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__NOTOC__
__NOTOC__
{{COVID-19}}
{{SI}}


{{CMG}} {{AE}}{{Arash.M}}
{{CMG}}; {{AE}} {{Arash.M}}, {{Fs}}


{{SK}}  
{{SK}} MFS, fisher syndrome


==Overview==
==Overview==


[[Miller|Miller Fisher Syndrome]] (MFS) is an acute peripheral neuropathy which can develop after exposure to a viral or bacterial infection. It includes triad of [[ophtalmoplegia]], [[areflexia]] and [[ataxia]]. In [[covid-19]] pandemic period, while [[covid-19]] typically presents with fever, SOB and respiratory symptoms, MFS with prior history of covid-19 has been seen in several cases all around the world.  
[[Miller Fisher Syndrome]] (MFS) is an acute [[peripheral neuropathy]] that can develop after exposure to a [[Virus|viral]] or [[bacterial]] infection. It includes triad of [[ophthalmoplegia]], [[areflexia]] and [[ataxia]]. In [[COVID-19]] pandemic period, while [[COVID-19]] typically presents with [[fever]], [[shortness of breath]] (SOB) and [[respiratory]] symptoms, MFS with prior history of [[COVID-19]] has been seen in several cases all around the world. One retrospective study in 214 patients has shown that 8.9 % of [[COVID-19]] patients have reported peripheral [[neurological]] symptoms.
<br> One retrospective study in 214 patients has shown that 8.9 % of [[covid-19]] patients have reported peripheral neurological symptoms.


==Historical Perspective==
==Historical Perspective==


The first reported case of MFS with history of covid-19 was detected on January 2020 in Shanghai, who was a middle-age woman diagnosed with MFS presented with [[areflexia]], acute weakness in both legs and severe fatigue. Further reports were announced by medical groups in Spain and the USA which presented [[neuro-ophtalmological]] symptoms. <ref><nowiki>{{</nowiki>https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619<nowiki>}}</nowiki></ref>
* The first reported case of MFS with a history of [[COVID-19]] was detected in January 2020 in Shanghai, who was a middle-aged woman diagnosed with MFS presented with [[areflexia]], acute [[weakness]] in both legs and severe [[fatigue]].
* Further reports were announced by medical groups in Spain and the USA which presented neuro-ophtalmological symptoms. <ref><nowiki>{{</nowiki>https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619<nowiki>}}</nowiki></ref>


==Classification==
==Classification==


MFS is a rare variant of [[Guillain-Barre syndrome]], characterized by [[ophtalmoplegia]], [[areflexia]] and [[ataxia]].
* MFS is a rare variant of [[Guillain-Barre syndrome]], characterized by [[ophtalmoplegia]], [[areflexia]] and [[ataxia]].


==Pathophysiology==
==Pathophysiology==


MFS is related to dysfunction of third, forth and sixth cranial nerves. A typical serological finding in patients with MFS and prior history of [[covid-19]] is antibodies against [[GQ1b ganglioside]], though negative test for antibodies does not rule out the diagnosis. The presence of ophtalmoparesis in MFS is related to a action of [[anti-GQ1b antibodies]] on the neuromuscular junction between the cranial nerves and ocular muscle. [[ELISA test]] is positive in 70% to 90% of patients.<ref><nowiki>{{</nowiki>https://pubmed.ncbi.nlm.nih.gov/10695710<nowiki>}}</nowiki></ref>
* [[Miller Fisher Syndrome]] (MFS) is related to dysfunction of third, fourth, and sixth [[cranial nerves]].  
* A typical [[Serology|serological]] finding in patients with MFS and prior history of [[covid-19]] is antibodies against GQ1b [[ganglioside]], though negative test for [[antibodies]] does not rule out the [[diagnosis]].  
* The presence of [[ophthalmoparesis]] in MFS is related to a action of anti-GQ1b [[antibodies]] on the [[neuromuscular junction]] between the [[cranial nerves]] and [[Ocular muscles|ocular muscle]]. [[ELISA test]] is positive in 70% to 90% of patients.<ref><nowiki>{{</nowiki>https://pubmed.ncbi.nlm.nih.gov/10695710<nowiki>}}</nowiki></ref>


==Causes==
==Causes==
Although MFS has been detected in some patients with covid-19, other viral and bacterial infections can also cause MFS
 
*[[Influenza virus]]
* Although [[Miller Fisher Syndrome]] (MFS) has been detected in some patients with [[COVID-19]], other viral and [[bacterial]] infections can also cause MFS:
*[[Cytomegalovirus]]
**[[Influenza Virus]]
*[[Zika virus]]
**[[Cytomegalovirus]]
*[[Mycoplasma]]
**[[Zika virus]]
*[[Campylobacter]]
**[[Mycoplasma]]
**[[Campylobacter]]


==Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases==
==Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases==
MFS must be differentiated from other diseases that cause ophthalmoplegia, areflexia, and ataxia, such as [[myasthenia gravis]], [[botulism]], [[diphtheria]], [[brain stem stroke]], [[brain stem encephalitis]] and [[basal meningitis]]. It is essential to rule out emergent neurological disorders like stroke or brain injury in patients with MFS symptoms.<ref><nowiki>{{</nowiki>https://rarediseases.org/rare-diseases/miller-fisher-syndrome/<nowiki>}}</nowiki></ref>
 
*For further information about the differential diagnosis, [[COVID-19-associated Miller-Fischer syndrome differential diagnosis|click here]].
* To view the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
While the incidence of MFS is one or two person per million each year, the prevalence of MFS associated with covid-19 is still unknown.
 
* While the [[incidence]] of MFS is one or two-person per million each year, the [[prevalence]] of MFS associated with [[COVID-19]] is still unknown.


==Risk Factors==
==Risk Factors==
There are no established risk factors for MFS associated with covid-19.
 
* There are no established [[Risk factor|risk factors]] for MFS associated with [[COVID-19]].


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for patients with MFS caused by covid-19.
 
* There is insufficient evidence to recommend routine [[Screening (medicine)|screening]] for patients with MFS caused by [[COVID-19]].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
There is an increased risk of death in patients over the age of 60 year-old. Hence, the mortality rate is estimated to be 3.6%.  
 
<br> Risk factors for severe illness and poor prognosis include:
* There is an increased risk of death in patients over the age of 60-year-old. Hence, the [[mortality rate]] is estimated to be 3.6%.  
* Old age
* Risk factors for severe illness and poor [[prognosis]] include:
* Male gender
**[[Old age]]
* Patients with  
** Male gender
** [[Diabetes Mellitus]]
** Patients with  
** [[Hypertension]]
***[[Diabetes Mellitus]]
** [[COPD]]
***[[Hypertension]]
** [[CKD]]
***[[COPD]]
***[[CKD]]


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
Although the diagnosis of [[covid-19]] is based on respiratory symptoms, it can be associated with neurological symptoms, of which overlap the diagnosis of MFS. Consequently, in patient with prior history of covid-19, other neurologic diseases should be ruled out and [[anti-GQ1b]] antibody test should be considered. Also, in new patients with suspicious symptoms for covid-19 and neurological symptoms, nasal swab test and neurological examination should be considered.
 
<br> MRI may be performed as a part of diagnostic work up. Although in majority of cases no abnormality is detected, enlargement and prominent enhacement in orbits and retro-orbital region has been reported in some cases.<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>. <ref><nowiki>{{</nowiki>https://rarediseases.org/rare-diseases/miller-fisher-syndrome/<nowiki>}}</nowiki></ref>
* Although the diagnosis of [[COVID-19]] is based on [[respiratory]] symptoms, it can be associated with [[neurological]] symptoms, which overlap the diagnosis of MFS.  
* Consequently, inpatient with prior history of [[COVID-19]], other [[Neurological|neurologic]] diseases should be ruled out and anti-GQ1b [[antibody]] test should be considered.  
* Also, in new patients with suspicious symptoms for [[COVID-19]] and neurological symptoms, a nasal swab test and neurological examination should be considered.
* [[Magnetic resonance imaging|MRI]] may be performed as a part of the diagnostic workup. Although in majority of cases no abnormality is detected, enlargement and prominent enhancement in orbits and retro-orbital region has been reported in some cases.<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>. <ref><nowiki>{{</nowiki>https://rarediseases.org/rare-diseases/miller-fisher-syndrome/<nowiki>}}</nowiki></ref>


===History and Symptoms===
===History and Symptoms===
Symptoms of covid-19 associated with MFS include:
* Respiratory system symptoms
** [[shortness of breath]]
** [[cough]]
* Neurological symptoms
** [[headache]]
** [[ataxia]]
** [[ophthalmoplegia]]
** [[areflexia]]


<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>
==== Common symptoms ====
 
* Common [[symptoms]] of covid-19 associated with [[MFS]] include:
** [[Shortness of breath]]
**[[Cough]]
**[[Fever]]
**[[Ophthalmoplegia]]
**[[Areflexia]]
**[[Ataxia]]
 
==== Less common symptoms ====
 
* Less common symptoms of covid-19 associated with [[MFS]] include:
** [[Headache]]<ref><nowiki>{{</nowiki>http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609<nowiki>}}</nowiki></ref>
**[[Diplopia]]
**[[Blurred vision]]
**[[Ptosis]]
**[[Facial droop]]


===Physical Examination===
===Physical Examination===
Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:
 
* Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:
====Vitals====
====Vitals====
Abnormal signs associated with covid-19:
Abnormal signs associated with covid-19:
* [[Tachycardia]]
* [[Tachycardia]]
* [[Tachypnea]]
* [[Tachypnea]]
* Fever
*[[Fever]]
====neurological====
 
====Neurological====
* [[Eye dropping]]
* [[Eye dropping]]
* [[Blurry vision]]
* [[Blurry vision]]
Line 88: Line 110:


===Laboratory Findings===
===Laboratory Findings===
Laboratory findings consistent with the diagnosis of covid-19 include positive [[PCR]] nasal swab.
 
<br> Laboratory test for neurological signs are not diagnostic and should be used with other clinical parameters. They are include:
* Laboratory findings consistent with the diagnosis of COVID-19 include positive [[PCR]] nasal swab.
* Ganglioside (GM1) Antibodies, IgG and IgM
* Laboratory tests for neurological signs are not diagnostic and should be used with other clinical parameters. They include:
* GD1b Antibody, IgM
**[[Ganglioside]] (GM1) [[Antibodies]], [[IgG]] and [[IgM]]
* GQ1b Antibody, IgG
** GD1b [[Antibody]], [[IgM]]
** GQ1b Antibody, [[IgG]]


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with covid-19.
 
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19]].


===X-ray===
===X-ray===
CXR is less sensitive in detection of covid-19 in comparison with CT. However, in some cases [[lung consolidation]] and patchy peripheral opacities corresponding to [[ground glass opacities]] has been reported.<ref><nowiki>{{</nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/<nowiki>}}</nowiki></ref>
 
* [[Chest X-ray]] is less sensitive in detection of [[COVID-19]] in comparison with [[Computed tomography|CT]].  
* However, in some cases [[lung consolidation]] and patchy peripheral opacities corresponding to [[ground glass opacities]] has been reported.<ref><nowiki>{{</nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/<nowiki>}}</nowiki></ref>


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with '''covid-19'''.
 
<br> [[Lung Ultrasound]] may be helpful in evaluation of patients with '''covid-19'''. It indicates :
* Lung [[ultrasound]] may be helpful in the evaluation of patients with COVID-19. It indicates :
* Multiple [[B-lines]]
 
** Ranging from focal to diffuse with spared areas  
* Multiple B-lines
* Irregular and thickened pleural lines
** Ranging from focal to diffuse with spared areas
* Irregular and thickened [[pleural]] lines
* Subpleural consolidations
* Subpleural consolidations
* Alveolar consolidations
*[[Alveolar]] [[Consolidation (medicine)|consolidations]]
* Bilateral [[A-lines]]
* Bilateral [[A-lines]]


===CT scan===
===CT scan===
The preliminary findings of CT in '''COVID-19''' associated with '''MFS''' include:
The preliminary findings of [[Computed tomography|CT]] in COVID-19 associated with MFS include:
* Bilateral [[Ground Glass Opacities]]
* Bilateral ground glass opacities
* Air space consolidation  
* Air space [[Consolidation (medicine)|consolidation]]
* Bronchovascular thickening
* Bronchovascular thickening
* Traction bronchiectasis
* Traction [[bronchiectasis]]


===MRI===
===MRI===
Brain MRI may be helpful in the diagnosis of '''MFS''' in patients with prior history of '''covid-19''' and neurological manifestations. Although there can be no abnormalities, '''multiple cranial nerve enhancement''' has been reported in some patients.
 
* Brain [[Magnetic resonance imaging|MRI]] may be helpful in the diagnosis of MFS in patients with prior history of COVID-19 and [[neurological]] manifestations.  
* Although there can be no abnormalities, multiple [[Cranial nerves|cranial nerve]] enhancement has been reported in some patients.


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with covid-19 with MFS manifestations.
 
* There are no other diagnostic studies associated with COVID-19 with MFS manifestations.


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
No specific treatment and vaccine exists for '''covid-19''' yet. However, patients with moderate to severe [[ARDS]] and respiratory manifestations can benefit from '''Mechanical ventilation''' and ''' extracorporeal membrane oxygenation (ECMO)'''. In some patients the combination of antiviral therapies like protease inhibitors, ritonavir, and lopinavir indicated partial success in treatment of '''covid-19'''.
 
<br> '''Remdesivir''', a drug originally developed to treat [[Ebola virus]], showed positive results against SARS-CoV-2.
* No specific treatment and vaccine exists for covid-19 yet.  
<br> '''Dexamethasone''' has been announced as an effective treatment in patients with systematic manifestations.
* However, patients with moderate to severe [[ARDS]] and respiratory manifestations can benefit from [[Mechanical ventilation]] and [[extracorporeal membrane oxygenation]] (ECMO).  
* In some patients the combination of antiviral therapies like [[protease inhibitors]], [[Ritonavir clinical pharmacology|ritonavir]], and [[lopinavir]] (100-400mg/day)<ref name="CaoWang2020">{{cite journal|last1=Cao|first1=Bin|last2=Wang|first2=Yeming|last3=Wen|first3=Danning|last4=Liu|first4=Wen|last5=Wang|first5=Jingli|last6=Fan|first6=Guohui|last7=Ruan|first7=Lianguo|last8=Song|first8=Bin|last9=Cai|first9=Yanping|last10=Wei|first10=Ming|last11=Li|first11=Xingwang|last12=Xia|first12=Jiaan|last13=Chen|first13=Nanshan|last14=Xiang|first14=Jie|last15=Yu|first15=Ting|last16=Bai|first16=Tao|last17=Xie|first17=Xuelei|last18=Zhang|first18=Li|last19=Li|first19=Caihong|last20=Yuan|first20=Ye|last21=Chen|first21=Hua|last22=Li|first22=Huadong|last23=Huang|first23=Hanping|last24=Tu|first24=Shengjing|last25=Gong|first25=Fengyun|last26=Liu|first26=Ying|last27=Wei|first27=Yuan|last28=Dong|first28=Chongya|last29=Zhou|first29=Fei|last30=Gu|first30=Xiaoying|last31=Xu|first31=Jiuyang|last32=Liu|first32=Zhibo|last33=Zhang|first33=Yi|last34=Li|first34=Hui|last35=Shang|first35=Lianhan|last36=Wang|first36=Ke|last37=Li|first37=Kunxia|last38=Zhou|first38=Xia|last39=Dong|first39=Xuan|last40=Qu|first40=Zhaohui|last41=Lu|first41=Sixia|last42=Hu|first42=Xujuan|last43=Ruan|first43=Shunan|last44=Luo|first44=Shanshan|last45=Wu|first45=Jing|last46=Peng|first46=Lu|last47=Cheng|first47=Fang|last48=Pan|first48=Lihong|last49=Zou|first49=Jun|last50=Jia|first50=Chunmin|last51=Wang|first51=Juan|last52=Liu|first52=Xia|last53=Wang|first53=Shuzhen|last54=Wu|first54=Xudong|last55=Ge|first55=Qin|last56=He|first56=Jing|last57=Zhan|first57=Haiyan|last58=Qiu|first58=Fang|last59=Guo|first59=Li|last60=Huang|first60=Chaolin|last61=Jaki|first61=Thomas|last62=Hayden|first62=Frederick G.|last63=Horby|first63=Peter W.|last64=Zhang|first64=Dingyu|last65=Wang|first65=Chen|title=A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19|journal=New England Journal of Medicine|volume=382|issue=19|year=2020|pages=1787–1799|issn=0028-4793|doi=10.1056/NEJMoa2001282}}</ref> indicated partial success in treatment of [[COVID-19]].
* [[Remdesivir]] (100-200mg/day)<ref name="urlCoronavirus disease 2019 (COVID-19) investigational drug information for remdesivir">{{cite web |url=https://reference.medscape.com/drug/remdesivir-4000090 |title=Coronavirus disease 2019 (COVID-19) investigational drug information for remdesivir |format= |work= |accessdate=}}</ref>, a drug originally developed to treat [[Ebola virus]], showed positive results against [[SARS-CoV-2]].
* [[Dexamethasone]] (6mg/day)<ref name="urlCorticosteroids | Coronavirus Disease COVID-19">{{cite web |url=https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/immunomodulators/corticosteroids/ |title=Corticosteroids &#124; Coronavirus Disease COVID-19 |format= |work= |accessdate=}}</ref> has been announced as an effective treatment in patients with systematic manifestations.


===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of covid-19.
 
* Surgical intervention is not recommended for the management of covid-19.


===Primary Prevention===
===Primary Prevention===
Effective measures for the primary prevention of '''covid-19''' include handwashing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.
 
* Effective measures for the [[primary prevention]] of [[covid-19]] include hand-washing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Up-To-Date]]


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2], Fahimeh Shojaei, M.D.

Synonyms and keywords: MFS, fisher syndrome

Overview

Miller Fisher Syndrome (MFS) is an acute peripheral neuropathy that can develop after exposure to a viral or bacterial infection. It includes triad of ophthalmoplegia, areflexia and ataxia. In COVID-19 pandemic period, while COVID-19 typically presents with fever, shortness of breath (SOB) and respiratory symptoms, MFS with prior history of COVID-19 has been seen in several cases all around the world. One retrospective study in 214 patients has shown that 8.9 % of COVID-19 patients have reported peripheral neurological symptoms.

Historical Perspective

  • The first reported case of MFS with a history of COVID-19 was detected in January 2020 in Shanghai, who was a middle-aged woman diagnosed with MFS presented with areflexia, acute weakness in both legs and severe fatigue.
  • Further reports were announced by medical groups in Spain and the USA which presented neuro-ophtalmological symptoms. [1]

Classification

Pathophysiology

Causes

Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

  • While the incidence of MFS is one or two-person per million each year, the prevalence of MFS associated with COVID-19 is still unknown.

Risk Factors

Screening

  • There is insufficient evidence to recommend routine screening for patients with MFS caused by COVID-19.

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

  • Although the diagnosis of COVID-19 is based on respiratory symptoms, it can be associated with neurological symptoms, which overlap the diagnosis of MFS.
  • Consequently, inpatient with prior history of COVID-19, other neurologic diseases should be ruled out and anti-GQ1b antibody test should be considered.
  • Also, in new patients with suspicious symptoms for COVID-19 and neurological symptoms, a nasal swab test and neurological examination should be considered.
  • MRI may be performed as a part of the diagnostic workup. Although in majority of cases no abnormality is detected, enlargement and prominent enhancement in orbits and retro-orbital region has been reported in some cases.[3]. [4]

History and Symptoms

Common symptoms

Less common symptoms

Physical Examination

  • Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:

Vitals

Abnormal signs associated with covid-19:

Neurological

Laboratory Findings

  • Laboratory findings consistent with the diagnosis of COVID-19 include positive PCR nasal swab.
  • Laboratory tests for neurological signs are not diagnostic and should be used with other clinical parameters. They include:

Electrocardiogram

X-ray

Echocardiography or Ultrasound

  • Lung ultrasound may be helpful in the evaluation of patients with COVID-19. It indicates :

CT scan

The preliminary findings of CT in COVID-19 associated with MFS include:

MRI

  • Brain MRI may be helpful in the diagnosis of MFS in patients with prior history of COVID-19 and neurological manifestations.
  • Although there can be no abnormalities, multiple cranial nerve enhancement has been reported in some patients.

Other Diagnostic Studies

  • There are no other diagnostic studies associated with COVID-19 with MFS manifestations.

Treatment

Medical Therapy

Surgery

  • Surgical intervention is not recommended for the management of covid-19.

Primary Prevention

  • Effective measures for the primary prevention of covid-19 include hand-washing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.

References

  1. ↑ {{https://n.neurology.org/content/early/2020/04/17/WNL.0000000000009619}}
  2. ↑ {{https://pubmed.ncbi.nlm.nih.gov/10695710}}
  3. ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
  4. ↑ {{https://rarediseases.org/rare-diseases/miller-fisher-syndrome/}}
  5. ↑ {{http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609}}
  6. ↑ {{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/}}
  7. ↑ Cao, Bin; Wang, Yeming; Wen, Danning; Liu, Wen; Wang, Jingli; Fan, Guohui; Ruan, Lianguo; Song, Bin; Cai, Yanping; Wei, Ming; Li, Xingwang; Xia, Jiaan; Chen, Nanshan; Xiang, Jie; Yu, Ting; Bai, Tao; Xie, Xuelei; Zhang, Li; Li, Caihong; Yuan, Ye; Chen, Hua; Li, Huadong; Huang, Hanping; Tu, Shengjing; Gong, Fengyun; Liu, Ying; Wei, Yuan; Dong, Chongya; Zhou, Fei; Gu, Xiaoying; Xu, Jiuyang; Liu, Zhibo; Zhang, Yi; Li, Hui; Shang, Lianhan; Wang, Ke; Li, Kunxia; Zhou, Xia; Dong, Xuan; Qu, Zhaohui; Lu, Sixia; Hu, Xujuan; Ruan, Shunan; Luo, Shanshan; Wu, Jing; Peng, Lu; Cheng, Fang; Pan, Lihong; Zou, Jun; Jia, Chunmin; Wang, Juan; Liu, Xia; Wang, Shuzhen; Wu, Xudong; Ge, Qin; He, Jing; Zhan, Haiyan; Qiu, Fang; Guo, Li; Huang, Chaolin; Jaki, Thomas; Hayden, Frederick G.; Horby, Peter W.; Zhang, Dingyu; Wang, Chen (2020). "A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19". New England Journal of Medicine. 382 (19): 1787–1799. doi:10.1056/NEJMoa2001282. ISSN 0028-4793.
  8. ↑ "Coronavirus disease 2019 (COVID-19) investigational drug information for remdesivir".
  9. ↑ "Corticosteroids | Coronavirus Disease COVID-19".


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