Coronavirus illness 2019 (COVID-19), attributable to extreme acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has change into a pandemic of unprecedented harm, leading to hospitalizations and intensive care unit (ICU) admissions of older adults worldwide. Oropharyngeal dysphagia is likely one of the problems of endotracheal intubation in ICU sufferers. So far, three case studies have been revealed on dysphagia as a complication of COVID-19 and all three circumstances have a historical past of intubation.1–3 However, to one of the best of our data, there isn’t any revealed report on dysphagia in nonintubated COVID-19 sufferers. The inflammatory state of COVID-19, mixed with malnutrition and low mobility throughout hospitalization, could predispose the person to secondary sarcopenia and sarcopenic dysphagia, presenting a significant problem for clinicians caring for sufferers with COVID-19. Herein, we report a case of sarcopenic dysphagia following COVID-19 an infection in a nonintubated older grownup. The affected person’s written knowledgeable consent was obtained for this report.
An 85-year-old male was readmitted to the hospital for post-COVID-19 cough and issue in swallowing 3 days after his discharge from the COVID-19 unit, the place he had been hospitalized for six weeks. He had acquired remdesivir, favipiravir, dexamethasone, and low-molecular-weight heparin for extreme COVID-19 pneumonia, however by no means required ICU care. During his hospital keep as a consequence of COVID-19 pneumonia, the affected person had been confined to a mattress, as he had dyspnea on exertion. Physical remedy had not been initiated. Because of his lack of urge for food, he had been capable of eat roughly 25% of his estimated day by day vitality and protein necessities. He had not been evaluated for malnutrition or dysphagia. An oral diet complement had not been initiated, and he claimed to have misplaced >3 kg.
He was a nonsmoker with an unremarkable medical historical past. He actively labored as a college professor and reminisced about his day by day bicycle using, suggesting that he was in good bodily situation up till his preliminary presentation with COVID-19. He used to eat an enough and balanced that which met his day by day vitality and protein necessities. He had a steady physique weight and exercised commonly. Hence, sarcopenia and malnutrition previous to his hospitalization for COVID-19 had been unlikely.
On medical examination, he was afebrile with a blood stress of 117/78 mm Hg and a pulse charge of 90 bpm. O2 saturation was 96% on 4 L of oxygen by means of the nasal cannula. He described issue swallowing liquid and strong bolus, which was not current previous to his hospitalization for COVID-19. There was no signal of olfactory dysfunction. Gag reflex was current bilaterally. His consuming evaluation device (EAT-10) rating on admission was 40/40 (EAT-10 is a screening device for dysphagia and a rating of ≥3 is taken into account irregular)4.
The affected person had a physique mass index of 21.6 kg/m2. His Mini Nutritional Assessment (MNA) rating was 6/30, which was in step with malnutrition. According to the Global Leadership Initiative on Malnutrition (GLIM) standards, the affected person had stage 2 (extreme) malnutrition.
The European Working Group on Sarcopenia in Older People (EWGSOP)5 makes use of low muscle power as the primary parameter of sarcopenia. Low muscle amount and high quality affirm the prognosis and low bodily efficiency signifies severity. EWGSOP additionally offers cut-off factors for the above- talked about parameters; a handgrip power <27 kg for males signifies low skeletal muscle power. Our affected person had a handgrip power of 21.4 kg and a calf circumference of 29 cm, which had been irregular (cut-off level for calf circumference is 31 cm for each women and men). His appendicular skeletal muscle mass adjusted for top squared was 5.7 kg/m2 (for males, <7 kg/m2 is taken into account low) and his gait velocity was <0.8 m/s. The affected person was identified with extreme sarcopenia, as he had decreased muscle power and muscle mass mixed with low bodily efficiency. Acute stroke was dominated out with diffusion-weighted magnetic resonance imaging. Computed tomography of the lungs was in step with aspiration pneumonia in the correct decrease lobe, for which he was began on meropenem. He was consulted with the Ear Nose Throat clinic and a medical bedside evaluation of swallowing was carried out. Cough response was noticed when swallowing meals with liquid and thickened liquid consistencies. Flexible endoscopic analysis of swallowing (FEES) revealed the presence of residue in valleculae and over the epiglottis with obvious aspiration into the airway (Figure 1A and B). The penetration-aspiration scale (PAS) rating was 6 with 10 ml of yogurt and seven with 10 ml of water (PAS is an 8-point scale that’s used to outline the depth of airway invasion; a rating of 8 being the worst). The affected person was identified with oropharyngeal sarcopenic dysphagia and subsequent aspiration pneumonia after restoration from COVID-19, induced by extended immobilization and malnutrition as a consequence of hospitalization. Initially, enteral diet was began by means of a nasogastric feeding tube. A high-protein system was initiated, and the infusion charge was progressively elevated to succeed in 30 kcal and 1.5–1.8 g protein per kg physique weight day by day to realize the specified protein-energy targets.6, 7 β-Hydroxy-β-methylbutyrate (HMB) supplementation 1.5 g twice day by day (3 g/day), and vitamin D supplementation had been additionally began. A dysphagia rehabilitation program together with tongue-hold swallow, tongue base, and shaker workout routines was supplied till discharge. Percutaneous endoscopic gastrostomy (PEG) tube placement was carried out 1 week after his admission when he was now not on supplemental oxygen. On the subsequent day, he was began on enteral feeds by means of the PEG tube and discharged house with a reassessment scheduled for two months later.
At the follow-up go to 2 months after discharge, he was noticed to have gained 4 kg and had a handgrip power of 28 kg. Control FEES revealed postswallow clearance of blue-dyed water (Figure 2A). No penetration or aspiration was obvious with blue-dyed yogurt. The residue of fabric was seen on the laryngeal facet of the epiglottis and valleculae after the swallow (Figure 2B). PAS rating was 2 with water and three with yogurt. Oral feeding was launched together with enteral feeding by way of the PEG tube. The PEG tube was eliminated when the affected person resumed enough oral consumption.
Sarcopenia is both major (age-related) or secondary, as within the setting of an inflammatory systemic illness.5 Reports indicating an elevated danger for sarcopenia amongst survivors of COVID-19 got here as no shock as a result of proinflammatory cytokines play an important position in sarcopenia pathogenesis.5, 8 Physical inactivity and malnutrition as a consequence of hospitalization are additionally related to secondary sarcopenia, with extra pronounced results on older adults.5
Sarcopenia could result in dysphagia by means of the weakening of the muscle mass accountable for the coordination of swallowing, particularly sarcopenic dysphagia. Maeda et al8 have proven that sarcopenia and bodily operate are related to dysphagia within the absence of stroke, neurodegenerative illness, or most cancers.
Swallowing is a posh motor occasion thay requires the harmonious contraction of the tongue muscle mass, suprahyoids, thyrohyoids, pharyngeal elevators, and intrinsic laryngeal muscle mass9. Geniohyoid muscle atrophy and decreased tongue stress have particularly been related to dysphagia and aspiration in older adults.10, 11 Sarcopenic dysphagia could end in recurrent aspiration pneumonia, which is related to elevated mortality.12
Sarcopenia and malnutrition share widespread pathophysiological mechanisms together with irritation and oxidative stress.5 In a examine from Wuhan, China,13 the prevalence of malnutrition in older sufferers with COVID-19 was discovered to be as excessive as 52.7%. The lengthy hospitalization interval, throughout which the diet wants of the affected person weren’t met, could have contributed to the event of malnutrition and subsequent sarcopenic dysphagia. As dysphagia ultimately results in malnutrition due to insufficient dietary consumption, reverse causality can also be attainable.
SARS-CoV-2 is a neurotropic virus that has been proven to trigger peripheral nerve illness.14 Glossopharyngeal and vagal neuropathy, that are among the many neurological manifestations of COVID-19, could induce dysphagia.14 The cytokine storm of extreme illness might also irritate neurological harm. Although no main pathologies had been obvious within the central nervous system, we couldn’t rule out peripheral neuropathy in our affected person.
During his hospital admission for COVID-19, the affected person acquired a excessive dose of dexamethasone that was progressively tapered over 2 weeks. Treatment with dexamethasone might also have contributed to his muscle loss.
During this unprecedented disaster, throughout which hospitals are overloaded and well being programs on the breaking point, clinicians are being compelled to prioritize affected person care. Assessment of malnutrition and sarcopenia could also be ignored whereas struggling to maintain the affected person alive, as was the case with our affected person.
Clinicians caring for sufferers with COVID-19 ought to be conscious that dysphagia, which is related to elevated mortality in older adults, could happen even within the absence of intubation. We suggest that the evaluation of swallowing operate be a part of a medical routine in older COVID-19 sufferers with malnutrition or sarcopenia.
CONFLICT OF INTEREST
Büşra Can, Narkiza Ismagulova, Aslı Tufan, and İsmail Cinel contributed to the conception and design of the analysis; Necati Enver contributed to the acquisition and evaluation of the info; Büşra Can and Aslı Tufan drafted the manuscript. All authors critically revised the manuscript, conform to be absolutely accountable for guaranteeing the integrity and accuracy of the work, and skim and accepted the ultimate manuscript.
- 1, , , , , . Cranial nerves impairment in post-acute oropharyngeal dysphagia after COVID-19: a case report. Eur J Phys Rehabil Med. 2020; 56(6): 853– 857.
- 2, . Clinical Conundrum: Dysphagia in a Patient with COVID-19 and Progressive Muscle Weakness [published online ahead of print, 2020 Oct 31]. Dysphagia. 2020; 1– 2. https://doi.org/10.1007/s00455-020-10205-zect
- 3, , , , . Oropharyngeal Dysphagia and Aspiration Pneumonia Following Coronavirus Disease 2019: A Case Report. Dysphagia. 2020; 35(4): 545– 548. https://doi.org/10.1007/s00455-020-10140-z
- 4, , , et al. Validity and reliability of the consuming evaluation device (EAT-10) Ann Otol Rhinol Laryngol. 2008; 117(12): 919– 924.
- 5, , , et al. Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and prognosis [published erratum appears in Age Ageing. 2019;48(4):601]. Age Ageing. 2019; 48(1): 16– 31.
- 6, , , et al. ASPEN COVID-19 activity drive on diet analysis. medical diet analysis and the COVID-19 pandemic: a scoping evaluate of the ASPEN COVID-19 activity drive on diet analysis. JPEN J Parenter Enteral Nutr. 2021; 45(1): 13– 31.
- 7, , . COVID-19: a significant reason for cachexia and sarcopenia? J Cachexia Sarcopenia Muscle. 2020; 11(4): 863– 865.
- 8, . Sarcopenia is an unbiased danger issue of dysphagia in hospitalized older folks. Geriatr Gerontol Int. 2016; 16(4): 515– 521.
- 9. Physiology of swallowing. Dysphagia. 1989; 3(4): 171– 178.
- 10, , , et al. Aging-related geniohyoid muscle atrophy is expounded to aspiration standing in wholesome older adults. J Gerontol A Biol Sci Med Sci. 2013; 68(7): 853– 860.
- 11, , , , , . Decreased tongue stress displays symptom of dysphagia. Dysphagia. 2006; 21(1): 61– 65.
- 12. Aspiration pneumonia: incidence, mortality, and at-risk populations. JPEN Parenter Enteral Nutr. 2002; 26(6_suppl): S19– 24. dialogue S24-5.
- 13, , , et al. Prevalence of malnutrition and evaluation of associated components in aged sufferers with COVID-19 in Wuhan, China. Eur J Clin Nutr. 2020: 74(6): 871– 875.
- 14, , , et al. Neurologic manifestations of hospitalized sufferers with coronavirus illness 2019 in Wuhan, China. JAMA Neurol. 2020; 77(6): 683– 690.