Case Report: SARS-CoV-2 as an unexpected causal agent of predominant febrile hepatitis.

Background: Respiratory symptoms and pneumonia are the predominant features of Coronavirus disease 2019 (COVID-19) due to emerging SARS-CoV-2 virus, but extrapulmonary manifestations are also observed. For instance, some degree of liver injury has been described among patients requiring hospital admission for severe COVID-19. However, acute febrile hepatitis as an initial or predominant manifestation of COVID-19 has been rarely reported. Case presentation: A 34-year-old man without underlying medical conditions presented with fever of unknown origin for two weeks in the absence of respiratory symptoms or other complaints. Laboratory testing revealed isolated acute hepatitis, for which an extensive microbiological work-up did not reveal identification of the causal agent. PCR testing for SARS-CoV-2 on a nasopharyngeal swab was negative on two occasions and initial serology for SARS-CoV-2 (at 15 days from symptoms onset) was also negative. However, repeated SARS-CoV-2 serological testing at 30 days demonstrated seroconversion leading to the diagnosis of COVID-19-related hepatitis. The patient's condition progressively improved, while transaminases steadily declined and eventually returned back to normal within 30 days. Conclusions: We describe here a unique case of SARS-CoV-2 isolated febrile hepatitis in a young and previously healthy man, which was diagnosed by demonstration of seroconversion, while PCR screening was negative. This case report highlights the role of repeated serological testing for the diagnosis of extrapulmonary manifestations of COVID-19

Treatment of hemiplegic shoulder pain in the Netherlands: results of a national survey.

Objective: To describe the methods of treatment applied by physiotherapists, occupational therapists, rehabilitation physicians, nursing-home physicians and neurologists for hemiplegic shoulder pain, and to investigate their beliefs about the effectiveness of triamcinolone acetonide injections for this diagnosis. Design: Postal questionnaire with structured and open-ended questions. If necessary, a written reminder was sent after 2-3 weeks. Subjects: One hundred physiotherapists, 100 occupational therapists, 100 rehabilitation physicians, 100 nursing-home physicians and 100 neurologists in the Netherlands. These healthcare workers were all active in the rehabilitation of stroke patients. Results: The response was 351 (70.2), ranging from 58 (neurologists) to 83 (physiotherapists). Fifty-four different (combinations of) treatments were mentioned and were classified into eight treatment groups. The frequency of the first choice of treatment was: physiotherapy (32), prevention/instruction/education (22), oral medication (8), local injection (7), sling (4), referral (3), other therapies (4), and different combinations (20). In total, 86 respondents had applied local injections: 70 rehabilitation physicians, 10 nursing-home physicians and 6 neurologists. The injections used were: corticosteroids alone (51.2), in combination with a local anaesthetic (37.2) or a local anaesthetic only (9.3). Belief in the effectiveness of triamcinolone injections, measured on a 0-100 point scale, was: physiotherapists median 62.5 (IQR 29.75-71.75), occupational therapists median 50.0 (IQR 43.0-63.0), rehabilitation physicians median 70.0 (IQR 56.5-80.0), nursing-home physicians median 35.0 (IQR 21.0-64.5), neurologists median 47.0 (IQR 20.0-63.0). Conclusions: As preventive measures and physiotherapy, or a combination of both, were found to be the favourite methods of treatment for hemiplegic shoulder pain in this survey, it seems that most physicians and therapists rely on a mechanical approach to hemiplegic shoulder pain. Rehabilitation physicians used additional local (anti-inflammatory) injections