Emerging cases of coinfection of coronavirus disease 2019 (COVID-19) and tuberculosis (TB), although rare, have attracted the attention of health systems around the world and have arisen many concerns about the diagnosis, treatment, and prognosis of this coinfection especially in high TB burden countries. Here, we report a rare case and, to the best of our knowledge, the first reported case in Morocco of simultaneous diagnosis of an active pulmonary TB infection and a COVID-19 pneumonia. We present a case of a sixty-seven-year-old male patient who was admitted to our COVID-19 emergency department with a diagnosis of COVID-19 pneumonia, confirmed by nasopharyngeal swab's polymerase chain reaction (PCR) for detection of SARS-CoV-2. The atypical radiological findings suggested a TB coinfection which was later confirmed by sputum cultures and Xpert MTB/Rif assay. The patient also presented some complications including thrombosis of the left leg, pulmonary embolism and inaugural ketosis. Treatment was administered as per local protocols: broad spectrum antibiotics, corticosteroids, fixed dose-combination of antituberculosis treatment along with hydration and insulin therapy for ketosis treatment and anticoagulation. The patient was discharged after twenty-three days of hospitalization. Due to the currently limited data, further studies are necessary to establish any possible correlation between COVID-19 infection and the progression of a latent and/or the severity of an active TB infection. The coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is still spreading across the world since its start on December 2019 in Wuhan city, China, and then declared a pandemic by the WHO on March 2020 . There ith, 2020, a sixty-seven-year-old Caucasian male, with no medical or surgical history, presented to our emergency COVID-19 department with persistent dyspnea at rest, along with chest pain, and a persistent cough initially dry becoming productive fifteen days before admission, showing no improvement on clavulanic acid-amoxicillin taken by the patient on self-medication, in a context of fever and night sweats, and deterioration of general status including a weight loss of 10 kg, fatigue, and anorexia. However, the patient had not shown any signs of otorhinopharyngeal viral infection  and had not reported any known close contact with a COVID-19 except that his son had been treated for pulmonary TB infection a year earlier.On December 30Upon his admission, physical examination revealed a conscient bedridden patient, febrile at 38°C, tachypneic at 30 cpm, saturation levels at 86% on ambient air, tachycardic at 100 bpm, and normotensive with bilateral rhonchi, a swollen painful left leg with positive Homans' sign and vesicular eruption on his abdomen. On another note, his admission's capillary blood glucose was as high as 4 g/l and his urine strip revealed 2 positives for ketones and 2 positives for glucose, thus revealing an inaugural diabetic ketosis. His EKG and cardiac enzymes were normal.His laboratory findings showed an elevated white blood cells count (10240/ml)  with high neutrophilic count, a microcytic hypochromic anemia at 10.7 , lymphocytopenia at 710 , an elevated C-reactive protein at 208 , normal procalcitonin level 0.26 , elevated lactate dehydrogenase at 371 , elevated ferritin at 764 ng/ml , blood sugar at 2.29 g/l, and bicarbonates at 22.75 . His renal and liver full workup was normal. HIV and other viral serologies also came back negative. His chest computed tomography (CT) scan showed foci of pulmonary consolidation with diffused ground-glass opacities and multiple bilateral nodules and micronodules all in favor of a CO-RADS 5 with signs of active tuberculosis .Mycobacterium tuberculosis. A venous doppler ultrasound of his left leg revealed a total thrombosis of the superficial femoral, popliteal, and sural veins.His nasopharyngeal swab for COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR) came back positive, thus confirming a COVID-19 infection. Also, his sputum for MTB PCR was positive with no rifampicin resistance detected revealing a concomitant infection with ∗2 per day and was prescribed support stockings. Intravenous hydration was started as per ketosis correction protocol with correction of hydroelectrolytic disorders and intravenous and then subcutaneous insulin therapy with the following regimen: basal insulin in the evening with boluses of rapid insulin three times a day, depending on the patient's capillary blood sugar.The patient was admitted to one of our COVID-19 isolation units and was put under oxygenotherapy via a high flow nasal cannula at 6 liters/min. He was started on broad spectrum antibiotics (2 g of ceftriaxone) for 10 days, corticosteroids (methylprednisolone) 80 mg for 5 days, 40 mg of prednisolone orally, a fixed dose-combination of antituberculosis treatment (isoniazid + rifampicin + pyrazinamide + ethambutol), and anticoagulation with low-molecular weight heparin enoxaparin at 0.6 IUThe evolution was favorable with apyrexia on the second day of treatment, the oxygenotherapy was discontinued progressively over 10 days, the patient's COVID-19 PCR came back negative on day 15th of his admission, and his chest CT scan showed endoluminal defects of the segmental arteries of the left pulmonary base, focal cystic dilatation of the upper right lobe with focal parenchymatous consolidation, multiples bilateral micronodules, and lymphadenopathy in Barety's compartment all in favor of a pulmonary embolism with signs of active tuberculosis .After a stay of 23 days, the patient was discharged with a prescription of anti-TB therapy, antivitamin K (started on day 15th of admission), and oral corticosteroids (prednisone) for 10 days with progressive degression and a basal bolus insulin regimen.Our patient presented a rare case of simultaneously diagnosed coinfection of COVID-19 and active pulmonary TB. This coinfection was described in both genders and in all age groups including a three-month-old Gambian patient, with a slight predominance in males and migrants . These cIn In our case, the diagnosis of COVID-19 was confirmed by RT-PCR for SARS-CoV-2 done upon admission, systematically as per national protocols due to the ongoing pandemic. The complementary CT scan showed pulmonary condensation and diffused ground-glass opacities, commonly described in COVID-19 pneumonia . It alsoMycobacterium tuberculosis) like most of the reported cases , and LDH which was described in COVID-19 infection and linked to severe disease and higher mortality . On the Although thrombotic complications are frequent in COVID-19 infection, their exact incidence has not yet been determined. However, it is noted that their rate is higher in critically ill COVID-19 patients admitted to ICU wards in comparison to non-ICU patients . Their pThere is still no consensus considering the treatment of COVID-19 and tuberculosis coinfection. Our patient received the classic quadruple antituberculosis regimen (isoniazid + rifampicin + pyrazinamide + ethambutol) along with broad spectrum antibiotics for the COVID-19 pneumonia as per the national protocol in Morocco. In the cohort of Tadolini et al., while the antitubercular treatment was the same for drug susceptible M.tb, the reported treatment for COVID-19 was of different combinations of hydroxychloroquine, azithromycin, and lopinavir/ritonavir: 17 patients received a monotherapy, 9 a combination of two drugs, and 2 received 3 or more drugs . AntiretThe use of corticosteroids in COVID-19 is recommended in certain cases to modulate the inflammatory process as in our national COVID-19 protocol. Many cases in literature suggest the possibility of TB reactivation under these immunosuppressive treatments , but dueIn the study by Tadolini et al., 9 patients had both diseases diagnosed within the same week including 4 on the same day, and 14 had COVID-19 first . HoweverIn the same cohort, the mortality rate was as high as 6/49 (12.3%) and was reported in aging patient with 1 or plus comorbidities . The risIn conclusion, the possible overlap of symptoms of COVID-19 and TB must alert clinicians to think of TB coinfection when confronted with atypical clinical or radiological presentations, especially in migrants and high TB burden countries. Larger studies are needed to fully to explore and establish clear treatment and prevention protocols for this coinfection.Written informed consent was obtained from the patient for using images and other relevant data for publication in this study.In the mist of the ongoing pandemic, as all resources are being allocated to the fight against COVID-19, the emerging cases of COVID-19 and TB coinfection is ought to remind us of an evenly important fight, that against TB. Therefore, we strongly recommend testing for both diseases when faced with respiratory symptoms especially in high TB burden countries like ours or at least before atypical clinical or radiological presentations. The available data about these cases is limited still, and further studies are necessary to better comprehend the effects of COVID-19 on TB and vice versa.


Management of malignant pleural mesothelioma (MPM) is challenging as patients frequently present with unresectable disease and the response rates with systemic therapy alone remain low. Given the paucity of effective therapies for MPM, Tumor Treating Fields (TTFields) therapy was made available for use under an FDA-approved Humanitarian Device Exemption (HDE) protocol in 2019, but no real-world data beyond the initial trial have been published to date. We reviewed our retrospective series of five patients diagnosed with MPM and treated with TTFields with pemetrexed and platinum-based chemotherapy. This therapy resulted in a modest disease-stabilization rate with no significant device-related major toxicities. However, we observed universal low-grade skin toxicities related to the device which required medical management and self-discontinuation in 2/5 patients. We also observed lower device usage, compared to the STELLAR trial. Both of these represent opportunities for developing improved management guidelines and efforts to improve patient compliance. Purpose: The objectives of this study were to evaluate the implementation, device usage rates, clinical outcomes, and treatment-related toxicities associated with TTFields and pemetrexed plus platinum-based chemotherapy in patients with unresectable MPM, outside the initial trial results. Methods: Consecutive patients with unresectable MPM were enrolled onto an FDA-required HDE protocol from 2019 to 2021. All patients were treated with a protocol-defined regimen of continuous TTFields (150 kHz) and pemetrexed plus platinum-based chemotherapy. Results: Five patients with unresectable MPM were enrolled. The median number of 4-week TTFields cycles was 5 (range: 2–7 cycles). Median TTFields device usage in the first 3 months was 12.5 h per day (range: 5–16.8 h), representing 52% (21–70%) of the potential daily duration. The median follow-up was 5.4 months (range: 1.1–20.9 months). Treatment-related dermatitis was the only side effect associated with TTFields and was reported as grade 1–2 in all patients; no patient had grade 3+ device-related toxicities. Conclusions: This study represents the first results of real-world implementation of TTFields for MPM. In comparison to the initial clinical trial (STELLAR), compliance rates were lower, although skin-related toxicities appeared similar. Further initiatives and guidelines should be developed to manage treatment-related dermatitis and improve device usage.  Malignant pleural mesothelioma (MPM) is a rare disease linked to asbestos exposure, with a 5-year survival rate of only 10% . ManagemTumor Treating Fields (TTFields) are alternating electric fields with low intensity and intermediate frequency, and exhibit antimitotic effects on malignant cells through a polarization effect on the mitotic spindle ,9. TTFieFollowing Institutional Review Board approval, consecutive patients with histologically confirmed unresectable, locally advanced or metastatic MPM who were enrolled onto an FDA-required HDE protocol at a single tertiary care institution from November 2019 to September 2021 were included in this report. Relevant patient data collected from the shared electronic medical record included gender, age, primary tumor histology, race, tumor stage (American Joint Committee on Cancer staging), smoking status, and Eastern Cooperative Oncology Group (ECOG) performance status. In addition, previous treatment details including radiotherapy, chemotherapy, and surgery information were collected. All patients were prescribed TTFields with a usage recommendation of at least 18 h per day applied to the thorax with output parameters of 150 kHz with two sequential, perpendicular field directions at a maximal device output of 1414 milliampere root mean square, using the NovoTTF-100L System . 2 together with either cisplatin 75 mg/m2 intravenously on day 1 or carboplatin intravenously at a dose of area under the curve (AUC) 5 on day 1. Cycles were to be repeated every 21 days for up to 6 cycles in the absence of disease progression or unacceptable toxicity. In the event of chemotherapy toxicities, dose modifications were employed at the discretion of the treating medical oncologist. Maintenance chemotherapy, including single agent pemetrexed chemotherapy, was prescribed at the discretion of the medical oncologist.Treatment with the device was continuous, with breaks allowed for personal needs . TTFields were initiated on day 1 of treatment concomitantly with chemotherapy. Patients and their caregivers were trained in the use of the device by a trained health care provider and device support specialist. TTFields usage was recorded electronically by the device as average daily use in hours per day, and the information was reviewed and recorded at follow-up visits. Pemetrexed was administered intravenously at a dose of 500 mg/mAcute device-related toxicity was defined as any event within 90 days of the treatment and evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0 (NCI-CTCAEv5.0). Treatment response was evaluated using Modified Response Evaluation Criteria in Solid Tumors (RECIST) for MPM . PatientDescriptive statistics were computed. For continuous variables, the median and range were presented; sample sizes and percentages were presented for categorical variables. OS was defined as the time from TTFields treatment initiation to death or last follow-up. Progression-free survival (PFS) was defined as the time from TTFields treatment initiation to disease progression, death or last follow-up, whichever occurred first. PFS and OS were estimated using the Kaplan–Meier method. Statistical analyses were performed using SPSS, version 27 . Five patients with unresectable MPM were enrolled onto the HDE protocol during the study period. The histologic type was epithelioid in four patients and sarcomatoid in one patient . The medThe median number of pemetrexed and platinum-based chemotherapy cycles was 5 (range 2–6) during TTFields treatment; all patients were treated with the carboplatin and pemetrexed combination. None of the five patients developed any Grade 4+ chemotherapy-related adverse effects . The medThe overall median follow-up was 5.4 months (range 1.1–20.9 months) from initiation of TTFields treatment. Four patients were alive at the time of analysis. Patient #2 had a distant progression in gastrohepatic lymph nodes after six cycles of TTFields and five cycles of pemetrexed and platinum-based chemotherapy and died 13 months after the completion of his TTFields treatment due to disease progression. To date, the remaining 4/5 patients continue to have stable disease, and 2/5 patients continue to use the device. The 6-month and 1-year PFS were 80% and 53%, respectively. Median OS and PFS have not been reached yet.Despite advances in treatment, the prognosis of MPM remains poor. Most patients with MPM are candidates for chemotherapy during the course of their disease, and the combination of platinum with pemetrexed is currently considered the standard first-line approach for patients with disease that is not amenable to resection ,5. GivenIn clinical practice, given the limited treatment options, the first-line systemic therapy regimens for unresectable MPM are heterogeneous and include: pemetrexed and platinum-based chemotherapy, pemetrexed alone, platinum-based chemotherapy doublet and bevacizumab, and most recently ipilimumab and nivolumab. However, each of these treatment approaches have advantages and disadvantages leading to heterogeneous patient selection choices in real world clinical practice. Doublet chemotherapy remains the most commonly used approach in the majority of the world, yet the outcomes with this approach alone are poor . BevacizTreatment non-compliance is a major clinical issue for several reasons. Previous studies showed significant improvement in median OS with daily TTFields usage rates of ≥75% versus <75% , establishing the same practice standard for other disease sites ,20,21. FThe most common side effect associated with TTFields observed in all five patients in this series was skin irritation beneath the arrays. For this reason, it is important to monitor not only the patient’s clinical status and treatment-related toxicities from chemotherapy, but also their skin care regimens. Proper skin care can help reduce the risk of developing skin irritation while using TTFields and may help increase monthly usage . In thisIn oncology, the analysis of real-world data to answer clinical questions that cannot be directly or completely answered using data from clinical trials has gained interest in recent years . It is cOur study has several limitations. First, given the retrospective nature of the study, prior treatments were not standardized with respect to chemotherapy and radiotherapy regimen. Second, a limited number of patients with heterogeneous clinical stages were enrolled onto this HDE protocol over the last 2 years due to the rarity of the MPM diagnosis and indications for TTFields treatment. Third, our study has a short follow up interval limiting long-term side effects evaluation or survival estimates. We do report the acute toxicity experience and TTFields patient usage rates in our study, however longer follow up is needed to draw conclusions on long-term safety and efficacy. Fourth, because of the retrospective design of our study, we did not have patient-reported outcomes or quality of life metrics recorded for the patients. In conclusion, this study represents the first analysis of real-world implementation of TTFields with pemetrexed and platinum-based chemotherapy in MPM treatment to date. We showed that this treatment combination is a feasible treatment strategy for appropriately selected patients. Further strategies are required to increase treatment usage rates since the real world usage was lower than the suggested daily usage and help to manage device-related skin adverse effects.


Borderline personality disorder (BPD) is a prevalent, devastating, and heterogeneous psychiatric disorder. Treatment success is highly variable within this patient group. A cognitive neuroscientific approach to BPD might contribute to precision psychiatry by identifying neurocognitive factors that predict who will benefit from a specific treatment. Here, we build on observations that BPD is accompanied by the enhanced impact of the aversive effect on behavior and abnormal neural signaling in the amygdala. We assessed whether BPD is accompanied by abnormal aversive regulation of instrumental behavior and associated neural signaling, in a manner that is predictive of symptom reduction after therapy. We tested a clinical sample of 15 female patients with BPD, awaiting dialectical behavior therapy (DBT), and 16 matched healthy controls using fMRI and an aversive Pavlovian-to-instrumental transfer (PIT) task that assesses how instrumental behaviors are influenced by aversive Pavlovian stimuli. Patients were assessed 1 year after the start of DBT to quantify changes in BPD symptom severity. At baseline, behavioral aversive PIT and associated neural signaling did not differ between groups. However, the BOLD signal in the amygdala measured during aversive PIT was associated with symptom reduction at 1-year follow-up: higher PIT-related aversive amygdala signaling before treatment was associated with reduced clinical improvement at follow-up. Thus, within the evaluated group of BPD patients, the BOLD signal in the amygdala before treatment was related to clinical symptom reduction 1 year after the start of treatment. The results suggest that less PIT-related responsiveness of the amygdala increases the chances of treatment success. We note that the relatively small sample size is a limitation of this study and that replication is warranted. Borderline personality disorder (BPD) is a prevalent and devastating psychiatric disorder associated with severe functional impairments and high mortality rates . Costs fAlthough several psychotherapeutic treatments exist for BPD, the response is highly variable and treatment effects are modest overall . For exaMaladaptive and inflexible behavior in BPD has been argued to reflect derailed interaction between two principle controllers of human behavior, i.e., an instrumental and a Pavlovian controller . InstrumRelying on the biosocial model of emotion regulation, DBT is one of the leading evidence-based psychotherapies for BPD with the main focus on skillfully regulating impulsive and emotion-driven behavior . DBT teaSpecifically, we measure aversive PIT, which refers to the observation that aversive instrumental actions, such as inhibition and withdrawal, are potentiated in the context of aversive Pavlovian CS, i.e., stimuli that predict aversive outcomes. Thus, aversive Pavlovian CS have been shown to inhibit instrumental approach actions  and to enhance instrumental withdrawal actions . AccumulThus, we hypothesize that borderline symptomatology might result from an imbalance between two major control systems of behavior: the motivational, reactive Pavlovian system on the one hand and a goal-oriented, instrumental system on the other. We explore this hypothesis by first investigating differences in baseline performance on a behavioral PIT task between healthy controls and BPD patients. Based on the above findings, we hypothesized that, relative to controls, BPD patients exhibit the enhanced impact of aversive Pavlovian CS on instrumental behavior, that is, greater aversive PIT . Furthermore, we expect increased PIT-related BOLD signal in BPD relative to controls in the amygdala. Critically, we expect that the between-subject differences in amygdala response are related to symptom reduction across 1 year of DBT in the BPD group.n = 29) were invited to participate in this study. Twenty-three patients volunteered. Imaging datasets were obtained for 15 patients , and clinical outcome measures after treatment were obtained for 14 of these patients , administered by a senior resident in psychiatry (author DG). To familiarize subjects during the first visit with the scanning environment and procedures, we employed a short scan session of about 15 min during which a structural MRI scan was obtained and subjects were familiarized with the instructions and instrumental and Pavlovian training stages in the scanner.During the second visit, before treatment started, subjects completed several questionnaires , of whicParticipants received a 1-year group version of the standard DBT protocol  divided The third and final follow-up session followed after treatment had ended, approximately 1 year after the pre-training scan session. Subjects completed the same questionnaires and participated in the same neuropsychological test battery as in the second session . In addiParticipants performed a computerized PIT task to assess how instrumental approach and withdrawal actions are influenced by aversive Pavlovian CS, i.e., aversive PIT . The expStage 1. Participants performed an instrumental learning task to earn as much money as possible. There were two Action Contexts in this task: (i) One in which the active response led to an approach and (ii) another in which the active response led to a withdrawal. In each context, different instrumental stimuli (mushrooms/shells) were repeatedly presented to the participant  after active responses (and punishment after not responding), and two no-go-stimuli, which yielded reward more often  after not responding (and punishment after go-responding). Instrumental learning was assessed by calculating the proportion of correct responses (p(correct)) over time.Stage 2. In this Pavlovian stage, different Pavlovian CS were conditioned (ditioned . During Conditioning was assessed in two ways: (1) participants indicated the degree to which they liked each of the CS (and USs) by using a visual analog scale (VAS), before and after the experiment; and (2) participants chose one of the two presented Pavlovian stimuli  in extinction on 12 interspersed query trials during the Pavlovian stage.Stage 3. In the PIT stage, we tested how instrumental approach and withdrawal actions (trained in stage 1) are influenced by aversive Pavlovian CS (conditioned in stage 2.). Therefore, stimulus presentation was the same as in the instrumental stage, except that Pavlovian CS from the Pavlovian stage 2 tiled the background from 250 ms before and during the trials, and this stage was run in nominal extinction, i.e., no juice or monetary outcomes were presented (resented . ParticiThere were two independent runs separated by a 2-min break (each including run-specific stimuli/CS), with each run including all three stages. Each instrumental stimulus was presented 12 times and each Pavlovian CS 32 times. These Pavlovian CS were counterbalanced over the eight instrumental stimuli.Whole-brain imaging was performed on a 1.5 Tesla MR scanner . Functional data were obtained using a multi-echo gradient T2*-weighted echo-planar (ME-EPI) scanning sequence   appetitive PIT . We therWe focused our analyses on aversive PIT, i.e., the effect of aversive Pavlovian CS on instrumental behavior. The effects of Action Context , CS Valence , and group  in the critical transfer test were assessed in terms of proportion of go-choices [p(go)] and the average number of button presses . Note that our previous work in healthy controls, on which the current study builds, revealed that the current paradigm was not sensitive to  appetitive PIT . We presThus, analyses were targeted at the degree to which aversive CS influenced instrumental behavior. More specifically, we analyzed across Action Context  how much the aversive Pavlovian CS  inhibited instrumental ‘go’ responding . In addition, we also assessed the Action Context specificity of aversive PIT, i.e., to what extent the effect of the aversive Pavlovian CS is dependent on Action Context . The dependent variables were first averaged across runs and normality was assessed, before they were submitted to a repeated measures ANOVA (rmANOVA), with Action Context  and CS Valence  as within-subject factors and group  as a between-subject factor. Due to non-normal distribution of p(go), we employed non-parametric tests to assess whether there was a significant aversive PIT effect across groups (related-samples Wilcoxon signed-rank test comparing the difference between p(go) for neutral Valence and p(go) for aversive as a function of Action Context) and whether there was a difference in aversive PIT between groups ] and aversive PIT across Action Contexts  between groups).per se; it critically captures its interaction, i.e., PIT. A further parametric regressor contained the expectation associated with each instrumental stimulus  per trial as estimated from a model-based analysis of behavior . Pre-processing steps and first-level fMRI analysis were identical to those employed by behavior  applied behavior . As suchThe parameter estimates for the neutral and aversive parametric PIT regressors were used in a 2 × 2 × 2 rmANOVA at the group level (with random effects) with Action Context  and Valence  as within-participant factors and group  as a between-participants factor. Within this rmANOVA, we assessed Action Context-specific aversive PIT and aversive PIT across Action Context for group differences. Moreover, we also assessed the main effect of Action Context. Based on t-test at the group level with aversive PIT in terms of the average number of button presses as a covariate for each group separately enabling comparison between groups. Based on To capture additional PIT signals related to stable patterns of behavior beyond trial-by-trial variation in instrumental vigor, we contrasted the main regressors  at the pOur primary measure of treatment success was the Borderline Personality Disorder Checklist, BPD47,  a 47-itep < 0.001 uncorrected) were then used to extract the mean beta weights of the left-out participant to calculate the aversive PIT contrast. This procedure was repeated for each participant. The GLM from the remaining participants thus serves as an independent localizer for the participant left out ], measured pre-treatment, with clinical symptom reduction 1 year later. A second-level random-effects simple regression analysis was conducted to assess whether PIT-related neural signal was associated with symptom severity at baseline, and/or symptom reduction over 1 year. To this end, we computed Action Context-specific aversive PIT-related BOLD signal [ - ], aversive PIT-related BOLD signal across Action Contexts [PIT regressor| approach&neutral + PIT regressor| withdrawal&neutral – ], as well as BPD47 scores at baseline and BPD47 change (before-after). These latter covariates of interest were tested in two simple regression analyses of the aversive PIT statistical parametric maps. Any relationship between the PIT-related BOLD contrasts and the BPD47 change (without a baseline relationship) would indicate that PIT-related signaling is predictive of symptom reduction. In addition, as a sensitivity analysis because of the small sample size, we also performed the non-parametric equivalent of this analysis with SnPM  and we eleft out .WB < 0.05, voxel-level) or in one of the following ROIs: The amygdala  correction for multiple comparisons across the whole brain (Pp = 0.48), but we note that the action-specific PIT effect was present in healthy controls (p = 0.008), but not in patients (p = 0.860) when examined separately.Consistent with our previous studies using this paradigm, we observed opposite effects of the aversive Pavlovian CS on approach and withdrawal actions (in terms of choice p(go),  = 33.7, p < 0.001, all other F < 1.8 and p > 0.2, There were no main task effects except for the main effect of Action Context in terms of the average number of button presses , and in trend with the BDI-II .The 14 patients who were seen at follow-up, 1 year after the start of therapy, showed a significant reduction in symptom severity as measured with the BPD47 , 13 < 2.2, all p ≥ 0.05).None of the neuropsychological tests reported in k = 22, Z = 3.79, pFWE = 0.027; non-parametric test with SnPM: peak voxel MNI-coordinates [−24 0 −18], pseudo-t = 4.22, pFWE = 0.013; and MNI-coordinates [22 4 −18], pseudo t = 3.19, pFWE = 0.06). The robustness of these effects was confirmed by cross-validation (r(14): −0.655, p = 0.011) and by supplementary analyses on mean beta estimates extracted from the anatomically defined bilateral amygdala (Pearson r(14): −0.667, p = 0.009). Note, that no significant relation was observed between baseline BPD47 scores and PIT-related amygdala signal (Pearson r(14):0.33, p = 0.25).Pre-treatment PIT-related BOLD signal in the bilateral amygdala was related to BPD symptom reduction after 1 year . Higher F to enter ≤ 0.05 and o F to remove ≥ 0.10) identified two predictors of symptom reduction. Indeed, pre-treatment PIT-related signal in the bilateral amygdala accounted for variance in symptom reduction over and above the other collected baseline measures. Verbal fluency was the only other selected predictor of symptom reduction  = 11.6, p = 0.002, standardized coefficients beta for amygdala signal:0.64, p = 0.003; and for the verbal fluency: −0.48, p = 0.016). All other measures did not enter the model . Next, we examined whether the predictive effect of pre-treatment PIT-related amygdala signal was specific to BPD47 change or whether it extended to other changes in clinical or neuropsychological measures. Indeed, stepwise multiple regression analysis with this amygdala signal as a dependent variable revealed that the association of this signal with BPD47 improvement  = 9.6, p = 0.009) did not extend to any of the other changes in clinical or neuropsychological measures . This is relevant because improvement in borderline severity was accompanied by improvement in depressive symptoms as measured with the BDI-II , as well as improvement in verbal fluency .Next, we explored the specificity of this predictive effect with respect to other (more easily acquired) baseline measures, including baseline BPD47, OQ, BDI-II, BIS, BAS, box completion time, verbal fluency, and digit span . A stepwResults failed to confirm our prediction that patients with borderline personality disorder exhibit abnormal aversive PIT compared to healthy controls at the group level. However, on an individual level, the results demonstrate that the BOLD signal in the amygdala elicited during the aversive PIT task is related to symptom reduction in these patients across 1 year of follow-up. Greater PIT-related responsiveness of the  amygdala was associated with reduced clinical improvement 1 year later. More specifically, this suggests that individual differences in the degree to which amygdala processing relates to trial-by-trial instrumental responding in the context of an aversive Pavlovian CS predict resistance to clinical improvement of (or slower recovery from) BPD. Thus, participants who showed increased coupling between the amygdala BOLD signal and instrumental behavior during aversive Pavlovian CS presentation showed less clinical improvement. In more general terms, this suggests that individual differences in amygdala response could predict clinical improvement of BPD.Based on observations that BPD is associated with the abnormal impact of aversive stimuli on behavior , we emplThe key observation of this study is that neural activity of the amygdala in BPD patients is associated with clinical symptom reduction. These results substantiate the promise of neurocognitive strategies for predicting treatment outcomes in various psychiatric disorders . The conMoreover, our results provide converging evidence for the validity of the PIT paradigm for predicting clinical symptom changes , which The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by METC Oost-Nederland. The patients/participants provided their written informed consent to participate in this study.DG, QH, TV, and RC contributed to conception and design of the study. DG collected the data and performed the statistical analysis under supervision of RC. DG and RC wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.


Zika virus (ZIKV) is a vector-borne flavivirus with a known teratogenic effect, yet the full spectrum has not been delineated. Studies on endemic areas tried to characterize the clinical outcomes of ZIKV intrauterine exposure. We aimed to describe early neurodevelopmental outcomes on prenatally ZIKV-exposed children in a non-endemic ZIKV area. This is a prospective observational cohort study conducted from May 2016 to December 2021 at Hospital Universitari Vall d’Hebron in Barcelona, Catalonia, Spain. We monitored for up to 24 months 152 children extracted from a pregnant women cohort with suspected ZIKV infection; eleven women  fulfilled the criteria for a confirmed ZIKV infection. Among the 152 children included, we describe two cases of congenital ZIKV syndrome (CZS) born from women with a confirmed ZIKV infection. Additionally, we describe five cases of other potentially ZIKV-related outcomes (OPZROs), all with normal birth cranial circumference and born to women with probable ZIKV infection. The low exposed prevalence of adverse outcomes in asymptomatic children at birth in a non-endemic area suggests that close follow-up should be addressed by primary care pediatricians instead of pediatric specialists. Further studies are needed to assess the effects of ZIKV intrauterine exposure beyond two years of life. Zika virus (ZIKV) is mainly a vector-borne flavivirus related to epidemic outbreaks worldwide, especially in Latin American countries . HoweverCongenital ZIKV syndrome (CZS) severity and prognosis are directly associated with the head circumference (HC) at birth and central nervous system (CNS) damage. However, apparently healthy and asymptomatic infants at birth may eventually develop abnormalities detected in CNS imaging or in subsequent neurodevelopment assessments ,6. Few cIn addition to the limited knowledge about the long-term effects of ZIKV intrauterine infection on neurocognitive development, published studies have been conducted in areas with active vector-borne transmission of ZIKV ,9,10,11.This is a uncenter prospective observational cohort study of children born to ZIKV-infected mothers at the Hospital Universitari Vall d’Hebron in Barcelona, Catalonia, Spain, between May 2016 to December 2021.®  for data collection of the cohort of the children. Ethical approval was obtained from the committee of the center with the number PR(AMI)103/2016, and all the parents signed an informed consent before the inclusion of their babies in the study, and the study protocol followed the Spanish consensus document for ZIKV infection [We used REDCapnfection .A total of 152 newborns born to 150 mothers with confirmed or probable ZIKV infection during pregnancy (after travelling or coming from a ZIKV vector-borne endemic area) was included.All the pregnant women testing positive for ZIKV-IgG or ZIKV-IgM and (i) travelling to endemic areas during the pregnancy or the two previous months, or (ii) who had sexual partners that had visited endemic areas in the last 6 months were eligible for recruitment.®Zika Virus RT-PCR kit 1.0, Altona Diagnostics), ZIKV-IgG, and ZIKV-IgM    . In casePregnant women were classified at risk to be exposed to ZIKV regardless of the symptoms. The resulting newborns of the maternal cohort were recruited at birth and were followed up for a maximum period of 2 years.At recruitment, we collected demographic data, including birth date, gender, country of birth, and parents’ demographic data, especially the mother’s country of birth. In addition to all this data, laboratory tests (blood and urinary test) and microbiological analysis , and other samples such as saliva) were performed on the majority of the newborns. Serology confirmation in children was carried out at birth and during follow-up until negativization. Unfortunately, we could not perform ZIKV-PRNT in those newborns with positive ZIKV-IgG due to the lack of infrastructure in our reference laboratory.A confirmed congenital ZIKV infection was defined by microbiological analysis: (i) positive ZIKV RT-PCR in serum, urine, saliva, amniotic fluid, or CSF; and/or (ii) positive ZIKV IgM; and/or (iii) positive ZIKV IgG beyond 18 months old, or by compatible neuroimaging or phenotypic characteristics consistent with CZS.We created a monographic agenda dedicated exclusively to follow-up and to assess these children in our center. During this time, visits were scheduled at 1, 4, 9, 12, 18, and 24 months of age. On each visit, we collected anthropological data ; physical examination and neurodevelopment assessments ); serological analysis were tested until seroreversion; and at least one of ophthalmological check-up with an ocular fundus, hearing evaluation (Auditory Brainstem Response), and radiological imaging ) were performed.Loss of follow-up was recorded, and the reason for that loss was registered in the known cases.® 15 (StataCorp) for statistical analyses. To analyze the association between maternal and infant characteristics regarding confirmed or probable maternal infection status, we used χ2 or Fisher exact tests and reported p-values for each test.We used StataBetween May 2016 and December 2021, 152 children were included that were extracted from a cohort of 150 pregnant women. Referrals were based on maternal laboratory assay results suggestive of ZIKV infection during pregnancy.Eleven women  had a confirmed ZIKV infection, 7/144 were positive for blood ZIKV RT-PCR, 2/17 for amniotic fluid ZIKV RT-PCR, 1/94 for placenta ZIKV RT-PCR, and 7/150 (4.6%) were positive for ZIKV-IgM alongside a positive ZIKV-PRNT. The remaining 92.7% were probable ZIKV infections, 126/150 (84%) were positive for ZIKV-PRNT, and 13/150 (8.6%) had unknown ZIKV-PRNT status.Most of the women were immigrants or visiting friends and relatives coming from Latin American countries (95.7%), whereas European-born women travelling for tourism to Latin America represented less than 5% of the cohort . Of the whole group, 119/152 (79.3%) were asymptomatic.Among the 152 children included in the study, 70 (46.7%) were male and 12/152 (7.9%) were preterm (<37 weeks’ gestation). The mean (SD) gestational age was 39 (38–40) weeks, and the median (IQR) birth weight was 3240 g (2930–3515) with a median (IQR) z-score of −0.39 (−1 to 0.21). The median (IQR) birth cranial circumference was 34 cm (33–35) with a median (IQR) z-score of −0.35 (−1.1 to 0.38). The results of the mother–child pairs national cohort, with the main newborn outcomes just after delivery, have been previously published [Among 11 mothers with a confirmed ZIKV infection, we described two cases of CZS. The remaining nine children were asymptomatic at birth; four presented normal neurological development during follow-up, and five children were lost on follow-up between 4 and 9 months of life. Among women classified as a probable ZIKV infection during pregnancy, we described five cases of OPZROs: a perinatal stroke and four cases of neurodevelopmental impairment detected during follow-up. All of them were asymptomatic and had a within-range cranial circumference at birth.The total follow-up time was 1829.00 months , with a median follow-up time of 9.00  months; thus, 48.8% of the patients were followed up to 12 months, and only 27% completed the 24-month follow-up . There wConsequently, the collected data during follow-up is shown in the figure .Among these 152 children, we here showed the two cases of ZIKV congenital infection. No mother–infant pairs in the cohort were diagnosed as having coinfections. The rest of the participants were defined as children with probable ZIKV intrauterine exposure .We here describe two congenital infections caused by ZIKV and five cases of other potentially ZIKV-related outcomes (OPZROs).We describe a case of medical abortion in the second term of pregnancy. This woman did not recall any symptoms related to a ZIKV infection but tested positive for serum ZIKV RT-PCR, ZIKV-IgM, ZIKV-IgG, and ZIKV-PRNT at 15 weeks of pregnancy. Cerebral and musculoskeletal malformations were detected on the ultrasound at 20 weeks’ gestation. A fetal MRI was performed showing incipient microcephaly with cerebral atrophy and bilateral ventriculomegaly as well as cerebellar hypoplasia. In a posterior fetal ultrasound, generalized edema and club feet were also detected. Given these findings, obstetricians performed an amniocentesis, and ZIKV RT-PCR in amniotic fluid tested positive. Medical abortion was indicated at 22 weeks of pregnancy, and samples were obtained from the fetus testing positive for ZIKV RT-PCR in serum, CSF, and placenta as well as positive for ZIKV-IgM and ZIKV-IgG. The fetal autopsy confirmed the presence of microcephaly, cerebral atrophy, and ventriculomegaly with frequent parenchymal calcifications, bilateral polymicrogyria, and glioneuronal heterotopia. In the pathological anatomy of the placenta, particles morphologically compatible with viruses were found in the chorionic villi.Secondly, we present a case of CZS with positive ZIKV RT-PCR in amniotic fluid and ZIKV-IgG but negative serum ZIKV RT-PCR and ZIKV-IgM at birth. It was a symptomatic infection in the first trimester of the pregnancy (9–10 weeks of pregnancy). The mother reported having a non-pruriginous, maculopapular rash the day she returned from Colombia that lasted 3 days. At 11 weeks of pregnancy, the serum tested positive for ZIKV RT-PCR and ZIKV-IgG with an initially negative ZIKV-IgM. Posterior blood samples showed a positive ZIKV-IgM at 21 weeks of pregnancy and negative again from the 26th week of pregnancy. ZIKV RT-PCR was negative from the 21st week of pregnancy. Furthermore, the initial study also tested positive for Dengue virus (DENV) IgM and IgG. At 19 weeks of pregnancy, prenatal echography abnormalities such as microcephaly and intrauterine growth retardation were detected. Amniocentesis was performed during the second trimester with a positive ZIKV RT-PCR and a negative DENV RT-PCR in amniotic fluid. Further imaging studies were conducted such as a fetal MRI at the 2nd and 3rd trimesters that were consistent with echogenic findings. Genetic studies performed with the amniotic fluid ruled out any fetal chromosomopathy.Postnatal MRI showed severe microcephaly (−4SD), parenchymal calcifications, ventriculomegaly, lissencephaly, and pachygyria. Physical examination at birth highlighted increased muscle tone (hypertonia) with vivid osteotendinous reflexes (hyperreflexia). At birth, she presented with abnormal visual and auditory brainstem responses that normalized at 6 months old. The ocular fundus showed focal pigmentary retinal mottling affecting the macula at birth that softened over time, and ophthalmological monitoring showed persistent esotropia and hypertropia.During the neurodevelopment follow-up, she developed a profound intellectual disability, spastic tetraparesis, epilepsy, dysphagia, and failure to thrive. Intermittent treatment with botulism toxin for spastic tetraparesis was started at 20 months of age. The liquid dysphagia was addressed with thickening agents. Lastly, the failure to thrive was treated successfully with nutritional supplements. She had the first epileptic seizure at the age of 2 years old in the context of a respiratory infection, and then antiepileptic treatment was initiated.Periodic blood tests were done since birth showing persistent positive ZIKV IgG with seroreversion between 12 and 20 months old.Among the studied children, one presented tonic–clonic seizures early at birth with neuroimaging compatible with an embolic stroke. The cranial circumference at birth was normal (percentile 11). His mother tested positive for ZIKV-IgG and ZIKV-PRNT but negative for ZIKV-IgM and RT-PCR during the pregnancy. At 12 h of life, the patient presented with frequent hemiclonal seizures that required more than two antiepileptics to control the seizures. A cerebral MRI was consistent with a perinatal stroke, predominantly on the left posterior middle cerebral artery territory and bilateral border territory of the middle cerebral artery and posterior cerebral artery. All microbiological tests at birth were negative, including CSF samples for ZIKV RT-PCR, ZIKV-IgM, and ZIKV-IgG. ZIKV-IgM and IgG in serum were not done at birth but were negative at 4 months old. We had no other subsequent microbiological studies. Cardiological tests ruled out a cardiac cause of stroke. Neurologic development during follow-up  was appropriate with no appreciable impairment on the right side and normal ASQ-3 tests.Case 4 was child with probable ZIKV intrauterine exposure with a positive ZIKV-IgG and negative serum for ZIKV RT-PCR and ZIKV-IgM at birth. Seroreversion was determined at 4 months old with a negative ZIKV-IgG. The cranial circumference at birth was normal (percentile 68). During follow-up, we detected delayed language acquisition with some autistic spectrum features. Hearing tests and cranial ultrasound at birth were normal. Microarray Comparative Genomic Hybridization (array CGH) was performed and interpreted as normal. A posterior cerebral MRI showed craniofacial disproportion suggestive of microcephaly with stable cranial circumference growth (+1SD). During follow-up, he improved progressively, persisting with a slight delay in language use and short attention span at 2 years old.Case 5 was a child born to an asymptomatic mother who was returning from Honduras during the first trimester of the pregnancy. After arrival, her mother tested positive for ZIKV-IgG and ZIKV-PRNT. At birth, she was positive for ZIKV-IgG with negative ZIKV RT-PCR and IgM. Seroreversion was determined at 12 months of age with negative ZIKV-IgG. She first presented with proper neurodevelopment with correct audiometric and visual tests. The cranial circumference at birth was normal (60th percentile). However, at 12 months old, the physical examination showed slight axial hypotonia. In addition, the ASQ-3 highlighted an impairment in gross and fine motor spheres and altered social interaction. She was monitored by neuropediatricians that determined a global developmental delay with a severe delay in language acquisition and social interaction. Axial hypotonia and marked hyperlaxity in the lower limbs persisted in physical examination over time. Furthermore, we observed progressive microcephaly from the 48th percentile at 12 months old to the 11th percentile at 24 months old. Further studies such as a cerebral MRI and a metabolopathy screening showed no other alterations.Case 6 was a child with a positive ZIKV-IgG at birth whose mother presented positive ZIKV-IgG and ZIKV-PRNT during the pregnancy. Seroreversion of the baby was determined at 10 months old. Visual tests and neuroimaging were normal at birth. The cranial circumference at birth was normal (78th percentile). The auditory brainstem response showed mixed hearing loss with posterior normal behavioral audiometry. However, at 12 months old, a delay in language acquisition was detected, and the ASQ-3 showed impairment in social interaction. He was referred to a neuropediatrician who confirmed a specific language disorder with attention deficit hyperactivity disorder (ADHD) features. A cerebral MRI at 15 months old was normal. He improved progressively during follow-up and was discharged at 2 years old.Lastly, case 7 was a child with probable ZIKV intrauterine exposure. In this case, the newborn tested positive for ZIKV-IgG with a negative ZIKV-IgM and serum ZIKV RT-PCR. Seroreversion was determined at 7 months old. Visual and neuroimaging at birth were normal. The cranial circumference at birth was normal (14th percentile). However, auditory brainstem response showed mild hearing loss that resolved in subsequent controls. At 12 months old, the ASQ-3 test was abnormal in the problem-solving sphere. During follow-up, we observed a delay in language acquisition with difficulties in social interaction and social conduct and a short attention span. He improved over time and was discharged at 2 years old.Twelve children presented nonspecific and various abnormal findings on cranial ultrasounds with no clinical repercussions. Regarding cerebral MRI findings, 2/8 showed signs of microcephaly, 2/8 highlighted the presence of germinolytic cysts with no other abnormalities, one patient had findings related to prematurity, and finally one presented with nonspecific cerebral white matter impairment. These children with cerebral MRI findings presented normal neurologic development during follow-up.In this cohort, we describe cases of early neurological impairment in children prenatally exposed to ZIKV in non-endemic areas. This cohort was extracted from a maternal cohort based on serological results when returning from an endemic area (mostly visiting friends and relatives or emigrating to Spain). A specific schedule was created to assess these children appropriately for up to 24 months.We present two cases of confirmed CZS: one medical abortion at 22 weeks of pregnancy due to antenatal malformations, and a live-born infant with clinical and microbiological findings compatible with ZIKV congenital infection. Both mothers had confirmed ZIKV infections during pregnancy. Additionally, both children tested positive for ZIKV RT-PCR in amniotic fluid, but only the medical abortion tested positive for RT-PCR in serum and ZIKV-IgM. These findings agree with Rodó et al. , who sugWe also identified five cases of OPZROs, following the phenotype description published by Ades et al. , all of Recently more studies expressed the need for further follow-up to evaluate the long-term effects of intrauterine exposure to ZIKV ,25,26,27Compared with American cohort studies ,9, our cIt is also important to note the great challenges that ZIKV laboratory diagnosis has still to resolve due to the short viremia period and the cross-reactivity in serological assays with other flaviviruses. ZIKV-PRNT were not compared to other specific flavoviruses. Additionally, due to the COVID-19 pandemic, ISCIII, our national referral laboratory, did not have the infrastructure to perform ZIKV-PRNT on both children and mothers. Consequently, mother–infant pairs with a low likelihood of ZIKV infection during pregnancy might have been included in the study. At the same time, we could not provide the follow-up data we expected. Many patients were lost on follow-up, as only 27% completed the 24-month follow-up. Therefore, another limitation of our study is that not every child underwent all the tests expected from the study design. Although all of them underwent newborn hearing screening, only 60.2% had a subsequent hearing evaluation. Accordingly, 87.5% had a first ophthalmological check-up, and 64.4% had at least one radiological imaging. Regarding neurological assessment, we only received ASQ-3 results for 10% of the children at 18 months of age. These circumstances impacted our ability to confirm prenatal ZIKV exposure and assess the frequency of OPZROs among exposed children.Screening for ZIKV in exposed pregnant women is essential to conduct intensive prenatal ultrasound assessment in infected mothers. In addition, current data on congenital ZIKV infection supports that the spectrum of ZIKV infection in fetuses and infants extends beyond microcephaly and cerebral malformations to a pattern of structural anomalies and functional disabilities. The absence of clinical and radiologic anomalies at birth does not exclude later neurodevelopmental impairment.In this cohort, we describe 2 cases of CZS among 11 confirmed ZIKV intrauterine exposure. Another 5 children with probable but not confirmed ZIKV exposure presented neurological impairment during follow-up, although the relation between ZIKV exposure and these outcomes is uncertain.Confirming ZIKV infection in pregnant women and their children is challenging, especially in non-endemic areas, where a short period of ZIKV RNA detection forces the reliance on serologic testing. Health systems need to decide whether to invest time and resources on serological studies or to follow a significant number of children during their early childhood to detect potential neurological abnormalities. However, considering the low prevalence of neurodevelopmental impairment in asymptomatic children at birth in non-endemic areas, close follow-up only by primary care pediatricians seems reasonable.


Coronavirus causes an outbreak of viral pneumonia that spread throughout the world. Liver injury is becoming more widely recognized as a component of the clinical picture of COVID-19 infection. Hepatitis with serum ALT elevation has been reported in up to half of patients. Patients with CLD were at a higher risk of decompensation with liver failure, hospitalization, and mortality. The percentage of acute liver injury (ALI) varied from 5 to 28%. COVID-19 hinders HCV elimination by 2030. It is recommended to continue treatment of chronic HCV and chronic HBV if already receiving treatment. Consider using antiviral therapy to prevent viral flare-ups in patients with occult or resolved HBV and COVID-19 who are receiving immunosuppressive agents. Patients with AIH do not have an increased risk of adverse outcomes even in high-risk areas. There is an association between MAFLD and disease progression. Patients with any type of cancer are at a higher risk of infection and are more likely to develop more severe clinical outcomes. Most societies advise against immunosuppressant modifications in patients with mild COVID-19, whereas in rare cases such as severe lymphopenia, worsening pneumonia, or bacterial or fungal superinfection, reduction or discontinuation of antiproliferative agents and lymphocyte-depleting therapies has been suggested. Coronaviruses are enveloped single-stranded RNA diverse group of viruses infecting animals and can cause mild to severe respiratory infections in humans. A novel coronavirus designated as SARS-CoV-2 emerged in the city of Wuhan, China, causing an outbreak of viral pneumonia and spread all over the world , 2, nameThe pathophysiological and immunological mechanisms of liver injury in patients with COVID-19 are poorly understood.Angiotensin-converting enzyme 2 (ACE2), the susceptible receptor for SARS-CoV-2 virus entry into the cells, is highly expressed in the vascular endothelium of small and large arteries and veins but not in the sinusoidal endothelium, Kupffer cells, or T and B lymphocytes . Chai etDirect hepatic infection was evidenced by showing SARS-CoV-2 particles in the cytoplasm of hepatocytes of COVID-19 patients , 8. Rececytokine storm that causes severe immune damage to the lungs as well as the liver [Crosstalk between hyperinflammation and dysregulated immune responses is characterized into three phases: the immune activation stage, secondary hemophagocytic lymphohistiocytosis (sHLH) stage, and immune suppression stage . In the he liver , 17. Thehe liver , 19, T che liver .cytokine storm [IL-6 is a potential risk factor in patients with COVID-19 developing severe liver injury , 21. IL-ne storm . The trane storm .Abnormal coagulation has been significantly associated with poor prognosis for patients with severe COVID-19 with hepatic dysfunction. Both neutrophils and monocytes are playing a significant role in amplifying blood clotting in response to proinflammatory stimuli , 24.Hepatic ischemia/hypoxia reperfusion injury involves a biphasic process of ischemia-induced cell injury and reperfusion-induced inflammatory response. Both ischemia and reperfusion injury lead to hepatic apoptosis and elevated liver enzymes , 26.mechanisms of liver injury are variable and include dysregulated immune responses with markedly elevated plasma levels of proinflammatory cytokines as IL-6 and TNF-α [The nd TNF-α –29, dirend TNF-α , the usend TNF-α .There are liver unique concerns in the pharmacologic management of COVID-19. Remdesivir in controlled trials demonstrated no significant impact on liver function tests as compared with placebo contrary to preclinical investigations [igations . The samigations ; howeverigations . Howeverigations . In patiigations . Patientigations . Currentigations . The useigations . Anticoaigations  and configations . Italianigations .Macrovesicular steatosis was the most common finding, involving 30 patients (75%). Mild lobular necroinflammation and portal inflammation were present in 20 cases each (50%). Vascular pathology, including sinusoidal microthrombi, was infrequent, seen in six cases (15%). PCR of liver tissue was positive in 11 of 20 patients tested (55%).In a study done by Lagana et al. , MacrovePatients with CLD per se do not appear to be over-represented in cohorts of patients with COVID-19 where they make up less than 1% of reported cases . Liver iLiver function test abnormalities: LFT abnormalities ranged from 37 to 69% –51. The The impact of COVID-19 extends beyond the direct morbidity and mortality associated with exposure and infection. The emergence of COVID-19 occurs at a critical moment in the context of hepatitis elimination with only 10 years remaining to reach the Global Health Sector Strategy targets by 2030 . AlthougStreptococcus pneumonia and influenza [In addition to standard of care, it is recommended to continue treatment of chronic HCV and chronic HBV if already receiving treatment, use telemedicine/local laboratory testing for follow-up visits in patients receiving antiviral therapy, and send follow-up prescriptions by mail. Treatment for HCV and HBV should be initiated according to the guidelines , 62; avonfluenza .The percentage of acute liver injury (ALI) varied from 5 to 28%. This wide range of differences in the percentage of ALI might be due to differences in the percentage of patients with severe COVID-19 or differences in the percentage of patients with underlying chronic liver diseases , 50. Ji Streptococcus pneumonia and influenza is essential for all patients [Several reviews endorse that even in fairly endemic areas, sufferers with AIH are not displaying extended hazards of detrimental consequences. In a study from Italy, 26% of AIH patients reported COVID-19 that did not require hospitalization. Only 4 confirmed cases, 3 of which were hospitalized and 1 old-aged patient with comorbidities, died . No diffpatients .Obesity represents a great hazard for severe COVID-19 . Hu and Zhang et al.  reportedIn one of the largest multicenter network studies on LT and COVID-19, Mansoor et al.  found LTNo great difference in mortality was found in LT patients with COVID-19 whether mild or severe in comparison with the general population. The incidence in a large Italian LT survey was 1.25%, and most patients (75%) had a mild disease . ConversIn a systematic review, liver transplant patients with confirmed COVID-19 from 15 studies, were more likely to present with concurrent diarrhea . In a naIn patients with mild COVID-19, no need to make immunosuppressant modifications. In case of severe lymphopenia, worsening pneumonia, or bacterial or fungal superinfection, reduction or discontinuation of antiproliferative agents and lymphocyte-depleting therapies has been suggested .The already licensed COVID-19 vaccines are immunogenic, and the short-term safety record appears excellent in healthy individuals aged 16 years. Based on current knowledge, there is no evidence to contradict the safety and immunogenicity of currently approved vaccines in patients with CLD and hepatobiliary cancer or in immunocompromised patients after liver transplantation. Given the high risk of serious health consequences of SARSCoV-2 infection in such patients, the potential benefits of the vaccine are likely to outweigh the risks associated with vaccination. Therefore, SARS-CoV-2 vaccination is recommended in patients with CLD, hepatobiliary cancer, and candidates for liver transplantation. Optimal timing of vaccination in transplanted recipients is still unestablished but vaccination 3–6 months after transplantation is advisable . Recentl


Abnormal coagulation and increased risk of thrombosis are some of the symptoms associated with COVID-19 severity. Anti-phospholipid antibodies (aPLs) present in critically ill COVID-19 patients contribute to systemic thrombosis. The aim of this study was to identify key common genes to characterize genetic crosstalk between COVID-19 and antiphospholipid syndrome (APS) using bioinformatics analysis and explore novel mechanisms of immune-mediated thrombosis in critically ill COVID-19 patients. The transcriptome data of mononuclear cells from severe COVID-19 patients and APS patients were evaluated to obtain the common genes. The protein–protein interaction network and cytoHubba module analysis in Cytoscape software were used to find the associated hinge genes and hub genes. Among the common differentially expressed genes, TIMELESS depletion was identified only in patients with severe COVID-19 and not in patients with mild COVID-19, and it was validated with the GSE159678 dataset. Functional analyses using gene ontology terms and the Kyoto Encyclopedia of Genes and Genomes pathway suggested that TIMELESS might contribute to the production of antiphospholipid antibody and thrombosis in both COVID-19 and APS patients. The potential role of TIMELESS and autophagy genes in momonuclear cells were further investigated, and GSK3B was found to be associated with TIMELESS. Autophagy targeting agents have a therapeutic potential against COVID-19 and thrombogenesis in APS, which may be related to the role of autophagy genes in the modification of circadian clock proteins. Interference with TIMELESS and other genes associated with it to regulate autoantibody expression may be a potential strategy for immunotherapy against thrombogenesis in severe COVID-19 patients. Although the novel coronavirus is considered as a pneumophilic virus, severe COVID-19 is not only a viral pulmonary infection, but also causes pathological clinical manifestations in multiple organs, accompanied by major coagulation abnormalities and thromboembolic events, such as pulmonary embolism, carotid thrombosis, deep vein thrombosis, and pregnancy thrombosis4. The incidence rate of thrombotic complications in severe COVID-19 patients was reported to be 31% by Klok et al.5, which is much higher than the incidence of thrombotic complications in critically ill patients prior to the COVID-19 pandemic. The incidence of abnormal coagulation events in patients who died of COVID-19 was reported to have reached 71.4%6.The highly pathogenic and infectious novel coronavirus disease 2019 (COVID-19) has created a major health crisis worldwide. As of February 2022, more than 424,822,000 patients were confirmed to be infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and among them, more than 5,890,300 cases of death were reported 8. Thirdly, both APS and COVID-19 infection have a significant impact on the autoimmune system. Therefore, it is critical to investigate the biological pathways mediating the pathological mechanisms of APS and COVID-19. This would explain whether COVID-19 infection induced the expression of aPLs or whether aPLs were directly involved in mediating the hemostasis abnormalities observed in COVID-19 patients. Our study aimed to uncover novel mechanisms of immune-mediated thrombosis in severe COVID-19 patients, and identify potential prognostic biomarkers for this devastating disease.Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arteriovenous or venous thrombosis with elevated persistent antiphospholipid antibodies (aPLs). Combined with previous studies, we found that there were three similarities between APS and COVID-19. Firstly, patients with APS or COVID-19 showed a marked clinical heterogeneity. Patients with APS or COVID-19 developed spontaneous thrombosis of large vessels, affecting a single site, while a small percentage of patients developed rapidly progressive, life-threatening, and multi-organ micro-vessel thrombosisActivation of monocytes and the presence of aPLs in APS patients has a synergistic effect on thrombosis. In this study, two databases were selected for analysis. GSE164805 dataset was selected for analyzing mRNA expression of mononuclear cells from SARS-CoV-2 infected patients, and GSE50395 dataset was selected for analyzing monocyte mRNA expression from APS patients. GSE159678 dataset was used as a validation dataset to verify the expression of target mRNA in patients with severe COVID-19. All the three datasets were obtained from the Gene Expression Omnibus (GEO) Database. The initial work was to identify the differentially expressed genes (DEGs) from GSE164805 and GSE50395 datasets, and then to find the common DEGs between COVID-19 and APS patients. On the basis of the commonly expressed genes, gene aggregation analysis and pathway analysis were further carried out to understand the biological processes underlying the expressed genomes. It is crucial to identify the hub genes from the common DEGs. Thus, we developed protein–protein interaction (PPI) networks to identify the key hub genes. Core genes identified from the hub genes were searched for their targeted miRNAs. Autophagy related genes in the monocytes were screened, and the association between core genes and autophagy was identified by PPI networks. The workflow of this analysis is shown in Fig. 9. The COVID-19 (GSE164805) dataset was provided by Zhang et al.10. The APS dataset (GSE50395) was provided by Perez-Sanchez et al.11. The COVID-19 dataset (GSE164805) included mRNA expression data of mononuclear cells from 5 samples for each of the following patients: healthy individuals; patients with mild COVID-19 symptoms; and patients with severe COVID-19 symptoms. The criteria for cut-off for GSE164805 was obtained using adjusted P-value < 0.01 and log2-fold change > 1.0. The APS dataset (GSE50395) contained mRNA expression data of monocytes from 3 samples for each of the following patient groups: healthy individuals; and patients with APS. The cut-off criteria for GSE50395 dataset was obtained using P-value < 0.01 and log2-fold change > 1.0. The GSE159678 dataset was used to validate the expression of target mRNA in monocytes from severe COVID-19 patients.The GSE164805 dataset describes the transcriptomic data from human mononuclear cells in COVID-19 patients, and the GSE50395 dataset describes the transcriptomic data from human monocytes in APS patients. Demographic and clinical characteristics of all population in both studies are summarized in Supplementary Table https://www.ncbi.nlm.nih.gov/geo/geo2r/) is an interactive online tool that was used to identify DEGs between the mononuclear cell samples from COVID-19 patients and healthy individuals, and the DEGs between mononuclear cell samples from healthy individuals and APS patients. Fold-change (FC) threshold was set to 2. COVID-19 adj. P < 0.01 and APS P < 0.05 were considered to be statistically significant. The differentially expressed genes were presented in the form of volcano map drawn by limma rapid differential analysis tool on the SangerBox web (http://sangerbox.com/). The common genes between COVID-19 and APS patients were analyzed by Venn diagram (http://bioinformatics.psb.ugent.be/webtools/Venn/).GEO2R  pathway (www.kegg.jp/feedback/copyright.html) is commonly used to understand metabolic pathways and contains important gene annotations13. The GO term and KEGG pathway were obtained through the network platform DAVID (https://david.ncifcrf.gov/tools.jsp) for the common DEGs that were identified in the previous step. Enrichment analysis bubble diagram were drawn using the Sangerbox tools, a free online platform for data analysis (http://sangerbox.com/Tool).Gene annotation uses the term gene ontology (GO), which can be divided into three categories including biological processes, molecular functions, and cellular componentshttps://string-db.org/) retrieval tool was used to generate functional gene interaction networks and predict information regarding gene interaction. Interaction relationships were defined through interaction attachment information, and by using the confidence ratings generated by Web tools. In order to obtain a better visual expression of the PPI networks and to identify the hinge genes, we conducted a secondary analysis on part of the obtained PPI using the Cytoscape software (http://apps.cytoscape).Constructing the PPI networks is a prerequisite for the systematic study of cell biology, which is mainly applied to protein–protein and protein-DNA interactions. The STRING (http://apps.cytoscape. org/apps/cytohubba), which is a plugin of Cytoscape software. Based on the degree topology algorithm of Cytohubba, the top five genes in the PPI networks were calculated as the hub genes. Hub genes create concentrated regions that can be detected as an important module of the PPI networks.The hub genes were analyzed using cytoHubba (http://sangerbox.com/Tool) was used to predict the functional effect of the single gene. The matrix data was processed by GSEA simple analysis. The most significant pathways were screened by P < 0.05. The visualized pictures were made by using the SangerBox tool of GSEA.GSEA  and the tests are described in the legends. Sample size and P values are cited in the figures and figure legends.The GSE164805 dataset was used to identify DEGs between COVID-19 patients and healthy individuals. A total of 11,056 DEGs were obtained, including 6105 up-regulated genes and 4951 down-regulated genes. A total of 53 differentially expressed genes were identified in the APS dataset GSE50395, among which 18 genes were up-regulated and 35 genes were down-regulated. The differential genes are shown in the volcano plot in Fig. David and Sangerbox enrichr web tools were used for gene set enrichment analysis. GO term and KEGG pathway of 8  common DEGs were analyzed in this study. The GO term was used to analyze the biological process (BP), cellular component (CC), and molecular function (MF) of the differential genes, which are presented in Table Six common DEGs were provided as input to the STRING, and the file produced from the analysis was reintroduced into the Cytoscape software for visual representation. In the PPI analysis of the screened genes, using the STRING platform, we set the confidence to 0.7. 65 nodes and 570 edges were obtained, as shown in Fig. Seven common DEGs  were identified from the GSE164805 dataset of patients with mild COVID-19, and the GSE50395 dataset from APS patients , F2 (gene encoding lupus anticoagulant and prothrombin), and CRLS1 (gene encoding cardiolipin) as the key words into the STRING website for PPI interaction analysis. Genes encoding antiphospholipid antibodies were derived from the “Gene” module of NCBI. More protein network information was added through the "more" module. Finally, a PPI networks diagram containing 53 nodes and 510 edges was obtained. ApoH and F2, but not CRLS1, showed an association with TIMELESS expression, which was dependent on the role of the hub genes  Fig. . TP53, aGSEA pathway enrichment analysis of TIMELESS gene was implemented in the sangarbox website. The up-regulated genes in the KEGG Pathway and GO term maps were plotted according to the enrichment score (ES). KEGG pathway data indicated that TIMELESS was involved in intestinal immune network for IgA production, aminoacyl t-RNA biosynthesis and antigen processing and presentation Fig. A. GO terIn order to further explore the role of TIMELESS in thrombogenesis, we identified 13 candidate genes responsible for thrombosis by searching "thrombosis AND homo AND APS" in the "Gene" module of the NCBI website (Supplementary Table https://www.targetscan.org/) to find the target microRNAs  of TIMELESS. All the target miRNAs were compared with the autophagy genes associated with TIMELESS, which showed that GSK3B was regulated by miR15a-5p, miR-424-5p, miR-6838-5p, miR-16-5p, miR497-5p, miR15b-5p and miR-195-5p respectively; PARA1 was regulated by miR129-1-3p, and miR129-2-3P. According to the PPI networks analysis, TIMELESS also had a higher combined score with PARP1 and GSK3B , the remaining studies continued to analyze GO, KEGG pathway and the PPI regulatory networks. The change in target gene expression in monocytes was validated with the GSE159678 dataset.Since the beginning of the COVID-19 pandemic, increasing number of reports have drawn an association between COVID-19 and abnormal clotting parameters. Several cross-sectional studies reported a higher incidence of thrombosis in patients with COVID-19. Some studies attempted to explain the pathogenic mechanisms of COVID-19 related thrombosis, one of which was the appearance of aPLs. aPLs have long been considered as one of the mechanisms leading to pro-inflammatory and hypercoagulable states in APS18. FGF restores the activity of telomerase and maintains the replicative ability of endothelial cells, and promotes neo-vascularization19. GO term for the cellular component was nucleoplasm. Top GO terms according to the molecular function were fibroblast growth factor receptor binding 1-phosphatidylinositol-3-kinase activity and ligand-dependent nuclear receptor transcription coactivator activity. 1-phosphatidylinositol-3-kinase is involved in the regulation of monocyte apoptosis and autophagy21.Eight common DEGs were identified for the detection of GO terms. Among the biological processes, lung development, regulation of endothelial cell chemotaxis towards the fibroblast growth factor, and positive regulation of sprouting angiogenesis were identified as the top GO terms. TIMELESS and FGF are known to modulate lung morphogenesis, and their overexpression in lung cancer is associated with a low survival ratehttps://www.ncbi.nlm.nih.gov/gene/8914). We found that TIMELESS was the only common DEG presented in the hub genes, suggesting an important role of TIMELESS in the pathogenesis of both COVID-19 and APS.PPI networks analysis was performed on PPARGC1A, FGF2, FUBP1, ITGB8, SYCP2, FGF1, TIMELESS and FERMT1 genes, as these genes were the common DEGs. According to the PPI networks, TP53, TIMELESS, RPA1, RPA2 and RPA3 were identified as the hub genes due to their high degree of interaction. TIMELESS is a gene that edits highly conserved proteins and regulates several cellular functions such as cell survival after damage or stress; increase in DNA polymerase epsilon activity; maintenance of telomere length; and epithelial cell morphogenesis (8 found that the positive rate of aPLs was 47.0% (31/66) in severe COVID-19 patients, but not in patients with milder symptoms. IgA anti-β2GPI antibody was the most common aPLs, presented in 28.8% (19/66) of the severe COVID-19 patients. To find out whether TIMELESS was related to aPLs production, we performed a two-step analysis. Firstly, we analyzed the common DEGs between mild COVID-19 patients and APS patients. As we expected, TIMELESS was not found in common DEGs of mild COVID-19 patients. Furthermore, our analysis showed that severe COVID-19 patients had lower levels of TIMELESS gene expression as compared to patients with milder symptoms. Relying on the PPI networks analysis, we found an interaction between TIMELESS and aPLs target antigen, specifically β2GPI, LA and PT. Next, we conducted GO and KEGG pathway enrichment analysis on the TIMELESS gene using GSEA website. The KEGG pathway enrichment results for TIMELESS showed that the antigen processing and presentation pathway was up-regulated. Previous reports raised the possibility that Ly-6Clo monocytes played an important role in antigen presentation, which could drive T cell-independent antibody production by B cells22. In severe COVID-19 patients, TIMELESS depletion may be one of the contributing factors for the increased monocyte antigen presentation capacity. Infection-induced aPLs production has been widely reported24. IgA, an immunoglobulin subtype specialized for mucosal immunity, was the most common aPLs subtype. COVID-19 mainly affects the lung and intestinal mucosa; thus the preferential production of IgA subtypes may be related to the breakage of mucosal immune tolerance. In KEGG enrichment analysis, we also found a relationship between TIMELESS and the intestinal immune axis for IgA production. The presence of IgA aPLs may suggest a new subgroup of clinically relevant severe COVID-19 patients with APS. Previous studies reported aPLs as important biomarkers for thrombosis in APS patients25. Our previous study also showed that the anti-β2GPI antibody promoted thrombosis by binding to its target antigen β2GPI28. APOH and F2 were identified as thrombogenesis-related genes in APS and were again shown to interact with TIMELESS in the PPI networks analysis. Combined with the role of TIMELESS in the production of aPLs, and data from our previous studies, we speculated that TIMELESS played a potential role in regulating the thrombotic phenotype in COVID-19 patients.Xiao et al.32. Inhibition of autophagy suppresses the differentiation of monocytes into dendritic cells. Autophagy occurs to promote the depletion of genes associated with TIMELESS, such as CLOCK33. In the PPI analysis of TIMELESS, we found an association between TIMELESS, targeted miRNAs and GSK3, which was a gene screened from the autophagy related genes that could be directly associated with TIMELESS. The GSK3 system represents a “regulating valve” that modifies the core circadian clock proteins34. Previous studies showed that SARS-CoV-2 used the autophagy mechanism of the host cells to promote its growth and replication35. Treatment of SARS-CoV-infected Vero E6 cells with GSK3 inhibitors inhibited viral replication37. Inhibition or knockdown of GSK3β, a highly conserved isoform of GSK3, reduced the transformation of endothelial cells into thrombus phenotypes, which was stimulated with anti-β2GPI antibodies. Several autophagy targeting drugs have been used to inhibit the replication of SARS-CoV-2 virus39. Previously approved drugs that target autophagy, may also reduce the risk of thrombosis in APS patients by directly modulating the binding of aPLs/β2GPI complexes to phospholipids in monocytes40. Continuously evolution and mutation of SARS-Cov-2 necessitates the development of drugs with good safety and efficacy profiles. Therefore, it is important to use high-throughput and virtual screening tools for the rapid development of efficacious and safe drugs that could overcome the dysfunctional immune responses associated with SARS-CoV-2 infection.Monocytes are circulating mononuclear phagocytes with fundamental ability to differentiate into dendritic cells, and autophagy is a necessary process. Autophagy also plays an important role in innate and adaptive immunity; helps to clear intracellular pathogens directly through exogenous autophagy or participates in MHC II restrictive antigen presentationSeveral studies have explored the important regulatory roles of key genes in COVID-19 by bioinformatics analysis. To date, there are no studies investigating the transcriptomes of COVID-19 and APS patients. We attempted to identify common genetic alterations in the monocytes from COVID-19 and APS patients. TIMELESS may interact with thrombogenic factors and impact the production of aPLs by participating in monocyte differentiation. The autophagy pathway may also be involved, since it was identified from the analysis of the interactions between autophagy genes and core genes. The correlation between disease severity and immune dysfunction in COVID-19 patients should serve as a consideration during drug development and evaluation. The pathogenic mechanisms and complications associated with COVID-19 need to be further studied. As SARS-CoV-2 is a recent discovery, there were only a few available datasets to analyze its thrombosis complications. With the availability of future datasets, the research on symptomatic and preventive treatment of COVID-19 patients would become more and more important.Supplementary Information 1.Supplementary Information 2.Supplementary Information 3.Supplementary Information 4.


Emerging human adenovirus type 55 (HAdV-55) causes fatal pneumonia in adults. There is a lack of studies on severe pneumonia caused by HAdV-55 in children.We conducted a retrospective review of pediatric patients hospitalized at Guangzhou Women and Children’s Medical Center with severe pneumonia from 2013 to 2020 who had human adenovirus (HAdV) detected in throat samples or bronchoalveolar lavage fluid using RT-PCR. The presence of HAdV-55 was determined by PCR amplification of the hypervariable regions of the hexon gene. Demographic, clinical, etiological, and outcome data were collected and analyzed.Over the eight-year period, HAdV-55 was detected in three severe and six critical pediatric pneumonia patients. None of the patients had any underlying diseases, and had a median age of 18 months . The male to female ratio was 2:1. All patients presented with fever and cough, and three patients presented with wheezing and diarrhea. Six patients had coinfections with other respiratory pathogens, such as bacteria, Mycoplasma pneumoniae and fungi. Three critical patients developed plastic bronchitis (PB). The median lengths of invasive mechanical ventilation and hospital stay of the critical patients were 10  days and 25  days, respectively. Three critical patients died, although two of them received extracorporeal membrane oxygenation (ECMO) and blood purification. Three surviving patients developed post-infectious bronchiolitis obliterans (PIBO) at the follow-up.HAdV-55 can cause fatal pneumonia in children, and shows a high rate of co-infection with other respiratory pathogens and a poorer prognosis combined with PB. Thus, HAdV-55 may be an important subtype in patients with HAdV-induced pneumonia who develop PIBO. Among them, HAdV-3 and HAdV-7 most frequently lead to severe pneumonia in children (Human adenovirus (HAdV) is an important pathogen causing community-acquired pneumonia (CAP) in children, accounting for 4%–10% of hospitalized cases , comorbidities, clinical symptoms , signs , laboratory tests (whole-blood cell count and blood chemistry), as well as lung microbiological characterization and imaging (computed tomography). Concomitant medications, respiratory support, complications, and outcomes were registered.Children with respiratory distress and hypoxemia [sustained saturation of peripheral oxygen (SpO2) <90% at sea level] were considered as having severe pneumonia . ChildreThroat swab samples or bronchoalveolar lavage fluid (BAF) were collected from hospitalized pediatric patients with severe or critical pneumonia. The samples were collected and refrigerated at 2–8 °C in a viral transport medium before being transported on ice and analyzed immediately, or stored at −80 °C until analysis. Viral genomic DNA was extracted using a TaKaRa Mini BEST Viral RNA/DNA Extraction Kit Ver.5.0 , according to the manufacturer’s instructions and then tested for HAdV using the TaqMan real-time PCR kit  as previously reported . HAdV-poNon-continuous variables were summarized as median (interquartile range).Over the eight-year period, a total of nine patients with HAdV-55-induced severe pneumonia were admitted to our hospital. All nine patients had a median age of 18 months  and no underlying disease at the time of admission. Five patients were younger than 2 years of age, and four patients were older than 3 years. The male to female ratio was 2:1. Three patients were hospitalized in spring, four in summer, and two in autumn. Five patients were hospitalized in 2019.The clinical characteristics of the patients are summarized in According to the determination criteria, patients 1–6 had critical pneumonia and patients 7–9 had severe pneumonia. Patients with severe pneumonia included two males and one female, with a median age of 12 months . Patients with critical pneumonia included four males and two females, with a median age of 52.5 months . Four critical patients were older than three years of age. The patients’ laboratory characteristics are shown in Mycoplasma pneumoniae derived in three patients, and induced by fungi with Aspergillus fumigatus and Talaromyces marneffei in two cases respectively.The co-infections of HAdV-55 with other respiratory pathogens is shown in All patients underwent chest computed tomography (CT) scan. The chest CT features were mainly patchy shadows (6/9), lung consolidation (6/9), pleural effusion (5/9), and mediastinal and hilar lymph node enlargement (3/9). Ground-glass opacity was observed in one patient. Among the patients with pulmonary consolidation, four had single lobe consolidation and two had multi-lobe consolidation.Fiberoptic bronchoscopy (FB) and bronchoalveolar lavage were performed in seven patients. Of those, three revealed a whitish rubbery material occluding the right inferior lobar bronchus (patient 2), multi-lobar bronchus (patient 4), and left inferior lobar bronchus (patient 5), which were considered to be associated with plastic bronchitis (PB). One patient was confirmed to have PB, however the plastic cast was removed successfully through lavage and negative pressure suction. In the other two patients, the plastic cast failed to be successfully removed, therefore the patients were clinically considered to have PB, and refractory hypoxemia could not be improved by invasive mechanical ventilation (IMV). None of the patients were able to undergo multiple bronchoscopic alveolar lavages to remove PB because such an operation under IMV would aggravate hypoxia.Among the three patients with severe pneumonia, two required oxygen support through inhalation and received 2 mg/kg/day methylprednisolone during 3–5 days for persistent wheezing. All three patients received intravenous immunoglobulin (1 g/kg/d for 2 days) to alleviate inflammatory storms. The average length of hospital stay of these patients was 16.67 ± 8.08 days.Treatments and outcomes for the critically ill patients are shown in Three surviving patients developed post-infectious bronchiolitis obliterans (PIBO) during the follow-up, including two patients with severe pneumonia and one with critical pneumonia. One of them has been symptom-free for 8 years. The other two presented wheezing after physical activity, regularly received inhaled glucocorticoid therapy and have been followed up for 2 years. Chest CT of all patients showed mosaic perfusion and air trapping during follow-up .The number of children with HAdV-induced CAP has increased significantly due to an epidemic of HAdV infection occurred in Southern China in 2019. During the study period, 55.56% of the patients diagnosed with HAdV-55-induced CAP were infected in 2019. Previous studies have found that HAdV-55 can cause fatal pneumonia in immunocompetent adults , 5. AlthTalaromyces marneffei which is characteristic of immunocompromised patients, however he was confirmed not to have immunodeficiency by whole gene sequencing. In addition to age, the potential factors leading to critical illness derived from of HAdV-55 are so far undetermined.Epidemiological surveys showed that most children with HAdV pneumonia are younger than 5 years of age, and 50% of the pediatric patients with severe HAdV pneumonia are younger than 2 years of age , 16. ThiThe most common clinical manifestations of pediatric HAdV-55-induced pneumonia are fever, cough, and wheezing. However, differences in the relative frequency of symptoms have been reported, such as a higher proportion of patients presenting wheezing and diarrhea in our study than previously published . In our Mycoplasma pneumoniae infection. M. pneumoniae is not only the most prevalent organism in co-infection with HAdV, but is also known to easily lead to severe illness when co-infected with HAdV in pediatric patients . Among these patients, three had patients . Other cpatients . HoweverTo our knowledge, pediatric patients with PB secondary to HadV-55 have not been reported. Three critical patients had complications with PB, including one case with a definite diagnosis and two cases with a clinical diagnosis. PB is a rare critical disease characterized by the formation of plastic casts of the bronchial tree that obstruct the airways. HAdV-associated PB is mainly observed in case reports and is caused by HAdV-7 –22. RemoIt is generally known that HAdV infection predominates in PIBO, which is a chronic obstruction of the airflow associated with inflammatory lesions of the small airways , 23. PIBThis study had several limitations. First, this was a single-center, small sample study. We did not routinely perform virus typing for mild adenovirus pneumonia. In addition, we did not compare clinical features with those of children with HAdV-7 infection, which is the most common cause of severe pneumonia in children. It is difficult to evaluate the severity of the patient’s condition caused by HAdV-55 or other pathogens due to co-infections. The failure to exclude the influence of co-infection on the results is one of the limitations of this study. Future researchers should adjust the variable of co-infection in the experimental design.Our data provides new insights into the clinical features of severe HAdV-55 pneumonia in pediatric patients. HAdV-55 can cause fatal pneumonia in healthy children. Severe, especially critical, patients showed a high rate of co-infection with other respiratory pathogens. Thus, HAdV-55 may be a relevant subtype in patients with HAdV-induced pneumonia who develop PIBO.