Background: Multisystem inflammatory syndrome (MIS) associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is a life-threatening condition first described in children (MIS-C). It is characterized by a hyperinflammatory state that involves the cardiovascular, gastrointestinal, dermatologic, and neurologic systems without severe respiratory system involvement. Myocarditis is one of the cardiovascular presentations of MIS that might be complicated with cardiogenic shock. There are few case reports describing SARS-CoV-2-related MIS in adults (MIS-A). Case Summary: Three cases of healthy young adults diagnosed with severe acute respiratory syndrome-CoV-2 related (MIS-A). The main presentation was cardiogenic shock secondary to histologically proven myocarditis, which resolved rapidly after initiation of medical therapy including anti-inflammatory and immunosuppressive drugs. All the cases, however, required mechanical circulatory support (MCS) as a bridge to recovery. CONCLUSIONS: It appears reasonable to treat the patient with fulminant myocarditis in SARS-CoV-2-associated MIS-A with high-dose corticosteroid “pulse” therapy in order to suppress the inflammatory response and MCS to correct initial metabolic derangement and reestablish/maintain vital organ perfusion. Addition of IV immunoglobulin and other immunomodulators should be assessed in a case-by-case basis especially considering the associated cost resource allocation.

Unusual clinical course Methylene blue has multiple uses in medicine. It is generally used to treat refractory vasoplegia and methemoglobin toxicity, and can be used as a dye to localize the parathyroid glands intra-operatively. In refractory vasoplegia, methylene blue inhibits endothelial nitric oxide and guanylate cyclase, causing vasoconstriction and potentially stabilizing blood pressure. Multiple complications have been associated with the use of methylene blue. These are related to either the sole effect of methylene blue or the combined effect of methylene blue and certain antidepressants, such as selective serotonin reuptake inhibitors (SSRIs). To the best of our knowledge, in the setting of post-cardiac surgery vasoplegia, there have been no reports of the neurological toxicity of methylene blue in the absence of SSRI use. In this case report, we describe the anticholinergic manifestations associated with the use of methylene blue in post-cardiac surgery vasoplegia. A male patient in his mid-sixties with severe mitral regurgitation underwent elective mitral valve replacement. Postoperatively, he was hypotensive and required a high dose of vasopressors. Methylene blue was administered to treat refractory vasoplegia. The patient became anuric and febrile, with bilateral mydriasis. Internal cooling and continuous renal replacement therapy were initiated, and symptoms rapidly resolved. The patient was discharged after prolonged hospitalization with a permanent catheter for hemodialysis. Anticholinergic toxidrome may explain the neurological adverse effects associated with high doses of methylene blue. Physicians should be cautious when using methylene blue in combination with other anticholinergic drugs and in conditions of renal failure. The development of methylene blue toxicity warrants the urgent discontinuation of the agent and early drug elimination.

Pneumonia is a common nonobstetric cause of acute respiratory distress syndrome (ARDS) and is the leading cause of intensive care unit admission in pregnant women. Acute respiratory distress syndrome is the most frequent indication for venovenous extracorporeal membrane oxygenation (VV ECMO) during pregnancy, with viral pneumonia as the primary etiology. The objective of this study was to review the maternal and fetal outcomes of pregnant and postpartum women with severe ARDS who were supported with VV ECMO. This retrospective observational study was conducted at a single ECMO center from December 2015 to March 2023. Eighteen pregnant and postpartum women who were supported with VV ECMO due to severe ARDS caused by viral pneumonia were included. The maternal and fetal survival rates were 83% and 61%. Major bleeding was a common complication for patients while on ECMO (38%). All maternal deaths were due to major bleeding. For pre-ECMO respiratory support, the mechanical ventilation (MV) duration ranged from 0 to 6 days, and the total MV duration ranged from 5 to 86 days. Survival rate among pregnant/early postpartum women who were placed on VV ECMO for respiratory support was not different from nonpregnant women. Bleeding remains a major complication that is associated with maternal and fetal mortality.

Background: Chronic obstructive pulmonary disease (COPD) is a significant burden in Saudi Arabia. Improving the attitudes, awareness, and knowledge of healthcare providers toward advance directives and/or advanced care planning (ACP) can increase the use of advance directives. This study aims to investigate healthcare providers’ knowledge, attitudes, and practices concerning advance directives for COPD patients in Riyadh, Saudi Arabia. Methods: This cross-sectional study was employed to assess the knowledge, attitudes, and practices of healthcare providers towards ACP for COPD patients in Riyadh between June and December 2024. The questionnaire was adapted from previous research. Multiple logistic regression was performed to assess the factors associated with good knowledge and positive attitude. Results: A total of 268 participants were included in the analysis. The total mean of knowledge score was 6.96 ± 2.22 out of 12. A total of 161 participants (60.1%) had a poor knowledge score, and 107 participants (39.9%) had a good knowledge score. The total mean of attitude score was 16.23 ± 23.21 out of 26. A total of 148 participants (55.2%) had a poor attitude score and 120 participants (44.8%) had positive attitude. Participants with over 15 years of experience exhibited significantly higher odds of good knowledge (OR = 6.76, 95% CI = 1.03−44.21, p = 0.04). Participants who lived in the Western region had significantly lower odds of good knowledge (OR = 0.32, 95% CI = 0.14–0.71, p = 0.005). Nurses and respiratory therapists had significantly lower odds of having positive attitude (OR = 0.19, 95% CI = 0.09−0.42, p = 0.0001 and OR = 0.34, 95% CI = 0.16–0.75, p = 0.007, respectively). Participants who lived in the Western region had significantly lower odds of having positive attitude (OR = 0.42, 95% CI = 0.19–0.95, p = 0.005). Conclusions: Healthcare providers in Saudi Arabia demonstrated a moderate level of knowledge of ACP for COPD patients. This was accompanied by a moderately positive attitude towards this practice. Future studies should examine effective educational and professional interventions to enhance ACP practices.