circumstances, we will bring you the compelling pictures that will help us to remember what we do and who we are. In this installment, see how the Abilities Research Center at the Department of Rehabilitation and Human Performance was converted into a well-being oasis for our front-line staff, and how The Mount Sinai Hospital continued to be physically transformed.