We read with great interest the recently published perspective "Erroneous Communication Messages on COVID-19 in Africa." In his perspective, Seytre 1 writes about the importance of miscommunication and how it affects society's attitudes. He goes on to discuss lingering mistrust generated by misinformation during the Ebola epidemic and its lasting impact on control of the COVID-19 pandemic. Social media has penetrated every sphere of our lives. Facebook, Twitter, Instagram, and blogs impact our thinking patterns, beliefs, and mental health. We concur with the author about the impact of miscommunication on society's mental, physical, and social fabric. In addition, we would like to highlight the personal toll it can take on individual members of any community. We are sharing two cases to highlight the real-world implications of social media misinformation during the current COVID-19 pandemic. Two middle-aged South Asian men of low socioeconomic status, living in separate shared housing, were exposed to COVID-19-positive contacts. Both patients presented to a designated COVID-19 treatment facility in Qatar after ingesting chemical substances. They had no past medical or psychiatric illnesses. The first man ingested about 15 mL of a surface disinfectant but did not report any symptoms. The second man experienced multiple episodes of non-bilious vomiting after ingesting approximately 100 mL of alcoholbased hand sanitizer. Apart from mild derangement in their transaminases, other laboratory tests were unremarkable. Both patients tested positive for COVID-19, and both, fortunately, had an unremarkable clinical course. These men ingested the disinfectant and sanitizer based on a firm belief that it would protect them from SARS-COV-2 infection, built on social media advice. Unvetted information is freely available on social media. Opinion pieces are perceived as facts. There has been a perpetual stream of news on the pandemic, creating a sense of urgency and anxiety. Repeated exposure to this stream of misinformation may affect the construct of external reality. This may lead to a delusion-like experience, which has been linked to anxiety and social media overuse. 2,3 Social isolation has tipped the balance of relationships and emotional connections from real to virtual for many. Indeed, we are in a virtual, long-term, emotionally charged relationship of sorts with social media. This relationship has led to a delusion-like experience, affecting multiple people separated by space and time, with social media as the common denominator. 4-6 The two described cases are just the tip of the iceberg of a "hidden epidemic" of nonevidence-based medical advice regarding COVID-19 that is rampant on social media, and not limited by geographic, religious, cultural, or socioeconomic boundaries. This "epidemic" adds to the strain of the pandemic on medical and psychological healthcare resources. It is incumbent on us to fight this social misinformation epidemic, before it turns into another pandemic.

Coronavirus disease-2019 (COVID-19) was declared as a pandemic by WHO in March 2020. SARS-CoV-2 causes a wide range of illness from asymptomatic to life-threatening. There is an essential need to identify biomarkers to predict disease severity and mortality during the earlier stages of the disease, aiding treatment and allocation of resources to improve survival. The aim of this study was to identify at the time of SARS-COV-2 infection patients at high risk of developing severe disease associated with low survival using blood parameters, including inflammation and coagulation mediators, vital signs, and pre-existing comorbidities. This cohort included 89 multi-ethnic COVID-19 patients recruited between July 14th and October 20th 2020 in Doha, Qatar. According to clinical severity, patients were grouped into severe (n=33), mild (n=33) and asymptomatic (n=23). Common routine tests such as complete blood count (CBC), glucose, electrolytes, liver and kidney function parameters and markers of inflammation, thrombosis and endothelial dysfunction including complement component split product C5a, Interleukin-6, ferritin and C-reactive protein were measured at the time COVID-19 infection was confirmed. Correlation tests suggest that C5a is a predictive marker of disease severity and mortality, in addition to 40 biological and physiological parameters that were found statistically significant between survivors and non-survivors. Survival analysis showed that high C5a levels, hypoalbuminemia, lymphopenia, elevated procalcitonin, neutrophilic leukocytosis, acute anemia along with increased acute kidney and hepatocellular injury markers were associated with a higher risk of death in COVID-19 patients. Altogether, we created a prognostic classification model, the CAL model (C5a, Albumin, and Lymphocyte count) to predict severity with significant accuracy. Stratification of patients using the CAL model could help in the identification of patients likely to develop severe symptoms in advance so that treatments can be targeted accordingly.

COVID-19 has a broad spectrum of clinical presentations, including central nervous system manifestations that are not uncommon. The high pretest probability of COVID-19 in pandemic can lead to anchoring. We present a patient of COVID-19 pneumonia who presented with dyspnea and acute confusional state. His initial workup was suggestive of tuberculous meningoencephalitis with lymphocytic pleocytosis, high protein in CSF analysis, and suspicious MRI findings, which was later confirmed with a positive CSF culture. To the best of our knowledge, it is the first such case. Anchoring to the diagnosis of COVID-19 may deter clinicians from considering other concurrent diagnoses and a poor outcome consequently.

Autoimmune hepatitis (AIH) is a chronic disease characterized by hepatocellular inflammation and destruction. Its pathogenesis remains unclear. Current evidence suggests that environmental factors, including viral infections, are implicated as possible triggers. We present a case of a 36-year-old lady with systemic lupus erythematosus who presented with abdominal pain, nausea, vomiting, and jaundice. She was initially diagnosed as acute hepatitis E virus (HEV) infection based on positive serology, but she did not improve with conservative management. Subsequently, she underwent liver biopsy that showed features characteristic of AIH. We discuss the role of HEV as a possible trigger of AIH. We also highlight the possibility of cross-reactivity between liver antigens and HEV as an explanation for the positive HEV serology in AIH. We explore the management options of cases in which both acute HEV infection and AIH coexist, which might be challenging as there is no current consensus whether to start immunosuppressive therapy or to manage such cases conservatively. Moreover, we discuss previous similar cases in which different lines of management were chosen.

Data on inhaler technique and its effects on maternal and fetal outcomes during pregnancy are seldom reported. The primary objective of this study was to evaluate inhaler technique and identify errors in inhaler use among pregnant women with asthma. Secondary objectives were to identify factors associated with poor inhaler technique and study the association between inhaler technique and maternal and fetal outcomes. This was a cross-sectional, face-to-face, prospective study of 80 pregnant women with physician-diagnosed asthma. Seventy-three and 41 asthmatic pregnant women reported using pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs), respectively. Overall, wrong inhaler technique was observed in 47 (64.4%) subjects. Among pMDI users, correct inhaler use was observed in only 26/73 (35.6%) of the patients, with lack of coordination between inhalation and generation of the aerosol and failure to breathe out gently before using the inhaler, being the most common errors. Among DPI users, 21 (51.2%) demonstrated correct inhaler use, with failure to perform a breath-hold for 10 seconds after inhaling the powder and to exhale gently before using the inhaler being the most common errors. Significant associations between inhaler technique and patient's understanding of asthma medications and the kind of follow-up clinic (respiratory versus nonrespiratory clinic) were found. No significant associations between inhaler technique and various maternal and fetal outcomes or asthma control were found. In conclusion, improper inhalation technique is significantly prevalent in pregnant asthmatic women, particularly among those being followed in nonspecialized respiratory clinics. The lack of significant association between the inhaler technique and asthma control (and hence maternal and fetal outcomes) may simply reflect the high prevalence of uncontrolled asthma and significant contribution of other barriers to poor asthma control in the current patient's cohort. Multidisciplinary management of asthma during pregnancy with particular emphasis on patient's education is imperative.

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