The SARS-CoV-2 virus has created an unprecedented impact on healthcare globally. Being a novel virus, several treatments have been explored against COVID-19. During the early stages of the disease, treatment is mainly supportive. While several studies have suggested different treatment modalities, there is still no definitive treatment against COVID-19. Re-purposing already established medications, with excellent safety profiles, is a possible approach for treating the disease in its early stage. Having a mode of transmission as a droplet mode, several studies have supported how the nose can contain the primary route of entry of SARS-CoV-2. Hence, we postulated that re-purposing a commercially available nasal spray containing xylitol and grapefruit seed extract (GSE), namely Xlear Nasal Spray® (Xlear, Inc., American Fork, USA) could be used as an adjunct treatment of COVID-19. With a well-established safety profile, the components of this nasal spray have been studied and have been shown to have potential efficacy against viral pathogens, including coronavirus, and may potentially regulate pathways important in the initial entry of infection, replication, and systemic response to SARS-CoV-2. We present a series of three mild-moderate risks, symptomatic, COVID-19 patients, treated with the intranasal combination, as an adjuvant to their ongoing treatment, with rapid clinical improvement and shorten time to negativization on repeat intranasal swab test via PCR. No safety issues were noted during the course of treatment. Xlear nasal spray, containing xylitol plus GSE, given its established safety profile and compelling clinical results described here, could be a potential adjunct treatment option in mild-moderate COVID-19 cases.

This potentially life-threatening disease poses an interesting perspective on adverse events that can occur or can be exacerbated following the Ad26.COV2.S (Johnson & Johnson) vaccine. The authors report findings in a 65-year-old female patient who experienced facial diplegia, an atypical variant of Guillain-Barré syndrome, two weeks after receiving the Ad26.COV2.S vaccine against coronavirus disease 2019. Post-approval pharmacovigilance of each vaccine helps better understand the long-term outcomes, and reporting adverse events is crucial for advancements in medical knowledge.

Hypoxic-ischemic encephalopathy (HIE) typically manifests in the neonatal period. The degree of hypoxia following intrapartum asphyxia determines the structural changes in the brain, which can cause functional deficits in the affected child leading to developmental deficits and recurrent seizures. Management requires physical therapy, occupational therapy, and anti-seizure medications. We present a rare case of an 11-year-old female with a past medical history of epilepsy and cerebral atrophy secondary to hypoxic injury at birth. The patient presented to the hospital following a witnessed seizure and loss of consciousness for one hour. Given the past medical history and clinical findings, it was determined that a mild-to-moderate encephalopathic process resulted in a lower seizure threshold. HIE can manifest beyond the neonate years mainly due to the structural changes within the brain. Therefore, it is essential to understand aspects of HIE beyond the neonate years to manage this condition for a better patient outcome.

Citrullinemia refers to a family of autosomal recessive disorders involving the urea cycle. Three forms exist, which have different implications. Type I citrullinemia exists in both mild and severe forms. It arises due to mutations with argininosuccinate synthase leading to accumulation of ammonia and producing symptoms of lethargy, poor feeding, and seizures. Type II citrullinemia occurs due to citrin mutations involved in the urea cycle transport or during neonatal cholestasis. Management of both conditions requires low-protein diets along with arginine, sodium benzoate, and sodium phenylacetate. While traditional treatment shows improved outcomes, modifications may be necessary depending on a patient’s presentation. We present a unique case of a 19-year-old wheelchair-bound female with a past medical history of heterozygous type I citrullinemia, seizures, and chronic encephalopathy presented to a local children’s hospital for evaluation of altered mental status with a lethargic mental state. She was initially found to have an ammonia level of 329 µmol/L and choledocholithiasis on admission. Dietary modification with intravenous dextrose and intralipids with oral lactulose saw improvement in her labs. However, her ammonia level increased to 381 µmol/L despite such interventions. Intensive care was required to normalize her serum ammonia level and clear her for a magnetic resonance cholangiopancreatography (MRCP). We present a unique case of heterozygous type I citrullinemia with some overlap with type II citrullinemia features. Further studies are needed to understand better the observed unique presentation and long-term clinical implications associated with the disease.