key: cord-0757118-eva73jun
authors: Badrah, Mai; Riad, Abanoub; Kassem, Islam; Boccuzzi, Michela; Klugar, Miloslav
title: Craniofacial pain in COVID‐19 patients with diabetes mellitus: Clinical and laboratory description of 21 cases
date: 2021-02-15
journal: J Med Virol
DOI: 10.1002/jmv.26866
sha: 963f467ae25298bd0b4b97b763291c2d29dbe25b
doc_id: 757118
cord_uid: eva73jun

The pandemicity of diabetes mellitus (DM) has always been a challenging concern for oral and maxillofacial practitioners which got aggravated by the coronavirus disease (COVID-19) pandemic. DM is an independent risk factor for COVID-19 morbidity and mortality; on the other hand, COVID-19 outbreak has deteriorated the access of diabetic patients to palliative care and limited their outdoor activities and their nutrition. Similar to the Severe Acute Respiratory Syndrome (SARS) and the Middle Eastern Respiratory Syndrome (MERS), COVID-19 is strongly associated with altered glycemic levels thus leading in some cases to new-onset diabetes. In accordance with the CARE guidelines, we aim to report the characteristics of twenty-one consecutive diabetic type-2 COVID-19 patients who presented to our department from April to August 2020 with throbbing craniofacial pain. This article is protected by copyright. All rights reserved.

The pandemicity of diabetes mellitus (DM) has always been a challenging concern for oral and maxillofacial practitioners which got aggravated by the coronavirus disease (COVID-19) pandemic. [1] [2] [3] is an independent risk factor for COVID-19 morbidity and mortality; on the other hand, COVID-19 outbreak has deteriorated the access of diabetic patients to palliative care and limited their outdoor activities and their nutrition. Similar to the severe acute respiratory syndrome (SARS) and the Middle Eastern respiratory syndrome, COVID-19 is strongly associated with altered glycemic levels thus leading in some cases to new-onset diabetes. 4, 5 In accordance with the CARE guidelines, we aim to report the characteristics of 21 consecutive diabetic type-2 COVID-19 patients who presented to our department from April to August 2020 with throbbing craniofacial pain. 6 Out of the 5730 diabetic patients with COVID-19 who visited our outpatient clinics or admitted to the inpatient department during the referenced period, those 21 patients (0.37%) sought specialist care due to their new-onset pain ( Table 1 ).

The referenced patients had undergone a polymerase chain reaction (PCR) testing for COVID-19 which confirmed their infection with a mean cycle threshold (C t ) of 28.43 ± 5.64 , and none of them experienced severe respiratory symptoms that required hospitalization. Their mean age was 51.71 ± 10.62 (38-75) years old with a mean body mass index of 21.76 ± 2.7 (18-26), and the majority (66.7%) were males. On the day of their visit to our department, their mean hemoglobin A1c (HbA1c) was 6.7 ± 9.11 (5) (6) (7) (8) indicating that the majority of them had controlled DM (76%). Regarding their COVID-19 symptoms; three patients (14.3%) had a mild fever, four patients (19%) experienced dry coughing, and only two patients (9.5%) had a sore throat. Myalgia (muscles pain) was experienced by only two patients (9.5%). According to the Australian guidelines, 3 patients (14.3%) had a moderate course of illness, and 18 patients (85.7%) had a mild course of illness. 7 The clinical examination had been carried out systematically by a qualified maxillofacial surgeon beginning with a general assessment of the head and neck, followed by inspection of the ears, nose, oropharynx, and lymph nodes, and neurologic screening. 8 On examining their chief complaint, pain severity was assessed by the patient using an 11-item numerical rating scale when with "0" denoting "no pain" and "10" denoting "pain as bad as you can imagine." 9

The mean pain severity was 7.14 ± 1.15 (5) (6) (7) (8) (9) , and it had between 3 and 10 episodes every day with a mean of 6.19 ± 1.89 episodes/ day. The duration of the pain was estimated from the day of consultation until the day when the patient reported that the pain had completely been relieved; the mean duration was 16.95 ± 8.89 11 All these factors may be attributed to the inflammatory mechanism by which the craniofacial structure can be affected especially in older patients when tissue susceptibility to pain increases with ageing. 12 Given that our cases' median age was 49-year old, the relationship between diabetes and pain in the orofacial muscles can be related to glutamate's role whose neurotoxicity is mediated by the NMDA receptors found in neuronal tissues and peripheral nonneuronal tissues and cells as β-cells. 13, 14 In contrast to diabetic neuropathies, including focal neuropathy of the face, which are mainly triggered by long-standing hyperglycemia, our cases had meticulous control of their blood glucose levels through medications. 15 various populations due to the significant increase in psychoemotional stress that aggravates bruxism and temporomandibular disorders, all the cases in this series reported that they had no history of bruxism nor prior experience with orofacial pain. 16, 17 In conclusion, this case series provides the first clinical evidence on a possible interference of COVID-19 with craniofacial tissues leading to an inflammatory-mediated pain that warrants further investigation for the pathophysiologic mechanisms of pain perception in diabetic patients infected by SARS-COV-2.

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